Hypovolemic Patients Research Articles

Pre-hospital blood products and calcium replacement protocols in UK critical care services: A survey of current practice

IntroductionIn the United Kingdom, prehospital blood products are increasingly carried for the early resuscitation of hypovolaemia in patients who are shocked or in cardiac arrest. There is an association between hypocalcaemia and mortality in trauma patients, but no current national guidelines on the timing or dose of calcium replacement exist. The objective of this study was to establish the availability of prehospital blood products, and the current calcium replacement protocols used by UK prehospital services. MethodsA cross sectional survey of all UK air ambulances and additional prehospital critical care organisations was conducted in April-May 2022 via an on-line questionnaire. The survey asked 11 questions about availability of prehospital blood products, calcium replacement for patients requiring prehospital blood products, and the use of point of care testing. ResultsThere was a 100% response rate with 20/22 UK air ambulances carrying blood products and five additional prehospital services identified. There were 15 different combinations of prehospital blood products. 23/25 services had a standard operating procedure for the replacement of calcium. This was recommended before any blood product administration in 5 services (22%), during or after the 1st unit in 5 services (22%), during or after the 2nd unit in 6 services (26%) and during or after the 4th unit in 7 services (30%). Only six services carried point of care testing and no services routinely used this to measure calcium levels in patients requiring prehospital blood products. ConclusionIn 2022, 91% of UK air ambulances carry prehospital blood products and there is significant variation between services in the combination of blood products provided. There is no consensus on the timing or dose of calcium replacement. Further prospective research should examine the association between traumatic bleeding and ionized calcium levels before and during blood product transfusion in order to produce more robust guidelines for routine calcium replacement.

Correlation between Angiotensin Serum Levels and Very-Low-Frequency Spectral Power of Heart Rate Variability during Hemodialysis.

Cardiovascular regulatory mechanisms that fail to compensate for ultrafiltration and cause hypovolemia during hemodialysis (HD) are not completely understood. This includes the interaction between the autonomic nervous system and the biochemistry that regulates blood pressure and modulates cardiac activity and vascular tone in response to hypovolemia in patients treated with HD. The objective was to evaluate the association of spectral indices of heart rate variability (HRV) with serum levels of angiotensin II, angiotensin 1–7, nitric oxide and total antioxidant capacity during HD. Electrocardiographic records were obtained from 20 patients during HD (3 h), from which HRV data and spectral power data in the very-low-frequency (VLF), low-frequency (LF) and high-frequency (HF) bands were generated. Three blood samples per patient were collected during HD (0.0, 1.5, 3.0 h) to determine the levels of biomarkers involved in the pressor response during HD. Angiotensin II had a positive correlation with VLF (r = 0.390) and with LF/HF (r = 0.359) and a negative correlation with LF (r = −0.262) and HF (r = −0.383). There were no significant correlations between HRV and the other biomarkers. These results suggest that during HD, VLF could reflect the serum levels of angiotensin II, which may be associated with the autonomic response to HD.

Effects of experimental hypovolemia and pain on pre-ejection period and pulse transit time in healthy volunteers.

Trauma patients may suffer significant blood loss, and noninvasive methods to diagnose hypovolemia in these patients are needed. Physiologic effects of hypovolemia, aiming to maintain blood pressure, are largely mediated by increased sympathetic nervous activity. Trauma patients may however experience pain, which also increases sympathetic nervous activity, potentially confounding measures of hypovolemia. Elucidating the common and separate effects of the two stimuli on diagnostic methods is therefore important. Lower body negative pressure (LBNP) and cold pressor test (CPT) are experimental models of central hypovolemia and pain, respectively. In the present analysis, we explored the effects of LBNP and CPT on pre‐ejection period and pulse transit time, aiming to further elucidate the potential use of these variables in diagnosing hypovolemia in trauma patients. We exposed healthy volunteers to four experimental sequences with hypovolemia (LBNP 60 mmHg) or normovolemia (LBNP 0 mmHg) and pain (CPT) or no pain (sham) in a 2 × 2 fashion. We calculated pre‐ejection period and pulse transit time from ECG and ascending aortic blood velocity (suprasternal Doppler) and continuous noninvasive arterial pressure waveform (volume‐clamp method). Fourteen subjects were available for the current analyses. This experimental study found that pre‐ejection period increased with hypovolemia and remained unaltered with pain. Pulse transit time was reduced by pain and increased with hypovolemia. Thus, the direction of change in pulse transit time has the potential to distinguish hypovolemia and pain.

