Intravenous Fluid Hydration Research Articles

Hemophagocytic Syndrome in an Adolescent With Crohn Disease Receiving Azathioprine and Infliximab

Hemophagocytic Syndrome in an Adolescent With Crohn Disease Receiving Azathioprine and Infliximab

Is Fluid Therapy Associated With Cerebral Edema in Children With Diabetic Ketoacidosis?

Diabetic ketoacidosis is the most common cause of morbidity and mortality in children with type I diabetes mellitus, and cerebral edema is the leading cause of pediatric diabetic ketoacidosis death. Excessive intravenous fluid administration has been implicated as a cause of cerebral edema. We perform an evidence-based emergency medicine review assessing the association of intravenous fluid hydration and cerebral edema. We searched MEDLINE and EMBASE for comparative studies. Because of the low incidence of cerebral edema, we included observational studies in our review. We sought studies including patients younger than 18 years and with diabetic ketoacidosis. We defined cerebral edema, using clinical, radiographic, pathologic criteria, or treatment for intracranial pressure. Three studies met criteria for this review, of which 2 used fluid volume/body weight per unit of time, and the third measured cumulative total volume during hourly periods. The first 2 studies showed no statistically significant association between intravenous fluid administration and cerebral edema. The third study showed a significant association (odds ratio 6.55; 95% confidence interval 1.38 to 30.97) between the total volume (uncorrected for body weight) of infused fluid and the risk of cerebral edema. Accepting the inherent limitations of observational studies, we found a lack of strong or consistent results implicating rate or volume of fluid administration as a precipitant cause of cerebral edema in patients with diabetic ketoacidosis.

Does N-Acetylcysteine Prevent Contrast-Induced Nephropathy During Endovascular AAA Repair? A Randomized Controlled Pilot Study

To examine if N-acetylcysteine (NAC) reduces the incidence of contrast nephropathy during endovascular abdominal aortic aneurysm repair (EVAR) as evidenced by changes in markers of renal function. Twenty consecutive men (mean age 72 years, range 65-79) undergoing EVAR were randomized to receive standard intravenous fluid hydration or standard fluid hydration and NAC (600 mg BID orally, 4 doses). Venous blood and urine were collected prior to the procedure and for 5 postoperative days and analyzed blindly for serum creatinine, urinary retinol-binding protein (RBP), and albumin/creatinine ratio (ACR). There were no significant differences in baseline demographics between the groups. No patient developed acute renal failure. In both groups, urinary RBP rose significantly from baseline (median 15 microg/mmol to peak 699 microg/mmol in controls versus 17 to 648 microg/mmol in the treatment group, p<0.003). There were similar significant rises in ACR (p<0.02). There was, however, no significant difference in the postoperative RBP or ACR between the groups at any time point. EVAR causes significant acute renal injury in most patients. This was not attenuated by N-acetylcysteine. The causes of renal injury are probably multifactorial, the long-term clinical significance of which is unclear.

Aggressive Outpatient Management of Severe Ovarian Hyperstimulation Syndrome Avoids Complications and Prolonged Disease Course

Aggressive Outpatient Management of Severe Ovarian Hyperstimulation Syndrome Avoids Complications and Prolonged Disease Course

