Intravenous Fluid Infusion Research Articles

Avoiding iatrogenic thrombo-embolism: the "KAPLIT" technique

In patients with traumatic injury of an upper limb it is often necessary to both secure intravenous (IV) access and record blood pressure noninvasively in the other upper limb. This may cause intermittent obstruction to the flow of IV fluids during cuff inflation. Also backflow of blood into the IV tubing when the cuff is inflated and the temporary stasis which occurs predisposes to clotting of blood in the IV tubing/catheter. Overenthusiastic efforts to push IV fluids without disconnection and flushing of IV line may pose a possible risk of embolizing the clotted blood thrombus into circulation. We describe a simple technique to prevent backflow of blood into the IV tubing when both intravenous fluid infusion and non-invasive blood pressure cuff are in the same limb. This may prevent clot formation and eliminate the risk of an iatrogenic thrombo-embolism.

Effects of Prone and Reverse Trendelenburg Positioning on Ocular Parameters

: In a pilot study of awake volunteers, intraocular pressure (IOP), choroid layer thickness, and optic nerve diameter were shown to increase in the prone position over 5 h with a nonsignificant trend of attenuation using a 4-degree increase of table inclination. These effects have previously not been isolated from anesthetic and fluid administration over a prolonged period, using an adequate sample size. : After institutional review board approval, 10 healthy volunteers underwent IOP measurement (Tono-Pen XL, Medtronic Solan, Jacksonville, FL) as well as choroidal thickness and optic nerve diameter assessment (Sonomed B-1000, Sonomed, Inc., Lake Success, NY, or the I System-ABD, Innovative Imaging, Inc., Sacramento, CA) on a Jackson table (Orthopedic Systems, Inc., Union City, CA), during 5 h horizontal prone and 5 h 4-degree reverse Trendelenburg positioning. Measurements were assessed as initial supine, initial prone, and hourly thereafter. Vital signs were recorded at each position and time point. : IOP, choroidal thickness, and optic nerve diameter were observed to increase with time in the prone position. A small degree of reverse Trendelenburg attenuated the increase in choroidal thickness but not IOP or optic nerve diameter. : Prolonged prone positioning increases IOP, choroid layer thickness, and optic nerve diameter independent of anesthetics and intravenous fluid infusion and 4 degrees of table inclination (15 cm of head to foot vertical disparity) may not attenuate these effects.

Assessment of intravascular volume by transthoracic echocardiography during therapeutic hypothermia and rewarming in cardiac arrest survivors

Aim To study haemodynamic effects and changes in intravascular volume during hypothermia treatment, induced by ice-cold fluids and maintained by ice-packs followed by rewarming in patients after resuscitation from cardiac arrest. Materials and methods In 24 patients following successful restoration of spontaneous circulation (ROSC), hypothermia was induced with infusion of 4 °C normal saline and maintained with ice-packs for 26 h after ROSC. This was followed by passive rewarming. Transthoracic echocardiography was performed at 12, 24 and 48 h after ROSC to evaluate ejection fraction and intravascular volume status. Central venous pressure (CVP), central venous oxygen saturation (ScvO 2) and serum lactate were measured. Fluid balance was calculated. Results Twelve hours after ROSC, two separate raters independently estimated that 10 and 13 out of 23 patients had a decreased intravascular volume using transthoracic echocardiography. After 24 and 48 h this number had increased further to 14 and 13 out of 19 patients and 13 and 12 out of 21 patients. Calculated fluid balance was positive (4000 ml the day 1 and 2500 ml day 2). There was no difference in ejection fraction between the recording time points. Serum lactate and ScvO 2 were in the normal range when echocardiography exams were performed. CVP did not alter over time. Conclusions Our results support the hypothesis that inducing hypothermia following cardiac arrest, using cold intravenous fluid infusion does not cause serious haemodynamic side effects. Serial transthoracic echocardiographic estimation of intravascular volume suggests that many patients are hypovolaemic during therapeutic hypothermia and rewarming in spite of a positive fluid balance.

