Intravenous Crystalloid Fluids Research Articles

Acute kidney injury and hypercalcemia associated with veterinary supplements applications in adult man

The compound “ADE” is an injectable oil for veterinary use which contains large amounts of vitamins A, D and E. The parenteral application in humans leads to a granuloma reaction which triggers hypercalcemia. A 42-year-old man was admitted with lower limb pain, nephrolithiasis and nephrocalcinosis. Laboratory tests revealed creatinine 4.59 mg/dl, calcium 13.3 mg/dl and parathormone 13.8 pg/ml. He underwent an ureterolithotripsy, stent placement, intravenous crystalloid fluids, and corticosteroid. He improved symptoms, kidney function and normalized serum calcium. The “ADE”-induced hypercalcemia diagnosis can be challenging. The early diagnosis may avoid negative outcomes.

Implementing E-MOTIVE for detection and treatment of postpartum haemorrhage in South Africa.

Postpartum haemorrhage is the leading cause of preventable maternal mortality in South Africa. In a significant breakthrough in the management of PPH, the E-MOTIVE trial found that a multifaceted health service intervention reduced severe PPH after vaginal delivery by 60% in 78 hospitals in Nigeria, Kenya, Tanzania and SA. The E-MOTIVE approach comprises objective blood loss measurement monitored every 15 minutes during the first hour after delivery to detect PPH early and trigger a bundle of first-line treatments, including massaging the uterus, oxytocin infusion, tranexamic acid infusion, intravenous crystalloid fluids, examination for the cause, emptying the bladder and, if necessary, escalation of care. E-MOTIVE was integrated into the existing Essential Steps in Managing Obstetric Emergencies algorithm. Certain research-related elements of the trial setting cannot be replicated in routine practice. Therefore, we need to develop local strategies to ensure the essential clinical elements of the intervention are implemented. Potential strategies include incorporating the E-MOTIVE principles into national guidelines, ongoing training strategies and ensuring all facilities are equipped with necessary medication, equipment and delegations. This breakthrough intervention provides hope for women in SA, and requires a purposeful, co-ordinated implementation strategy on a national scale to reach all levels of the health service.

New Insights into the Fluid Management in Patients with Septic Shock.

The importance of fluid resuscitation therapy during the early stages of sepsis management is a well-established principle. Current Surviving Sepsis Campaign (SSC) guidelines recommend the early administration of intravenous crystalloid fluids for sepsis-related hypotension or hyperlactatemia due to tissue hypoperfusion, within the first 3 h of resuscitation and suggest using balanced solutions (BSs) instead of normal saline (NS) for the management of patients with sepsis or septic shock. Studies comparing BS versus NS administration in septic patients have demonstrated that BSs are associated with better outcomes including decreased mortality. After initial resuscitation, fluid administration has to be judicious in order to avoid fluid overload, which has been associated with increased mortality, prolonged mechanical ventilation, and worsening of acute kidney injury. The "one size fits all" approach may be "convenient" but it should be avoided. Personalized fluid management, based on patient-specific hemodynamic indices, provides the foundations for better patient outcomes in the future. Although there is a consensus on the need for adequate fluid therapy in sepsis, the type, the amount of administered fluids, and the ideal fluid resuscitation strategy remain elusive. Well-designed large randomized controlled trials are certainly needed to compare fluid choices specifically in the septic patient, as there is currently limited evidence of low quality. This review aims to summarize the physiologic principles and current scientific evidence regarding fluid management in patients with sepsis, as well as to provide a comprehensive overview of the latest data on the optimal fluid administration strategy in sepsis.