Effectiveness and safety of hypotension fluid resuscitation in traumatic hemorrhagic shock: A systematic review and meta-analysis of randomized controlled trials.

BackgroundAlthough the resuscitation of an adult trauma patient has been researched and written about for the past century, the ideal fluid strategy to infuse during the initial resuscitation period remains unresolved. This work was aimed at assessing the effect of hypotensive versus conventional resuscitation strategies in traumatic hemorrhagic shock patients on mortality, and the need for blood transfusions including adverse events.MethodsThis systematic review and meta-analysis were performed following the PRISMA guidelines. Electronic databases were searched for randomized controlled trials (RCT) comparing the effect of hypotension versus conventional fluid resuscitation for traumatic hemorrhagic shock patients. Two reviewers independently performed the screening, data extraction, and bias assessment. The data analysis was completed using the Cochrane Collaboration’s software RevMan 5.4.ResultsData from 28 RCTs on 4503 patients were included in the final meta-analysis. Patients receiving hypotension fluid resuscitation compared with conventional fluid resuscitation experienced less mortality (12.5% vs. 21.4%; RR = 0.58; 95% CI: 0.51–0.66; p < 0.001), fewer adverse events (10.8% vs. 13.4%; RR = 0.70; 95% CI: 0.59–0.83; p < 0.001), including fever acute respiratory distress syndrome (7.8% vs. 16.8%) or multiple organ dysfunction syndrome (8.6% vs. 21.6%).ConclusionsThis meta-analysis showed that hypotensive fluid resuscitation significantly reduced the mortality of hypovolemic shock patients. Findings are low in certainty and should be interpreted with caution. Therefore, there is an urgent need for larger, multicenter, randomized trials to confirm these findings.

Fluid-responsiveness, blood volume and perfusion in preoperative haemodynamic optimisation of hip fracture patients; a prospective observational study.

Preoperative resuscitation strategies in patients with hip fracture (HF) are lacking. We aimed to investigate fluid-responsiveness, peripheral perfusion index (PPI) and blood volume (BV)-status in patients with HF undergoing resuscitation in the preoperative phase. In a prospective observational study, we evaluated preoperative fluid-responsiveness, indices of perfusion and BV before and after lumbar epidural analgesia in 50 patients with HF shortly after admittance. Initially, 18 (36%) patients were fluid-responsive (≥10% increased SV in response to 250 ml fluid bolus) and 13 (26%) presented hypovolaemia (deviation of measured BV from estimated BV ≤ 0.9). According to fluid-responsiveness, no difference in absolute values of cardiac index (CI) (2.7L [2.1-3.3] vs. 2.8 L [2.3-3.4], p= .5) was seen, but cardiac output (CO) rose significantly in the hypovolaemic patients: 9% [5-18] vs. 1% [-3-7], p= .004. After epidural analgesia, 26 (52%) patients were again fluid-responsive and 15 (30%) were hypovolaemic. CI was now significantly lower in fluid-responsive patients (2.2L [1.7-2.7] vs. 2.9 L [2.3-3.5], p= .001). Prior to epidural analgesia, no significant trend towards hypovolaemic patients having lower indices of perfusion was seen. After epidural analgesia, more patients with hypovolaemia presented with PPI≤1.5 (8 (53%) vs. 3 (9%), p= .001) and absolute values of PPI were also significantly lower if IBV was low (1.4 [0.9-3.2] vs. 3.2 [2.4-4.8], p= .01). PPI correlated with hypovolaemia after epidural analgesia (rho 0.4 [0.1-0.7], p= .007). Preoperative fluid-responsivity in HF patients might be attributable to elements of hypovolaemia and sympathetic compensatory ability conjointly, confounding the use of SV-guided resuscitation. PPI could be associated with BV, which may support clinicians during perioperative haemodynamic optimisation.