68-Year-Old Man With Chronic Diarrhea, Nausea, and Vomiting

68-year-old man presented with a history of myocardial infarction and gastroesophageal reflux disease (GERD), as well as a 3-year history of diarrhea, nausea, and vomiting that had worsened over the previous 1 to 2 months. The patient reported 6 to 8 loose stools per day, bilious vomiting every 3 to 4 days, epigastric abdominal pain, anorexia, and involuntary weight loss (10 kg during the previous year) but no melena, hematochezia, or hematemesis. He denied foreign travel. The patient was hospitalized several times for dehydration at an institution elsewhere, with normal findings on abdominal radiography and magnetic resonance angiography (MRA), benign polyps revealed on colonoscopy, and inflammatory changes of the lower esophagus shown on esophagogastroduodenoscopy (EGD) (no biopsies were performed). The patient was admitted to our institution because of dehydration due to persistent diarrhea and vomiting. The patient’s medications were irbesartan at 150 mg/d, metoprolol at 100 mg twice daily, and aspirin at 81 mg/d. Notably, he had been noncompliant with pantoprazole, prescribed for GERD, due to concern that this medication contributed to his symptoms. Besides aspirin, the patient denied regular use of nonsteroidal anti-inflammatory drugs. He reported a 50-pack-year smoking history and mild alcohol use. Physical examination revealed an illappearing man. Vital signs were notable for orthostatic changes. Findings on examination of the abdomen were unremarkable. Laboratory test results revealed the following (reference ranges shown in brackets): erythrocytosis (hemoglobin, 18.7 g/dL [13.5-17.5 g/dL]), leukocytosis (white blood cell count, 26.2 × 10 9 /L [3.5-10.5 × 10 9 /L]), and an elevated creatinine level (2.6 mg/dL [0.9-1.4 mg/ dL]), all of which resolved with intravenous fluid hydration. Hepatic and pancreatic enzyme levels were normal. Fecal leukocytes and stool cultures including ova and parasites, Giardia lamblia, and Clostridium difficile were all negative. Computed tomography (CT) of the abdomen showed thickening of the walls and folds of the stomach, distal duodenum, and proximal jejunum (Figure 1).

Mesenteric Venous Thrombosis in a Patient with Pancreatitis and Protein C Deficiency

Mesenteric vein thrombosis is an uncommon manifestation of hypercoagulable states. A case is reported of superior mesenteric vein (SMV) thrombosis in a patient with pancreatitis and protein C deficiency. A discussion of SMV thrombosis identification, management, and outcomes is included. The patient presented with a significant history of alcohol abuse and constant, midepigastric abdominal pain associated with nausea and vomiting. Amylase and lipase were elevated, and the patient was treated for pancreatitis. His symptoms initially responded to intravenous fluid hydration, but soon his clinical picture worsened, with increased nausea and vomiting, abdominal pain, and distension. Contrasted computed tomography of the abdomen revealed SMV thrombosis. A hypercoagulable workup revealed protein C deficiency. After a 3-month course of oral anticoagulant therapy, the SMV thrombosis resolved.

Lateral gluteal myonecrosis in a patient undergoing partial nephrectomy in the modified flank position

This is the first report of postoperative rhabdomyolysis occurring in a patient positioned in the “modified flank position,” with the kidney rest positioned under the top of the iliac crest. The patient was treated with aggressive intravenous fluid hydration and hyperbaric oxygen therapy with maintenance of normal renal function and near complete recovery of gluteal muscle function.

Acute recurring pancreatitis: A manifestation of duodenal amyloid deposition. Case report and review

Acute recurring pancreatitis (ARP) secondary to duodenal amyloid deposition has not been previously reported. Although there have been reports of cases of solitary duodenal amyloidoma and GI tract amyloid deposition, the complication of ARP has not been described. Most reports of ARP describe associations with medications, ethanol ingestion, pancreas divisum, choledochocele, and gallstones.1 Management typically consists of intravenous fluid hydration, withdrawal of the underlying precipitant (if known), bowel rest, and analgesia. This report presents a case of ARP secondary to duodenal amyloid deposition that was refractory to conservative therapy and required surgical intervention.

Bacterial Cholangitis.

The treatment of acute bacterial cholangitis requires broad-spectrum antibiotics to cover against gram-negative aerobic enteric organisms (Escherichia coli, Klebsiella species, and Enterobacter species), gram-positive Enterococcus and anaerobic bacteria (Bacteroides fragilis and Clostridium perfringens). Approximately 20% of patients with acute cholangitis fail to respond to conservative treatment with antibiotic therapy and require urgent biliary decompression, which is the mainstay of therapy. This is best accomplished by endoscopic retrograde cholangiopancreatography (ERCP) and placement of a nasobiliary drainage tube or a large bore (10 F or larger) indwelling plastic stent. Alternative therapy includes percutaneous transhepatic biliary drainage or surgical biliary decompression, but these carry a significantly higher morbidity and mortality. Supportive care includes intravenous fluid hydration to prevent renal failure and close monitoring of vital signs for determination of potential septicemia.