Effects of large volume, ice-cold intravenous fluid infusion on respiratory function in cardiac arrest survivors

International guidelines for cardiopulmonary resuscitation recommend mild hypothermia (32–34 °C) for 12–24 h in comatose survivors of cardiac arrest. To induce therapeutic hypothermia a variety of external and intravascular cooling devices are available. A cheap and effective method for inducing hypothermia is the infusion of large volume, ice-cold intravenous fluid. There are concerns regarding the effects of rapid infusion of large volumes of fluid on respiratory function in cardiac arrest survivors. We have retrospectively studied the effects of high volume cold fluid infusion on respiratory function in 52 resuscitated cardiac arrest patients. The target temperature of 32–34 °C was achieved after 4.1 ± 0.5 h (cooling rate 0.48 °C/h). During this period 3427 ± 210 mL ice-cold fluid was infused. Despite significantly reduced LV-function (EF 35.8 ± 2.2%) the respiratory status of these patients did not deteriorate significantly. On intensive care unit admission the mean PaO 2 was 231.4 ± 20.6 mmHg at a F iO 2 of 0.82 ± 0.03 (PaO 2/F iO 2 = 290.0 ± 24.1) and a PEEP level of 7.14 ± 0.31 mbar. Until reaching the target temperature of ≤34 °C the F iO 2 could be significantly reduced to 0.63 ± 0.03 with unchanged PEEP level (7.23 ± 0.36 mbar). Under these conditions the PaO 2/F iO 2 ratio slightly decreased to 247.5 ± 18.5 ( P = 0.0893). Continuing the saline infusion to achieve a body temperature of 33 °C, the F iO 2 could be further reduced with unchanged PEEP. The infusion of large volume, ice-cold fluid is an effective and inexpensive method for inducing therapeutic hypothermia. Resuscitation from cardiac arrest is associated with a deterioration in respiratory function. The infusion of large volumes of cold fluid does not cause a statistically significant further deterioration in respiratory function. A larger, randomized and prospective study is required to assess the efficacy and safety of ice-cold fluid infusion for the induction of therapeutic hypothermia.

Serious adverse drug reaction in a woman with hyperemesis gravidarum after first exposure to vitamin B complex containing vitamins B1, B6 and B12

We report the case of a pregnant woman who suffered from hypotension after first exposure to intravenous administration of a combination drug containing vitamins B1, B6 and B12 (Vitamedin; Daiichi-Sankyo, Tokyo, Japan). A 27-year-old Japanese woman received an intravenous infusion of fluid containing a vitamin B complex due to hyperemesis gravidarum. Thirty minutes after the start of infusion she was found to be in hypotension. The patient had stupor, general sweating, blood pressure of 82/50 mmHg, and low percutaneous oxygen saturation (SpO(2)) of 88%. We immediately stopped the infusion, lifted her legs and administered oxygen. Three minutes after these treatments, she quickly recovered to a good general condition. A skin prick test for vitamin B12 was positive, but tests for B1, B6, mannitol and saline were negative, indicating this adverse reaction was one of drug hypersensitivity due to the vitamin B12 in Vitamedin. Patients should be observed carefully immediately after the administration of Vitamedin.

Cooling intravenous fluids by refrigeration: implications for therapeutic hypothermia

Background:ILCOR recommend the use of therapeutic hypothermia (32–34°C) for 12–24 h in unconscious adult patients with spontaneous circulation after cardiac arrest with a VF rhythm. Among various methods of inducing...

Prehospital therapeutic hypothermia for comatose survivors of cardiac arrest: a randomized controlled trial

Intravenous infusion of ice-cold fluid is considered a feasible method to induce mild therapeutic hypothermia in cardiac arrest survivors. However, only one randomized controlled trial evaluating this treatment exists. Furthermore, the implementation rate of prehospital cooling is low. The aim of this study was to evaluate the efficacy and safety of this method in comparison with conventional therapy with spontaneous cooling often observed in prehospital patients. A randomized controlled trial was conducted in a physician-staffed helicopter emergency medical service. After successful initial resuscitation, patients were randomized to receive either +4 degrees C Ringer's solution with a target temperature of 33 degrees C or conventional fluid therapy. As an endpoint, nasopharyngeal temperature was recorded at the time of hospital admission. Out of 44 screened patients, 19 were analysed in the treatment group and 18 in the control group. The two groups were comparable in terms of baseline characteristics. The core temperature was markedly lower in the hypothermia group at the time of hospital admission (34.1+/-0.9 degrees C vs. 35.2+/-0.8 degrees C, P<0.001) after a comparable duration of transportation. Otherwise, there were no significant differences between the groups regarding safety or secondary outcome measures such as neurological outcome and mortality. Spontaneous cooling alone is insufficient to induce therapeutic hypothermia before hospital admission. Infusion of ice-cold fluid after return of spontaneous circulation was found to be well tolerated and effective. This method of cooling should be considered as an important first link in the 'cold chain' of prehospital comatose cardiac arrest survivors.