Protocolo terapéutico empírico de la sepsis

A group of measures has demonstrated to be very effective in reducing the high mortality of sepsis. First-line actions involve a practically immediate approach to a septic patient and include monitoring, evaluation of the source, extraction of blood cultures, adequate empirical antibiotic therapy in the first hour, and infusion of at least 30ml/kg of intravenous crystalloid fluids within the first three hours at the same time that determination of lactate, procalcitonin, and other analytical parameters is performed in order to quantifying organ damage. After the initial approach are second-line actions, in which control of the source of the infection must be proposed if necessary, reevaluating the presence of septic shock (need for vasopressors and lactate clearance), and considering the suitability of certain techniques (renal replacement therapy or ventilatory support) which in turn will determine ICU admission.

Hyperhemolysis Syndrome in SCD Patient: Reminder of a Rare but Life-Threatening Complication of Blood Transfusion

Background: Sickle cell disease (SCD) patients are at risk of developing multiple complications from transfusions, including alloimmunization to red blood cell (RBC) antigens, delayed hemolytic transfusion reactions, and hyperhemolysis syndrome (HS). HS is a serious complication of transfusion characterized by the destruction of both transfused and autologous RBCs with resulting severe anemia and post transfusion hemoglobin lower than pretransfusion levels. We report the case of a middle age female patient with known SCD who developed severe HS following a blood transfusion. We aim to remind physicians of the importance of conservative blood transfusions in SCD patients in order to avoid serious transfusion-related complications.Case report: A 57-year-old African American patient, with known history of SCD who was doing well with a baseline hemoglobin (Hgb) of 6-7 g/dl. Transfusion history included 4 units of Packed Red Blood Cell (PRBC) during the 5 years prior to this presentation, all of which for mild, non-resolving vaso-occlusive pain crisis. Her most recent transfusion was 7 days prior to her presentation, she received 1 unit of PRBC for a Hgb level of 6.3 g/dl, associated with mild musculoskeletal pain and fatigue. She presented to the Emergency Department 4 days later with worsening fatigue, decreased oral intake and dark urine. On presentation, she was normotensive, afebrile and mildly tachycardic. She had increasing oxygen requirements to maintain O2 saturation above 94%. Her blood work showed a Hgb of 2.8 g/dl (12-15 g/dL), hematocrit 8.3 % (36-46 %), RBC count 0.87 M/uL (4.15-5.55 M/uL), Mean Corpuscular Volume 95.5 fl (80-100 fl), elevated White Cell Count at 28.4 K/uL (3.8-10.6 K/uL), and platelet count 125 K/uL (150-450 K/uL). Hemolysis labs showed low haptoglobin of < 30 mg/dl (30-200 mg/dl), elevated Lactate Dehydrogenase at 3420 IU/L (< 250 IU/L), total bilirubin 2.7 mg/dl (< 1.2 mg/dl), direct bilirubin 0.6 mg/dl (0-0.3 mg/dl), and reticulocyte count 3.5% (0.5-1.5 %; reticulocytopenia relative to degree of anemia). A disseminated intravascular coagulation (DIC) panel showed fibrinogen of 263 mg/dL (200-450 mg/dL), D-dimer greater than 20 ug/mL (< 0.50 ug/ml), prothrombin time of 19.8 seconds (s) (11.5-14.5 s), and partial thromboplastin time of 32 s (22-36 s). High sensitivity troponin was elevated at 650 ng/L (< 19 ng/L). Antibody screen and direct antiglobulin test (DAT) were negative. Peripheral blood smear showed severe anemia with marked anisopoikilocytosis including numerous blister cells, occasional sickle cells and numerous nucleated red blood cells. The recent history of blood transfusion and the current laboratory workup were consistent with HS.Patient was admitted to the intensive care unit (ICU) for management; she initially received 1g intravenous iron dextran and intravenous immunoglobulin (IVIG) 0.4 g/kg for 5 days. She was also started on erythropoietin, folic acid, and vitamin B12. Her reticulocyte count improved to 19%. Given no improvement in Hgb levels, systemic steroids were started after ruling out infectious etiologies. She initially received methylprednisolone 125mg daily for 2 days, followed by oral prednisone 60mg daily for 7 days. Patient had increased oxygen requirements during admission, had an elevated lactate to 4 mmol/L, and had a drop in Hgb to 2.1 g/dL. She was still managed conservatively with oxygen supplementation and intravenous crystalloid fluids. The decision was to avoid transfusions unless they were life-saving. Patient remained in the ICU unit for 5 days, then was transferred to the hematology floor where she remained hospitalized for 7 days. Oxygen requirements and patient's symptoms steadily improved, hemolysis labs trended down, and reticulocyte count improved. Hgb levels improved gradually to highest of 5.7 g/dl prior to discharge. Patient was then discharged to follow up with her hematologist in the outpatient setting.Conclusion: This case aims to highlight the importance of early recognition of HS to avoid wrong management with RBC transfusion. Our patient had severe anemia and was managed with transfusion-free approach with good outcome. This case is also meant to remind physicians of the importance of conservative blood transfusions in SCD patients in order to avoid serious and life-threatening transfusion-related complications. DisclosuresNo relevant conflicts of interest to declare.