Thiazide-associated hyponatremia in internal medicine patients: analysis of epidemiological and biochemical profiles

Thiazide-associated hyponatremia (TAH) is a clinically important side effect of the therapy with thiazide and thiazide-like diuretics. This study aims to analyze epidemiological, biochemical, and symptomatological profiles (including volume status) of patients admitted with TAH. A retrospective hospital record study was performed. Epidemiological and biochemical parameters and symptoms were compared between the thiazide (n = 143) and non-thiazide (n = 282) groups. Patients in the thiazide group were classified as hypo-, normo-, or hypervolemic. Furthermore, the comparison of epidemiological, biochemical, partially pharmacotherapeutical, and symptomatological parameters between the hypovolemic and normovolemic groups was performed. The thiazide group showed lower s-Na (p = 0.008), s-K (p <0.001), s-Cl (p <0.001), measured s-osmolality (p = 0.021), and eGFR (p <0.001); higher s-urea (p <0.001), s-creatinine (p = 0.023), s-glucose (p <0.001), u-osmolality (p = 0.012), u-Na (p <0.001), u-K (p = 0.023), and u-Cl (p <0.001). Patients using thiazide were older (p <0.001), more likely to be female (p = 0.011), and with symptoms corresponding more to chronic hyponatremia. Compared to the normovolemic group (n = 93; 65%), the hypovolemic patients (n = 47; 32.9%) showed higher s-urea (p = 0.005), s-creatinine (p = 0.045), and s-UA (p = 0.010); lower eGFR (p = 0.032), u-Na (p = 0.015), u-Cl (p = 0.016), anorexia (p <0.001), and a higher frequency of furosemide use (p <0.001). Thiazide use is a crucial etiological cause of hypotonic hyponatremia among internal medicine inpatients, associated with more severe hyponatremia, but with no difference in the in-hospital mortality. Even in hypo-osmolar conditions of TAH, 32.9% of patients exhibited signs of volume depletion. FE-UA did not differ between the hypovolemic and the normovolemic patients in TAH conditions. Anorexia and the combination of thiazide together with furosemide, rather than thiazide use alone, were risk factors for hypovolemic hyponatremia without affecting FE-UA.

Stroke volume variation as an index of fluid responsiveness can be impaired by mental stress.

Cardiac stroke volume variation (SVV) measurement is one of the techniques to detect fluid-responsive hypovolemia in patients under mechanical ventilation. There is an ongoing effort to apply SVV for this purpose also in conscious patients. However, the effect of mental stress often occurring in conscious patients as a potential confounding factor on SVV is not known. The aim of our study was to compare effect of simulated hypovolemia and mental stress on SVV in healthy volunteers in the context of potential confounders - breathing pattern, respiratory sinus arrhythmia magnitude and sex. We examined 102 young healthy volunteers (58 females), mean age 18.6 years. Finger arterial blood pressure was recorded by volume-clamp photoplethysmographic method (Finometer Pro, FMS, Amsterdam, Netherland). From the blood pressure curve, a built in ModelFlow algorithm calculated stroke volume values (SV) for each heartbeat. Respiratory volume was recorded using calibrated respiratory inductive plethysmography (RespiTrace, NIMS, Miami Beach, FL, USA). During four phases of examination protocol (supine rest, head-up tilt (HUT), supine recovery, mental arithmetic task (MA)) we analyzed SVV related to respiratory activity. While during HUT we found an expected increase in SVV together with mean SV decrease, SVV significantly decreased during MA. The observed changes during MA could be attributed to an increased respiratory rate and/or decreased respiratory sinus arrhythmia. Sex related differences in SVV responses to HUT and MA were observed. We conclude that mental stress together with respiratory sinus arrhythmia and respiratory pattern changes can significantly influence SVV as a potential index of fluid responsiveness in conscious patients.

Fluid resuscitation with guidance of pulse pressure variability measured by continuous non-invasive arterial pressure monitor in postoperative hypovolemic patients: a prospective randomized controlled trial

Fluid resuscitation with guidance of pulse pressure variability measured by continuous non-invasive arterial pressure monitor in postoperative hypovolemic patients: a prospective randomized controlled trial

Intensive care of acute hypovolemia in combination with chronic heart failure in patients with polytrauma without acute myocardial injury