The effects of abdominal compartment hypertension after open and endovascular repair of a ruptured abdominal aortic aneurysm

This study assessed if emergency endovascular repair (eEVR) reduces the increase in intra-abdominal compartment pressure and host inflammatory response in patients with ruptured abdominal aortic aneurysm (AAA). Thirty patients with ruptured AAA were prospectively recruited. Patients were offered eEVR or emergency conventional open repair (eOR) depending on anatomic suitability. Intra-abdominal pressure was measured postoperatively, at 2 and 6 hours, and then daily for 5 days. Organ dysfunction was assessed preoperatively by calculating the Hardman score. Multiple organ dysfunction syndrome, systemic inflammatory response syndrome, and lung injury scores were calculated regularly postoperatively. Hematologic analyses included serum urea and electrolytes, liver function indices, and C-reactive protein. Urine was analyzed for the albumin-creatinine ratio. Fourteen patients (12 men; mean age, 72.2 +/- 6.2 years) underwent eEVR, and 16 (14 men; mean age, 71.4 +/- 7.0 years) had eOR. Intra-abdominal pressure was significantly higher in the eOR cohort compared with the eEVR group. The eEVR patients had significantly less blood loss (P < .001) and transfused (P < .001) and total intraoperative intravenous fluid infusion (P = .001). The eOR group demonstrated a greater risk of organ dysfunction, with a higher systemic inflammatory response syndrome score at day 5 (P = .005) and higher lung injury scores at days 1 and 3 (P = .02 and P = .02) compared with eEVR. A significant correlation was observed between intra-abdominal pressure and the volume of blood lost and transfused, amount of fluid given, systemic inflammatory response syndrome score, multiple organ dysfunction score, lung injury score, and the length of stay in the intensive care unit and hospital. These results suggest that eEVR of ruptured AAA is less stressful and is associated with less intra-abdominal hypertension and host inflammatory response compared with eOR.

Hypothermic preconditioning of donor organs prior to harvesting and ischaemia using ice-cold intravenous fluids

To promote organ transplantation and viability, hypothermia has been applied as a protective agent for decades. Current management of organ preservation includes hypothermia as a component of static storage. In rare cases, hypothermic perfusion is initiated in the donor organs prior to harvesting but this requires invasive perfusion techniques. Therefore, hypothermic organ protection is currently achieved only after organ retrieval and onset of ischaemic injury cascades. The relevant mechanisms of cellular and organ damage involve ischaemia-reperfusion injury and apoptosis. In this hypothesis, we propose the possibility of inducing hypothermic protective effects prior to organ harvesting using infusion of ice-cold (+4 degrees C) intravenous fluid in the organ donor. This method of cooling to mild hypothermia (32-34 degrees C) has been found feasible in e.g. cardiac arrest victims and already during the ischaemic insult. We hypothesize that cooling with ice-cold fluid preceding organ harvesting would downregulate organ metabolism and oxygen consumption resulting in improved tolerance to ischaemia. Furthermore, according to existing evidence, mild hypothermia possesses anti-apoptotic effects and suppresses reperfusion associated inflammatory response. Finally, diabetes insipidus is often observed in the brain dead donor. Subsequent hypovolemia is conveniently treated with additional infusion of cold intravenous fluid. We offer this hypothesis as a simple method of improving donor organ viability via improved tolerance to ischaemia and reperfusion injury. This method of hypothermic preconditioning seems safe, inexpensive and easily applicable in virtually every institution treating organ donors. The feasibility and effects of this hypothesis could be further evaluated in comparison to current treatment protocols in laboratory settings including evaluation of organ preservation.