Crystalloids and colloids

Administration of intravenous fluid is like giving drugs, in that they have both beneficial and harmful effects. The composition of intravenous crystalloid and colloid fluids used for resuscitation is described in detail. The use of fluids for intravascular volume replacement is discussed as well as some of the controversies of this in haemorrhagic shock and septic shock.

Certification Is for You ….

Certification Is for You ….

Variations in the management of diarrhoea induced by cancer therapy: results from an international, cross-sectional survey among European oncologists

BackgroundChemotherapy-induced diarrhoea (CID) is a common side effect of cancer treatment. While cytotoxic agents are the main cause of CID, targeted drugs, immunotherapy and radiotherapy can also cause diarrhoea. Patients with severe CID often require hospital admission for intravenous fluid resuscitation and supportive treatment. In other patient populations, such as children with infectious diarrhoea, therapy is based on evidence from randomised-controlled clinical trials. In contrast, few trials have investigated CID management, and hence, treatment guidelines are largely based on expert opinion.MethodsWe conducted an online survey on CID management and institutional routines across Europe to obtain a more detailed picture of current practice in CID treatment. We analysed the responses from a total of 156 clinicians from 83 different medical centres in 31 countries.ResultsCID (any grade) is recognised as a common clinical problem in patients undergoing antitumoral treatment and it can require hospital admission in a substantial subgroup of patients. There is a strong consensus among clinicians as to the choice of resuscitation strategies and drug treatment for severe CID; 85.9% (n=134) of all respondents prefer intravenous crystalloid fluids and 95.5% (n=149) routinely use loperamide. In sharp contrast, we have identified disparities in the use of bowel rest in CID; approximately half of all participants (57.7%; n=90) consider bowel rest in initial CID management, while the remainder (42.3%; n=66) does not.ConclusionsAs previous studies have shown that bowel rest is associated with adverse outcomes in diarrhoea due to causes other than chemotherapy, the results from this survey suggest that further research is needed as to its role in CID.

The Impact of Early Identification and a Critical Care-Based Sepsis Response Team on Sepsis Outcomes.

The Impact of Early Identification and a Critical Care-Based Sepsis Response Team on Sepsis Outcomes.

Perioperative trends in plasma colloid osmotic pressure in horses undergoing surgery.