The impact effect assessment of ethylmethylhydroxypyridine succinate on the energy efficiency of blood circulation in patients with polytrauma without traumatic myocardial injury during chronic heart failure. The state of blood circulation was studied in 66 patients with polytrauma without myocardial injury on the background of CHF. Troponin I levels in all patients did not exceed 0.3 ng/ml, and NT-proBNP – was above 100 pg/ml, which confirmed the presence of chronic heart failure. Patients has been divided into 2 groups. Group S (n=33) – patients receiving standard intensive care, group E (n=33) – patients who were additionally injected with ethylmethylhydroxypyridine succinate 600 mg/day during a week. NT-proBNP, hemodynamics, oxygen and energy budget within the admission, on the 3rd and 7th day were investigated. The indicators of the energy budget, estimated by the circulatory reserve (CR), has been improved in all patients. Upon admission and on the 3rd day, it was not differ between groups, on the 7th day the CR in groups C and E was accordingly 286±94 and 392±173 mW/m2 (p&lt;0.003). The level of NT-proBNP on the 7th day in groups C and E decreased to (109.1±8.5) and (65.8±23.3) pg/ml (p&lt;0.001). Chronic heart failure aggravates the course of acute hypovolemia in patients with polytrauma without myocardial damage. The main cause of aggravation of circulatory failure during polytrauma without traumatic myocardial damage is energy deficiency in the myocardium. Ethylmethylhydroxypyridine succinate reduces the myocardial energy requirement. The effect of ethylmethylhydroxypyridine succinate begins to develop after 3 days, reaching a maximum on the 7th day. Keywords: polytrauma, heart failure, NT-proBNP, ethylmethylhydroxypyridine succinate, energy of blood circulation.

English

BACKGROUND Stress response to intubation produces marked hemodynamic changes during direct laryngoscopy using muscle relaxants. Since attenuation of hemodynamic response to laryngoscopy and tracheal intubation leads to better outcomes, a method for providing good intubating conditions rapidly without using muscle relaxants is being sought. The objective of the present study was to compare the hemodynamic changes occurring while intubating with 2 different doses of propofol. METHODS We compared heart rate, systolic blood pressure, diastolic pressure and mean arterial pressure changes during tracheal intubation with 2 different propofol doses without using muscle relaxants. Intravenous fentanyl inhibits the sympathetic nervous response to direct laryngoscopy and tracheal intubation in both groups of patients and acts as pre-emptive analgesia. RESULTS Comparison of the hemodynamic parameters revealed no statistically significant differences between the low dose propofol (PL) and high dose propofol (PH) groups with regard to heart rate or blood pressure changes at similar intervals postintubation. Both patient groups showed blood pressure fall along with a reflex increase in heart rate at 1 minute to 5 minutes post-intubation, returning to nearbaseline values 10 minutes post-intubation. None of these changes was either clinically detrimental or produced incidents of desaturation or arrhythmias in any study patient. CONCLUSIONS Low dose propofol may be useful in elderly or mildly hypovolemic patients, intolerant to a higher drug dosage whereas, the higher propofol dose may be particularly useful in the adult with a higher muscle mass in situations where muscle relaxant is to be restricted or avoided. KEY WORDS Tracheal Intubation, Hemodynamic Changes, Different Doses Propofol.

Value of Urine Osmolality as a Monitoring Tool in Comparison with Central Venous Pressure in Resuscitation of Traumatic Hypovolemic Patients

Introduction: Hypovolemia is by far the commonest cause of shock and death in traumatic patients, results in multiple organ failure due to inadequate circulating volume and subsequent inadequate oxygen perfusion to organs and tissues. Fluid disturbance and resuscitation can be assessed and monitored by clinical observation by invasive or non-invasive method. One of the non-invasive methods is the urine osmolality an easy, and non-complicated method. Objective: Enhance the management of traumatic hypovolemic shock in emergency department through rapid evaluation of quantity and quality of hydration by a single physiological non-invasive method: the urine osmolality. Methods: This diagnostic cross-sectional comparative study was conducted in emergency department and randomly 40 patients with hypovolemic shock after severe major trauma during the preceding 8 hours according to the inclusion and exclusion criteria. Assessment is done according to primary survey for multiple trauma patient (ABCDE) approach. Results: The urine osmolality was significantly decreased during follow-up, from 1009±103.2 mOsm/kg H2O at admission to 759.8±69.1 mOsm/kg H2O at 8 hours (p&lt;0.0001), with about -25% change percent. The CVP was significantly increased during follow-up, from 5.0±1.9 cmH2O at admission to 8.7±2.6 cmH2O at 8 hours (p&lt;0.0001), with 74% change percent. There was significant intermediate correlation between urine osmolality and CVP of the studied population (r=0.36, p=0.025). Conclusion: Urine osmolality had good diagnostic values (86.0%) in comparison to CVP in monitoring resuscitation of traumatic hypovolemic patients.