The Use of Pre-Hospital Mild Hypothermia after Resuscitation from Out-of-Hospital Cardiac Arrest

Hypothermia has emerged as a potent neuroprotective modality following resuscitation from cardiac arrest. Although delayed hospital cooling has been demonstrated to improve outcome after cardiac arrest, in-field cooling begun immediately following the return of spontaneous circulation may be more beneficial. Cooling in the field following resuscitation, however, presents new challenges, in that the cooling method has to be portable, safe, and effective. Rapid infusion of intravenous fluid at 4 degrees C, the use of a cooling helmet, and cooling plates have all been proposed as methods for field cooling, and are all in various stages of clinical and animal testing. Whether field cooling will improve survival and neurologic outcome remains an important unanswered clinical question.

Short-term clinical outcomes of late preterm infants

Purpose : To identify the short-term clinical outcomes of late preterm infants and to test the hypothesis that late preterm infants have more clinical problems during the early postnatal period than term infants. Methods : One hundred late preterm infants [gestational age (GA) 34+0-36+6 weeks] and the same number of term infants (GA 37+0-41+6 weeks) were randomly selected from 289 late preterm infants and 825 term infants born in the Seoul National University Bundang Hospital between January 2007 and December 2007, and their electronic medical records were reviewed and analyzed. Results : Compared to term infants, late preterm infants had significantly more medical problems such as temperature instability (odds ratio [OR] 8.7), hypoglycemia (OR 17.5), intravenous fluid infusion (OR 10.2), evaluation for sepsis (OR 9.4), respiratory problems (OR 7.5), apnea and bradycardia (OR 8.6), phototherapy for jaundice (OR 3.6), and feeding intolerance (OR 10.0). Hospital stay was also significantly longer in late preterm infants. Conclusion : Late preterm infants had significantly more medical problems and increased length of hospital stay compared to term infants. More attention should be given to caring for these late preterm infants in newborn nursery during the early postnatal period.

Intravenous cannulation, intravenous infusion and prescription of intravenous fluids

Intravenous cannulation, intravenous infusion and prescription of intravenous fluids

The Value Of High Dose Frusemide In The Management Of 350 Open Prostatectomies

Background: The use of frusemide in open and closed prostatectomy has provided a distinct advance over osmotic diuretics. Objective: To report our experience in the use of high dose infusion of frusemide in the postoperative management of 350 open prostatectomy and discuss its benefits. Patient and Methods: The study included 350 consecutive patients with benign prostatic enlargement who were managed with open prostatectomy and high dose frusemide infusion for bladder irrigation. The age ranged between 49 and 90; the mean age was 61 years. 330 (94.0%) patients presented with urine retention. Other associated medical and surgical conditions were adequately treated before, during and after prostatectomy. Suprapubic prostatectomy was performed on 319 (91.1%) patients while retropubic prostatectomy was on 31 (8.9%) patients. General anaesthesia was administered on 196 (54.6%), spinal analgesia on 139 (39.7%) and epidural analgesia on 15 (4.3%) patients. Blood transfusion, intravenous fluid and frusemide were given during and after operation to replace losses and maintain urine flow. A group of 100 consecutive prostatectomy were given Darrows solution, 1 litre in the first day and 1 litre in the second day following operation. Patients were carefully monitored during the 48 hours of intravenous fluid and frusemide infusion regime. Fluid intake, urine output, sodium and potassium losses in urine were studied in both group of patients. Frusemide infusion regime was carefully followed. Fluid intake regulated to be at least 500mls ahead of urine output during the infusion regime. Frusemide administration was discontinued at the end of the first 24 hours following operation and oral fluids commenced. Results: Intraoperatively, 268 (76.6%) patients were transfused with one unit of blood each; 40 (11.4%) patients received 2 units of blood each while 42 (12.0%) patients did not require blood transfusion. The average daily urinary electrolyte losses were 450 mmol of sodium and 32 mmol of potassium. The levels of serum sodium and potassium remained within the normal range in all patients. In the first 24 hours fluid intake ranged between 5.5 and 8.5 litres while urine output ranged from 3.8 to 6.4 litres. 28 (8.0%) patients complained of nausea and 10 (2.9%) vomited each once following the bolus intravenous injection of 40mg of frusemide. Two patients died on the 6th and 8th postoperative days respectively. Mortality was 0.6 percent. Conclusion: The use of high dose frusemide infusion in open prostatectomy is simple to administer, safe, cost effective and not associated with significant potassium depletion. Keywords: Open prostatectomy, Fursemide infusion, Postoperative managementSahel Medical Journal Vol. 11 (1) 2008: pp. 28-33