Intramural hematoma of the duodenum, with endoscopic images

Purpose: We report a case of an intramural hematoma of the duodenum, correlating radiologic and endoscopic findings. A 27-year-old man presented with acute onset of right upper quadrant abdominal pain, nausea, and bilious vomiting the day after having jumped off the roof of a one-story house, while at work as a carpenter. He regularly drank 6 cans of beer a day, but denied any past history of pancreatitis or gastrointestinal disease. On physical examination, his abdomen had mild diffuse tenderness. Laboratory studies were abnormal for amylase level of 793 and lipase level of 3510. Ultrasound demonstrated abnormal echo-texture in the duodenum, with loss of typical laminated appearance and absence of normal peristalsis. Abdominal CT scan showed large intramural duodenal hematoma, without evidence of pancreatitis. The patient was treated with nasogastric suction and intravenous fluid hydration. Because of a drop in his hemoglobin from 13.3 to 8.6 gm|[sol]|dL by hospital day 5, an upper endoscopy was performed. It showed the proximal end of a duodenal hematoma (see photo), visible from the duodenal bulb. Barium study revealed duodenal lumen narrowing, with an extensive submucosal process extending from the first portion of the duodenum to the region of the duodenum-jejunum junction. Passage of the contrast in the small bowel indicated incomplete obstruction. The patient was started on a liquid diet, advanced to a soft diet, and was discharged on hospital day 8. On follow-up 10 days later, the patient was asymptomatic. Repeat CT scan showed marked resolution in the size of the intramural hematoma. This case serves as a reminder that even large duodenal hematomas can be treated conservatively, and that surgery should be reserved for those cases that have evidence of bowel perforation.

Acute chest syndrome in the postoperative sickle cell patient

Background/Purpose: Acute chest syndrome (ACS), a phenomenon of pulmonary sequestration in sickle cell disease (SCD) patients, is frequently missed in the postoperative SCD child. The constellation of symptoms range from fever and respiratory distress to abdominal discomfort. In its most fulminate state, the syndrome has been reported in some series to carry almost a 25% to 50% mortality rate in the postoperative patient. The incidence in pediatric patients in the era of minimally invasive surgery is unknown. Methods: Since December 1995, 63 episodes of ACS have been documented in the nearly 500 SCD children seen at our institution. Six of 63 episodes occurred within 2 weeks after a surgical procedure under general anesthesia. During this period, 59 operations were performed by the pediatric surgery service on SCD patients with an ACS incidence of 10.2%. Careful review of the preoperative, intraoperative, and post-operative management of these patients was performed. Results: All six received preoperative oxygen saturation monitoring and intravenous fluid (IVF) hydration. One half of these patients required transfusion to achieve a hemoglobin level of greater than 10 mg/dL. Documentation of intraoperative temperature, hypoxia, volume status, and hypercarbia as well as any atypical perioperative events were monitored and reviewed. All patients received postoperative oxygen supplementation and IVF hydration. Onset of ACS ranged from 1 hour to 7 days postoperatively. Only one of six was thought to be of microbial etiology (elevated mycoplasma titers), and all patients received prophylactic antibiotic and aggressive pulmonary therapy. Overall length of hospitalization was increased with an average stay of 6.1 days. There were no postsurgical ACS deaths. Conclusions: Despite close attention and avoidance of known risk factors for development of postoperative SCD complications, ACS occurred with an incidence much higher than previously reported in the literature (0.4% v 10.2%). Interestingly, five of six cases were after laparoscopic procedures suggesting that the advantages of laparoscopy, such as reduced postoperative pain, do not extrapolate to decreased incidence of ACS.