English

BACKGROUND Oxytocin is a peptide hormone produced in the hypothalamus, stored, and released by the posterior pituitary. Oxytocin is commonly administered during caesarean section to minimise blood loss. It can cause hypotension, tachycardia, arrhythmias, and decrease in cardiac output and ST-T wave changes which may be deleterious in hypovolemic and high-risk cardiac patients. Cardiovascular effects of oxytocin have not been well investigated. The purpose of this study was to determine the cardiovascular effects of oxytocin (5U) administered as rapid intravenous infusion over 1 minute followed by a maintenance infusion of 10U, study other adverse effects of oxytocin, assess uterine tone and the need for additional uterotonics and also assess the blood loss. We also wanted to maintain adequate uterine contractility to minimise blood loss and prevent post partum haemorrhage and also know if the cardiovascular effects of oxytocin could be tolerated by normal parturients. METHODS This is a prospective study. Hundred parturients undergoing elective caesarean delivery, under spinal anaesthesia were given 5U of oxytocin as rapid intravenous infusion over 1 minute followed by a 10U maintenance intravenous infusion. Intraoperative heart rate, non-invasive blood pressure (NIBP) and continuous electrocardiograph (ECG) changes were noted. Patients were observed for other adverse effects like chest pain, dysrhythmias, nausea, vomiting and generalised flushing. Uterine tone and the need for additional uterotonics were assessed. RESULTS Tachycardia was observed for the initial 2 minutes after oxytocin bolus which returned to the baseline values within 15 minutes. Diastolic blood pressure (12.7 %) and mean arterial pressure (9.6 %) showed greater fall than systolic blood pressure (5.9 %) due to the effects of oxytocin. Among the 100 parturients, one parturient complained of chest pain which developed during oxytocin bolus and subsided after 2 minutes, one had ST depression and another one developed atrial arrhythmias. CONCLUSIONS It can be inferred that oxytocin in the dose studied is safe in parturients who are normovolemic and without cardiac risk factors. It is effective in achieving adequate uterine tone and reducing blood loss. KEY WORDS Oxytocin, Cardiovascular Effects, Caesarean Section, Uterine Tone

Effect of Woolen Cloth to Maintain Temperature 39°C of Crystaloid Fluid Ringer Lactate at Room Temperature 18°C

Fluid resuscitation with 39ᵒC is one of the main therapies for hypovolemic (hemorrhagic) shock patients to prevent complications. In this time, we already have tools to keep the fluid warm, but not all health services have these tools. To find out the effectiveness of using woolen cloth against the temperature of Ringer Lactate 39°C crystalloid fluid at room temperature 18°C. This study used a pre-experimental method, with a static group comparison approach, with 4 Ringer Lactate liquid samples divided into 2 groups, namely groups using wool cloth and those not using woolen cloth. Data collected through observation sheets. Data analyzed using the Mann Whitney test. With this p value (0.00001) &lt;α (0.05), it can be concluded that there is a significant difference between the use of woolen cloth and those that do not use woolen cloth. The woolen cloth is effective to slow down the decrease in temperature of the crystalloid liquid Ringer Lactate 39ᵒC at room temperature 18ᵒC. The difference in temperature changes in the Ringer Lactate crystalloid fluid is influenced by several things including humidity, ambient temperature, and additional material used.

Use of loop diuretics in chronic heart failure: do we adhere to the Hippocratian principle 'do no harm'?

Use of loop diuretics in chronic heart failure: do we adhere to the Hippocratian principle 'do no harm'?