Use of cold intravenous fluid to induce hypothermia in a comatose child after cardiac arrest due to a lightning strike

We report a case in which mild hypothermia was induced successfully using a cold intravenous fluid infusion in a 12-year-old boy who was comatose following 21 min of cardiac arrest caused by a lightning strike.

Biphasic creatine kinase elevation in pseudoephedrine overdosage

Biphasic creatine kinase elevation in pseudoephedrine overdosage

Effect of Daily Prolonged Ketamine Anesthesia on Intraocular Pressure in Monkeys

Purpose: To determine if repeated intramuscular ketamine in monkeys on consecutive days affects intraocular pressure (IOP) and if the ketamine-induced IOP change has any relationship to systemic dehydration and/or changes in mean arterial pressure (MAP) of the animals. Methods: Nine monkeys were studied per four protocols. IOP was determined hourly for 6 hr by Goldmann tonometry under ketamine anesthesia on 3 (protocol 1) or 5 (protocols 2 and 3) consecutive days, or on alternating days 1, 3, and 5 (protocol 4). Monkeys in protocols 3 and 4, but not in protocols 1 and 2, received subcutaneous Ringer's fluids at the end of each 6-hr session on days 1–4 or days 1, 3, and 5; monkeys in protocols 2 and 3 received intravenous fluid infusion throughout the experiment on day 5. In protocols 2–4, MAP was measured hourly following each IOP measurement. Results: Monkeys receiving ketamine but no Ringer's fluids in protocol 1 or 2 showed significant IOP declines on days 2–3 or 2–4. The IOP declines were greater in magnitude in protocol 1 than in protocol 2. Daily subcutaneous Ringer's fluids appeared to delay IOP declines in protocol 3. Continuous intravenous fluid infusion on day 5 variably prevented IOP declines in protocols 2 and 3. Monkeys receiving ketamine and subcutaneous fluids on alternate days in protocol 4 showed no decline in IOP. No significant relationship between IOP and MAP was observed. Conclusions: Anesthesia induced by repeated intramuscular ketamine on consecutive days may produce significant IOP declines. Systemic dehydration during the anesthesia seems to be the predominant factor contributing to the IOP reduction. However, inter-individual differences in monkeys indicate that multiple factors may be involved. This study also suggests that fluid supplementation plus alternating anesthesia with recovery days may prevent IOP reduction in monkeys resulting from daily prolonged ketamine anesthesia.

Effects of Epidural Anaesthesia on Intraoperative Core Temperature Changes in Colorectal Cancer Surgery

Effects of Epidural Anaesthesia on Intraoperative Core Temperature Changes in Colorectal Cancer Surgery The purpose of our study was to compare two different methods of anaesthesia in colorectal cancer surgery with respect to the level of intra-operative heat loss and to evaluate its influence on surgical outcome. One hundred patients scheduled to undergo elective colorectal cancer surgery were randomised to receive general anaesthesia (GEN group) or combined general and epidural anaesthesia (GEN + EA group), with 50 patients in each group. Induction and maintenance of general anaesthesia were performed the same way in both groups. Core temperature in lower 1/3 of oesophagus was measured every five minutes after induction of anaesthesia till the end of the surgery. All postoperative complications were registered. There were no significant differences between both groups in respect to patient characteristics and operations carried out. Core temperature decreased during surgery from 36.5 ± 0.4 °C to 36.0 ± 0.5 °C in the GEN group, compared to 36.3 ± 0.4 °C to 35.7 ± 0.6 °C in GEN + EA group. Moreover, heat loss in the GEN + EA group was significantly higher (P &lt; 0.05) than in the GEN group. Surgical complications occurred in four (8%) patients in GEN group and eleven (22%) in the GEN + EA group (P = 0.09). Our study showed that heating of intravenous infusion fluids is not enough to protect from heat loss intraoperatively. Oesophageal core temperature decreased in all patients, but heat loss was greater in the combined general and epidural anaesthesia group. It seems likely that mild hypothermia is an important risk factor in the development of postoperative surgical complications.