Systemic availability and pharmacodynamic effects after multiple rectal administration of budesonide foam in healthy volunteers

Sulfasalazine is an anti-inflammatory agent commonly used in the treatment of autoimmune conditions such as inflammatory bowel disease and rheumatoid arthritis. Sulfasalazine is converted by gut bacteria into sulfapyridine and the clinically active metabolite 5-aminosalicylic acid (5-ASA), and its efficacy is proportional to the 5-ASA concentration within the intestinal lumen. Renal complications are commonly reported for the chemically similar 5-ASA derivative mesalamine, but are not well-known side effects of sulfasalazine therapy. We report a 72-year-old patient with Crohn’s disease managed with sulfasalazine for more than 10 years who presented with severe acute kidney injury (serum creatinine, 9.7 mg/dL). Renal ultrasound revealed calculi and he subsequently spontaneously voided innumerable stones, which were composed of sulfasalazine metabolites. His renal calculi cleared and serum creatinine concentration improved to 3.1 mg/dL after discontinuing sulfasalazine therapy and intravenous fluid hydration. His kidney function eventually returned to baseline. This case demonstrates that renal complications, in particular nephrolithiasis, may be an under-reported but potentially serious phenomenon in patients with inflammatory bowel disease treated with sulfasalazine and that their hydration status may play an important role in this process.

A Pentamidine-Treated Acquired Immunodeficiency Syndrome Patient Associated With Sudden Onset Diabetes mellitus and High Tumor Necrosis Factor α Level

INTRODUCTION found on his back. The hemoglobin level was 13.8 g/ dL, leukocyte count was 392/mL, and no abnormal About 60% of patients with acquired immunodeparameters of the renal and liver functions were found ficiency syndrome (AIDS) develop phenuexcept for 840 IU (normal, 140–360 IU) of lactic dehymocystis pneumonia.1 The present drugs drogenase (LDH). In addition, Human Immunodefiof choice include sulfamethoxazole/triciency Virus (HIV) antibodies were found, and the methoprim and pentamidine. Pentamidine-induced CD4/CD8 lymphocyte ratio was 0.05 (CD4 8 cells/mL, diabetes mellitus is a serious side effect. Plasma tumor CD8 165 cells/mL). On breathing room air, the patient necrosis factor a (TNF-a) increases in some AIDS pashowed severe hypoxemia (PaO2 46.5 Torr) with low tients.2 TNF-a is associated with the insulin resistance3 PaCO2 (27.2 Torr). Chest X-ray revealed bilateral difand pancreatic b cell dysfunction.4 We report one pafuse alveolar infiltrates. A bronchoalveolar lavage was tient with a very high level of plasma TNF-a who performed on hospital day 1, and the sample demonacquired diabetes mellitus following pentamidine strated the presence of Pneumocystis carini (silver treatment for pneumocystis pneumoniae. stain). He was treated with intravenous pentamidine isethionate 150 mg/day (3 mg/kg) and peroral sulfamethoxazole/trimethoprim (8 g/day). On hospital day CASE REPORT 11, plasma glucose was 80 mg/dL after breakfast. On A 29-year-old heterosexual man with a 4-week history hospital day 30, he had complaints of thirst, polydipsia, of fever, dyspnea, and productive cough was admitted and polyuria. Fasting plasma glucose was 1440 mg/ to our hospital. He had no previous history of any dl. Other laboratory data in this point showed urinary serious disease and no family member with diabetes glucose 41, urinary ketone 1, serum insulin 6 mU/ mellitus. He was found to have fever (37.48C), tachycarmL, serum C-peptide 1.5 ng/mL, serum ICA antibody dia (90 beats/min), tachypnea (30 breaths/min), and negative, serum GAD antibody negative, TNF-a 220 cyanosis. Chest auscultation revealed Velcro rales in pg/mL (normal LT 6) and IL-6 44 pg/mL (normal LT the bilateral lower lung area. Kaposi’s sarcoma was 25). The treatment of sulfamethoxazole/trimethoprim and pentamidine isethionate was discontinued. The patient received intravenous fluid hydration and regu-