To compare perioperative trends in plasma colloid osmotic pressure (COP) between horses undergoing orthopedic and colic surgery. Prospective clinical study September 2009-January 2011. Veterinary university teaching hospital. Thirty-three healthy, client-owned horses presenting for orthopedic surgery (non-GI) and 85 client-owned horses presenting for emergency exploratory celiotomy (GI, gastrointestinal). None. Data relating to the horse's parameters on presentation, surgical lesion, post-operative management and survival were extracted from computerized clinical records. Heparinized blood samples were taken on presentation (PreOp, pre-operative), on recovery from anesthesia (T0), at 12 (T12) and 24 (T24) hours post recovery. COP was measured within 4 hours of collection. There was no significant difference in PreOp or T0 COP between groups. Both groups had a significant decrease in COP during anesthesia. When compared to their respective pre-operative values, horses in the non-GI group had significantly increased COP at T12, whereas those in the GI group had significantly reduced COP. This trend was continued at T24. Horses in the GI group placed on intravenous crystalloid isotonic fluids post-operatively had a significantly lower COP at T12 and T24. Horses in the GI group that did not survive had significantly lower post-operative COP values at T24. Horses undergoing exploratory celiotomy had significantly lower COP post-operatively than those horses undergoing orthopedic surgery. This difference was more marked in those horses receiving isotonic crystalloid intravenous fluid therapy post-operatively and in those that did not survive to discharge. In the non-GI group an increase in COP post-operatively was common.

Prehospital intravenous fluid is associated with increased survival in trauma patients

Delivery of intravenous crystalloid fluids (IVF) remains a tradition-based priority during prehospital resuscitation of trauma patients. Hypotensive and targeted resuscitation algorithms have been shown to improve patient outcomes. We hypothesized that receiving any prehospital IVF is associated with increased survival in trauma patients compared with receiving no prehospital IVF. Prospective data from 10 Level 1 trauma centers were collected. Patient demographics, prehospital IVF volume, prehospital and emergency department vital signs, lifesaving interventions, laboratory values, outcomes, and complications were collected and analyzed. Patients who did or did not receive prehospital IVF were compared. Tests for nonparametric data were used to assess significant differences between groups (p ≤ 0.05). Cox regression analyses were performed to determine the independent influence of IVF on outcome and complications. The study population consisted of 1,245 trauma patients; 45 were excluded owing to incomplete data; 84% (n = 1,009) received prehospital IVF, and 16% (n = 191) did not. There was no difference between the groups with respect to sex, age, and Injury Severity Score (ISS). The on-scene systolic blood pressure was lower in the IVF group (110 mm Hg vs. 100 mm Hg, p < 0.04) and did not change significantly after IVF, measured at emergency department admission (110 mm Hg vs. 105 mm Hg, p = 0.05). Hematocrit/hemoglobin, fibrinogen, and platelets were lower (p < 0.05), and prothrombin time/international normalized ratio and partial thromboplastin time were higher (p < 0.001) in the IVF group. The IVF group received a median fluid volume of 700 mL (interquartile range, 300-1,300). The Cox regression revealed that prehospital fluid administration was associated with increased survival (hazard ratio, 0.84; 95% confidence interval, 0.72-0.98; p = 0.03). Site differences in ISS and fluid volumes were demonstrated (p < 0.001). Prehospital IVF volumes commonly used by PRospective Observational Multicenter Massive Transfusion Study (PROMMTT) investigators do not result in increased systolic blood pressure but are associated with decreased in-hospital mortality in trauma patients compared with patients who did not receive prehospital IVF.

Neuronal Ceroid Lipofuscinosis in a Mallard Duck (Anas platyrhynchos)

A 3-year-old male, hybrid mallard duck (Anas platyrhynchos) was presented with a 2-year history of progressive, ascending paresis and paralysis. On presentation, the bird was in sternal recumbency and displayed intermittent focal seizures and intention tremors. Proprioceptive deficits and absent withdrawal reflexes were observed in both pelvic limbs, wing extension was limited, and reflexes were diminished bilaterally. Other findings included emaciation and dehydration. Results of a complete blood count and plasma biochemical analysis revealed anemia, hypoproteinemia, hypoglycemia, and hyperuricemia. Radiographs were unremarkable and results of an Aspergillus antibody were weakly positive. The duck went into cardiopulmonary arrest and died approximately 1 hour after initiating treatment with intravenous crystalloid fluids. A postmortem diagnosis of neuronal ceroid lipofuscinosis (NCL) was made based on the presence of neuronal granular cytoplasmic material that was autofluorescent and stained with periodic acid-Schiff and Luxol fast blue. To our knowledge, this is only the second case report of NCL in an avian species and the first in waterfowl.