Effects of positive end-expiratory pressure on the predictability of fluid responsiveness in acute respiratory distress syndrome patients

The prediction accuracy of pulse pressure variation (PPV) for fluid responsiveness was suggested to be unreliable in low tidal volume (VT) ventilation. However, high PEEP can cause ARDS patients relatively hypovolemic and more fluid responsive. We hypothesized that high PEEP 15 cmH2O can offset the disadvantage of low VT and improve the predictive performance of PPV. We prospectively enrolled 27 hypovolemic ARDS patients ventilated with low VT 6 ml/kg and three levels of PEEP (5, 10, 15 cmH2O) randomly. Each stage lasted for at least 5 min to allow for equilibration of hemodynamics and pulmonary mechanics. Then, fluid expansion was given with 500 ml hydroxyethyl starch (Voluven 130/70). The hemodynamics and PPV were automatically measured with a PiCCO2 monitor. The PPV values were significantly higher during PEEP15 than those during PEEP5 and PEEP10. PPV during PEEP15 precisely predicts fluid responsiveness with a cutoff value 8.8% and AUC (area under the ROC curve) of ROC (receiver operating characteristic curve) 0.847, higher than the AUC during PEEP5 (0.81) and PEEP10 (0.668). Normalizing PPV with driving pressure (PPV/Driving-P) increased the AUC of PPV to 0.875 during PEEP15. In conclusions, high PEEP 15 cmH2O can counteract the drawback of low VT and preserve the predicting accuracy of PPV in ARDS patients.

Physiology of Human Hemorrhage and Compensation.

Hemorrhage is a leading cause of death following traumatic injuries in the United States. Much of the previous work in assessing the physiology and pathophysiology underlying blood loss has focused on descriptive measures of hemodynamic responses such as blood pressure, cardiac output, stroke volume, heart rate, and vascular resistance as indicators of changes in organ perfusion. More recent work has shifted the focus toward understanding mechanisms of compensation for reduced systemic delivery and cellular utilization of oxygen as a more comprehensive approach to understanding the complex physiologic changes that occur following and during blood loss. In this article, we begin with applying dimensional analysis for comparison of animal models, and progress to descriptions of various physiological consequences of hemorrhage. We then introduce the complementary side of compensation by detailing the complexity and integration of various compensatory mechanisms that are activated from the initiation of hemorrhage and serve to maintain adequate vital organ perfusion and hemodynamic stability in the scenario of reduced systemic delivery of oxygen until the onset of hemodynamic decompensation. New data are introduced that challenge legacy concepts related to mechanisms that underlie baroreflex functions and provide novel insights into the measurement of the integrated response of compensation to central hypovolemia known as the compensatory reserve. The impact of demographic and environmental factors on tolerance to hemorrhage is also reviewed. Finally, we describe how understanding the physiology of compensation can be translated to applications for early assessment of the clinical status and accurate triage of hypovolemic and hypotensive patients. © 2021 American Physiological Society. Compr Physiol 11:1531-1574, 2021.

Fluid Therapy During Cardiopulmonary Resuscitation

Cardiopulmonary arrest (CPA), the acute cessation of blood flow and ventilation, is fatal if left untreated. Cardiopulmonary resuscitation (CPR) is targeted at restoring oxygen delivery to tissues to mitigate ischemic injury and to provide energy substrate to the tissues in order to achieve return of spontaneous circulation (ROSC). In addition to basic life support (BLS), targeted at replacing the mechanical aspects of circulation and ventilation, adjunctive advanced life support (ALS) interventions, such as intravenous fluid therapy, can improve the likelihood of ROSC depending on the specific characteristics of the patient. In hypovolemic patients with CPA, intravenous fluid boluses to improve preload and cardiac output are likely beneficial, and the use of hypertonic saline may confer additional neuroprotective effects. However, in euvolemic patients, isotonic or hypertonic crystalloid boluses may be detrimental due to decreased tissue blood flow caused by compromised tissue perfusion pressures. Synthetic colloids have not been shown to be beneficial in patients in CPA, and given their documented potential for harm, they are not recommended. Patients with documented electrolyte abnormalities such as hypokalemia or hyperkalemia benefit from therapy targeted at those disturbances, and patients with CPA induced by lipid soluble toxins may benefit from intravenous lipid emulsion therapy. Patients with prolonged CPA that have developed significant acidemia may benefit from intravenous buffer therapy, but patients with acute CPA may be harmed by buffers. In general, ALS fluid therapies should be used only if specific indications are present in the individual patient.