Bowel rest, intravenous hydration, and continuous high-dose infusion of octreotide acetate for the treatment of chemotherapy-induced diarrhea in patients with colorectal carcinoma

A prospective trial was conducted involving 16 patients with colorectal adenocarcinoma using a regimen of continuous-infusion octreotide acetate (Sandostatin [octreotide acetate], Sandoz, East Hanover, NJ for the treatment of severe diarrhea induced by the weekly schedule of 5-fluorouracil (5-FU) in combination with leucovorin who were refractory to opiate therapy. Fifteen patients had tissue-documented metastatic colorectal adenocarcinoma. An additional patient was treated adjuvantly. Fifteen patients were treated with chemotherapy consisting of 5-FU and high-dose leucovorin. The octreotide acetate regimen used was a continuous infusion of 50 micrograms/h for 12 hours followed by 100 micrograms/h for 12 hours and subsequently 150 micrograms/h for 72 hours. All patients were previous failures of diphenoxylate atropine (Lomotil diphenoxalate], Searle, Chicago, IL) given 2.5 mg orally after each loose bowel movement, but no more than 20 mg in a 24-hour period. Opiate therapy was not continued beyond 48 hours. All patients also were treated with bowel rest (nothing by mouth) and intravenous fluid hydration as well as octreotide acetate. Complete resolution of diarrhea was seen in 15 of 16 patients (94%). In 4 patients this was accomplished during the 100 micrograms/h infusion, and in 11 patients during the 150 micrograms/h infusion. Recurrence of diarrhea was seen in two patients after a complete cycle of octreotide acetate. Both patients were restarted at 150 micrograms/h for 72 hours of octreotide acetate with resolution of the diarrhea within 36 hours of the infusion. No toxicity related to octreotide acetate was seen in this trial. The continuous-infusion regimen of octreotide acetate 150 micrograms/h is an effective and safe schedule for the treatment of chemotherapy-induced diarrhea together with bowel rest and intravenous fluid hydration in a group of patients in whom the majority were treated with the weekly schedule of 5-FU and high-dose leucovorin.

Transient oligohydramnios in a severely hypovolemic gravid woman at 35 weeks' gestation, with fluid reaccumulating immediately after intravenous maternal hydration

Oligohydramnios is known to accompany chronically hypovolemic maternal conditions, usually preeclampsia, pregnancy-induced hypertension, and intrauterine growth retardation. A case is presented in which an acute maternal hypovolemic situation with oligohydramnios was treated vigorously with intravenous fluid hydration; ultrasonography documented immediate reaccumulation of normal amniotic fluid volume.

Erfahrungen mit Cis-Platinum beim Osteosarkom

I8 patients with evaluable osteogenic sarcoma were treated with high-dose Cis-diaminodichloroplatinum (DDP) at a dose of 120 mg/m2 per course given with intravenous fluid hydration and mannitol diuresis. All 18 patients were previously treated with High dose Methotrexate (HDMtx) and citrovorum factor rescue (CFR), Adriamycin and Cyclophosphamide. The patients received treatment every two to three weeks as tolerated. All patients had at least three courses of Cis-platinum prior to the evaluation of tumor response. Two of the 18 patients had a complete response (3 and 9 months). One patient had a partial response which consisted of more than 75 % shrinkage of measurable pulmonary metastases (8 months). The remaining 15 patients had progressive disease while on Cis-platinum therapy. One patient developed renal failure after the 8th DDP course and prolonged Gentamycin administration. The overall response rate of 16.7 % observed in this series of patients with advanced and resistant osteogenic sarcoma was impressive in that all three responses were not only measurable but also clinically significant. Eck