Clinical Benefits After the Implementation of a Protocol of Restricted Perioperative Intravenous Crystalloid Fluids in Major Abdominal Operations

Clinical Benefits After the Implementation of a Protocol of Restricted Perioperative Intravenous Crystalloid Fluids in Major Abdominal Operations

A Case of Resistant Hypercalcemia of Malignancy with a Proposed Treatment Algorithm

To report and describe a case of refractory hypercalcemia of malignancy (HCM) associated with metastatic, transitional-cell carcinoma of the left ureter. A 71-year-old male complaining of generalized weakness and night sweats for the past 3 months was sent to the emergency department when routine laboratory tests revealed a corrected serum calcium concentration of 14.4 mg/dL. Intravenous crystalloid fluids and pamidronate were administered with achievement of normocalcemia, and the patient was discharged. Computed tomography scan and liver biopsy revealed recurrent transitional-cell carcinoma with extensive liver metastasis. The patient returned approximately 1 week after discharge with a serum calcium level of 13.9 mg/dL. An initial decrease in serum calcium was observed with intravenous fluids, pamidronate, and calcitonin, but the normalization slowed and reversed within 3 days. Normocalcemia was achieved upon administration of zoledronic acid and the patient was discharged on day 14. The patient died 1 week after discharge from complications unrelated to hypercalcemia. Hypercalcemia is common in patients with malignancy and is associated with potentially life-threatening sequelae. Four mechanisms of HCM have been recognized thus far, with ectopic tumor production of parathyroid hormone-related protein (PTHrP) being the leading cause. Treatment of HCM revolves around 2 principles: treatment of the underlying malignancy along with reduction of the serum calcium level. Evidence-based therapies for management include: intravenous crystalloid fluids with or without loop diuretics, bisphosphonates, calcitonin, gallium nitrate, and corticosteroids. Therapies used for this patient included aggressive hydration, calcitonin, and 3 distinct treatment courses of intravenous bisphosphonates with varying success. Other potential agents were explored for use in the event of continued hypercalcemia. These therapies remain viable options based on individual patient factors. To our knowledge, no published guidelines or algorithms exist for choosing between additional modalities in the treatment of refractory HCM. For patients with HCM who do not achieve a response from bisphosphonates, or for those who need repeated dosing more often than expected, changing to a different drug class could be an alternative. The specific mechanism of hypercalcemia should be considered when developing a treatment regimen for patients who have had a suboptimal response to initial therapy with bisphosphonates. Multiple treatment modalities exist for the treatment of hypercalcemia, each with a different mechanism of action. As with the treatment of other disease states, we can use this knowledge to more specifically target the mechanism of the patient's disease.

Clinical Benefits After the Implementation of a Protocol of Restricted Perioperative Intravenous Crystalloid Fluids in Major Abdominal Operations

Perioperative fluid replacement is a challenging issue in surgical care. The purpose of the present study was to investigate the effect of two different perioperative hydration protocols on the outcome in patients undergoing major abdominal operations. This was a prospective study involving 61 patients (42 men/19 women; mean age: 52 years; age range: 18-81 years) who underwent major abdominal operations. The study had two distinct phases: before (conventional group; administered 30-50 ml/kg per day of crystalloid fluids; n = 33) and after the implementation of a protocol of restricted use of intravenous fluids (restricted group; administered less than 30 ml/kg per day of crystalloid fluids; n = 28). The total volume of intravenous crystalloid fluids infused was recorded until postoperative day (POD) 4. Morbidity, mortality, and the length of postoperative hospital stay were the main clinical variables. Mortality was 4.9% (p > 0.05 between groups). Intravenous therapy in the restricted group was terminated earlier (p < 0.001) and the patients received 2.4 l less crystalloid fluid than did those in the conventional group from POD 1 through POD 4 (p < 0.001). The adoption of the restricted protocol shortened the postoperative hospital stay by 2 days (p = 0.02) and diminished the morbidity by 25% (p = 0.04). Restriction of perioperative intravenous crystalloid fluid is associated with reductions in morbidity and length of postoperative hospital stay after major abdominal operations.