Role of lung ultrasound in assessment of endpoint of fluid therapy in patients with hypovolemic shock

ABSTRACT Background: Different techniques are employed to assess the endpoint of fluid therapy in hypovolemic patients. Lung ultrasound (US) is increasingly becoming a diagnostic tool in the critical care setting, providing standardized data. The present study aimed to evaluate the role of lung US in comparison to central venous pressure (CVP) in assessment of endpoint of fluid therapy in patients with hypovolemic shock. Patients and methods: Observational cross-sectional study carried in 60 adult patients with hypovolemic shock admitted to the intensive care unit received lactated Ringer’s solution. CVP, blood pressure (BP), urine output (UOP), and lung US score were recorded on admission and during the period of resuscitation. Lung US score was correlated with CVP, BP, and UOP and evaluated in assessment of endpoint fluid therapy in comparison to CVP as a gold standard. Results: There was a significant increase in CVP, BP, UOP,and lung US score during fluid resuscitation. Lung US showed a significant positive correlation with CVP, BP, and UOP at different stages of fluid resuscitation. Lung US score showed a sensitivity of 95.7%, specificity of 92.9% with a positive predictive value of 97.8% negative predictive value of 86.7%, and the total accuracy was 95%. Conclusion: Lung US provides a simple noninvasive approach in assessment of endpoint (score ≥16) of fluid therapy in patients with hypovolemic shock with high sensitivity and specificity.

Bioreactance and Apelin in the Management of Severe Hyponatremia

Hyponatremia is a severe electrolyte disturbance associated with substantial morbidity and mortality. It often poses a diagnostic and therapeutic challenge. Accurate assessment of patient fluid-volume status is central to effective management. This pilot study aimed to evaluate the usefulness of the Cheetah NICOM bioreactance system and apelin in early differentiation between hypo- and euvolemia in patients with severe hyponatremia. Methods: Patients > 50 years of age with a serum sodium ≤ 125 mmol/L were eligible for inclusion after written informed consent. Blood- and urine analyses of cardiovascular load (NT-proBNP), osmotic stress (copeptin, apelin, osmolality, sodium), mineralocorticoid status (aldosterone, renin) and sympathetic activity (methoxycathecholamines) were analysed at baseline and after isotonic sodium chloride infusion. Bedside bioreactance examination was used to visualise parameters, including stroke volume before and after passive leg raise test. Classification of volume status was made retrospectively blinded for biomarker and bioreactance results. Results: 8 patients (4 hypovolemic and 4 euvolemic), 79 years old, median plasma sodium 120 mmol/L were included. At the Emergency Department volume status was misclassified in all hypo- and in 2 of 4 euvolemic patients. Apelin was significantly higher in hypovolemic patients ((299 vs. 175 ng/ml), p = 0.021). All hypovolemic, but none of the euvolemic, patients had a level above 250 ng/ml. Copeptin did not differ between groups. All patients in the hypovolemic group increased their stroke volume after passive leg raise. Conclusions: Apelin seems to be a promising future biomarker in the early management of severe hyponatremia. Bioreactance measurements may offer a supplement to bedside evaluation of volume status.

Hospital Risk Factors Affecting Mortality and Morbidity in Polytraumatized Patients and Their Outcome

Background: Trauma is the leading cause of mortality among young individuals worldwide. Brain trauma and massive bleeding are the most severe complications of poly trauma. Another important complication is aspiration pneumonia that requires early detection and management. Objectives: The aim of the work was to assess the intra hospital risk factors namely aspiration pneumonia and hypovolemic shock that affecting mortality and morbidity in polytraumatized patients and their outcome as regards hospital mortality and length of stay. Patient and Method: This study was conducted on 56 polytrauma patients attending at Al-Azhar University Emergency Hospital, Damietta from November 2018 to October 2019. They were divided into two groups: patients with hypovolemic shock group and patients with aspiration pneumonia group. Furthermore, they were divided into survivors and non survivors groups. All patients subjected to resuscitation and stabilization, history taking, examination and laboratory and radiological investigations. Results: Hypovolemic shock and aspiration pneumonia showed statistically significant differences between both groups as regards mode of admission and duration till hospital arrival with a higher percentage of patients admitted after ER resuscitation or arriving early to hospital developing hypovolemic shock. While as, those patients admitted directly to ICU or arriving late to hospital developing aspiration pneumonia. The mortality rate in this study was 23.2% among poly trauma patients. Comparison between survivors and non-survivors revealed that older age had higher incidence of mortality in poly trauma patients. Conclusion: It could be concluded that aspiration pneumonia and hypovolemic shock were good predictors for morbidity and mortality in polytrauma.