Core Temperature Cooling in Healthy Volunteers After Rapid Intravenous Infusion of Cold and Room Temperature Saline Solution

Studies have suggested that inducing mild hypothermia improves neurologic outcomes after traumatic brain injury, major stroke, traumatic hemorrhage, and cardiac arrest. Although infusion of cold normal saline solution is a simple and inexpensive method for initiating hypothermia, human cold-defense mechanisms potentially make this route stressful or ineffective. We hypothesize that rapid infusion of 30 mL/kg of cold (4 degrees C, 39.2 degrees F) 0.9% saline solution during 30 minutes to healthy subjects (aged 27 [standard deviation (SD) 4] years) will reduce core body temperature to the therapeutic range of 33 degrees C to 35 degrees C (91.4 degrees F to 95 degrees F). Sixteen subjects were randomly assigned to receive either cold (4 degrees C, 39.2 degrees F) or room temperature (23 degrees C, 73.4 degrees F) normal saline solution. Subjects were not informed of their assignment, but blinding was not possible after initiation of the infusion. Core temperature, skin temperature, and vital signs were recorded every 2 minutes. Subjects indicated global discomfort during the infusion on a 100-mm visual analog scale at 5-minute intervals. Core temperature decreased in both the cold saline solution (1.0 degrees C [SD 0.4 degrees C]/1.8 degrees F [0.7 degrees F]) and room temperature saline solution (0.5 degrees C [SD 0.1 degrees C]/0.9 degrees F [0.2 degrees F]) groups, whereas skin temperature was unchanged. Slopes calculated from the core temperature cooling curves indicate that the majority of cooling occurred during the first half of the infusion. Examination of the core temperature cooling curves revealed a 2-phase temporal pattern in 30-minute cooling curves. The early phase, spanning 0 to 14 minutes, demonstrated rapid cooling in both groups, with a larger effect observed in subjects receiving cold saline solution. In this pilot study of healthy volunteers, rapid administration of cold saline solution to awake normothermic volunteers resulted in 1 degrees C (1.8 degrees F) cooling but did not induce a therapeutic plane of hypothermia. This change in core temperature was not accompanied by significant changes in skin temperature. These data suggest that a reduction in core temperature of about 1 degrees C (1.8 degrees F) can be achieved in healthy humans before a thermoregulatory response is triggered and that rapid infusion of cold intravenous fluids is insufficient by itself to overcome this response. The clinically relevant control arm of room temperature saline solution also resulted in mild core cooling.

Midline catheters: indications, complications and maintenance

Midline catheters are commonly inserted by nurses to make short and long-term infusion of intravenous fluids and medication easier. This article provides an overview of the value of these devices in adult nursing. It also describes the history and management of the midline catheter in relation to current research and evidence-based practice.

Errors of intravenous fluid infusion rates in medical inpatients

Prescriptions for intravenous (i.v.) fluids in hospitals may not be closely adhered to. This study prospectively examined whether prescribed i.v. fluids are administered at the correct rate. During a four-week period, the i.v. infusion rates in patients requiring continuous i.v. fluids and cared for by a single medical team in a district hospital were studied. The periods over which i.v. crystalloid fluid bags were administered were compared with the time prescribed. Of a total 207 bags, 53 (26%) were correctly administered at the prescribed rate (percentage error 10% to -10%), 138 bags (67%) were infused too slowly and 16 bags (8%) were infused too fast. Overall, the median (interquartile range) absolute percentage error (positive or negative) for all infused bags was 23% (9.7-50). Thirty-nine per cent of bags were infused accurately when a metered pump was used, compared to 21% of bags infused accurately when a metered pump was not used (p < 0.01). Marked inaccuracies in i.v. fluid infusion rates are common, and do not seem to be perceived by staff as important. Metered pumps improve accuracy. Increased awareness of such errors, and the routine use of metered pumps should help improve the accuracy of i.v. fluid infusion rates.