The admission of patients with pneumonia directly from the Emergency Department to Hospital in the Home.

Acute respiratory infection is often the commonest reason for patients to be admitted to hospital from the Emergency Department (ED). Hospital in the Home Units (HHUs) deliver acute hospital type care to patients at home. This study sought to review the safety and effectiveness of HHU care for patients with pneumonia referred directly from an ED to a HHU using standard selection criteria. A retrospective clinical audit of all patients with acute pneumonia referred from the ED to the HHU from March 2000 to March 2002. 45 episodes in 44 patients were identified. 19 patients were female and the mean age was 53 years. Seven (15.6%) patients were residents of nursing homes.In 23 (51.1%) episodes, patients had presented to ED already taking oral antibiotics for their current condition. In 30 patients, significant co-morbidities were identified.The mean temperature on presentation was 37.7° Centigrade. The range of oxygen saturation was 89-100%, with a mean of 95%. Positive chest xray findings were reported in 41 (91.1%) of 45 episodes. In 9 (20%) cases an effusion was also reported.Length of stay ranged from 1-20 days with a mean of 6.2 days. In all 45 episodes, patients were treated with ceftriaxone. Adjuvant oral therapy was initiated in 28 episodes. Other adjuvant therapy was initiated at admission: nebulised salbutamol (7); oral prednisolone (1).Intravenous crystalloid fluids were required at home for rehydration in 2 episodes. Antibiotic therapy was altered in two cases. Oral prednisolone was commenced in 4 episodes, nebulised salbutamol commenced in 7 episodes, and fluconazole and frusemide were each commenced in a single episode.In three cases the primary discharge diagnosis was not related to respiratory infection.In 5 episodes (11.1%), patients made an unplanned telephone call to HHU staff. In 4 (8.9%) episodes, an unplanned staff visit was required. One patient required a return to hospital to complete her inpatient treatment. Two patients were readmitted within 1 month of discharge from EHHU. Patients who present to EDs with respiratory infection requiring intravenous therapy may be safely referred directly into Hospital in the Home care.

The use of ultrapurified bovine hemoglobin solution in the treatment of two cases of presumed red maple toxicosis in a miniature horse and a pony

AbstractObjective: To report the use of ultrapurified bovine hemoglobin (PBHg) in the treatment of red maple toxicosis in horses.Summary: The use of PBHg in a miniature horse and a pony with clinical signs of red maple toxicosis is described. Initial treatment of the horses included blood transfusion in Case 1, and intravenous crystalloid fluids, nasogastrically administered mineral oil, and activated charcoal in both cases. Both cases received PBHg (16 and 11 ml/kg, respectively) when the hematocrit dropped below 10%. Clinical stabilization of the horses (reflected by improved vital signs and mucous membrane color, increase in PvO2, and increase in plasma hemoglobin) was temporary, lasting 12 and 42 hours, respectively. A whole blood transfusion was given 16 hours after the infusion of PBHg in Case 1 and 42 hours after the infusion of PBHg in Case 2. The horses were discharged on days 15 and 17, respectively. Both were stable on discharge and were reported to be doing well 1 month after discharge. New information provided: Ultrapurified bovine hemoglobin is shown to be safe in the treatment of red maple toxicosis. Ultrapurified bovine hemoglobin infusion resulted in temporary improvement in oxygen (O2) delivery as assessed by clinical and laboratory parameters. The use of PBHg may provide an ‘oxygen bridge’ in an acute hemolytic crisis in the horse. It may allow additional time in the treatment of red maple toxicity for the acute hemolysis to subside and for metabolism of the toxin to occur, thus providing a more optimal environment for an effective whole blood transfusion.