Intravenous Fluid Rehydration Research Articles

PSAT214 Management of Hyperparathyroidism Associated with Severe Hypercalcemia Presenting During Labour

Abstract Background Hypercalcemia is a rare pathology in pregnancy, and primary hyperparathyroidism (PHPT) has been described as the most common cause. No guidelines exist concerning treatment of PHPT during pregnancy, although most authors favor surgery as the treatment of choice during the second trimester. Nonetheless, management during the third trimester of pregnancy is challenging due to lack of current guidelines. Clinical case This 29-year pregnant female presenting at 38-weeks gestation with spontaneous rupture of membranes and admitted for latent labor. She was incidentally found to have hypercalcemia. Endocrinology was consulted for asymptomatic hypercalcemia in the third trimester of pregnancy. A diagnosis of primary hyperparathyroidism (PHPT) was suspected based on elevated serum calcium adjusted for albumin (16 mg/dL, normal range 8.5-10.5 mg/dL) and elevated PTH levels (121 pg/mL, normal range 14-65 pg/mL). In addition, parathyroid hormone related peptide (PTHrP) was less than 2.0 pmol/L (normal range <2.0 pmol/L), 25-hydroxy vitamin D was 35.6 ng/mL (normal range 30-50 ng/mL) and urine calcium/creatinine clearance ratio (CCCR) level was 0.02 (<0.01 familial hypocalciuric hypercalcemia is likely, >0.02 PHPT is likely) further supporting the diagnosis of PHPT. No parathyroid imaging was performed as there was no plan for surgical intervention at that time. Conservative management was initiated with aggressive oral and intravenous fluid rehydration. The patient subsequently had an uneventful vaginal delivery with the arrival of a healthy newborn eight hours after treatment was initiated. With continued IV and oral hydration, corrected calcium fell by a total of 5 mg/dL. Given an uneventful postpartum course as well as improving calcium levels with hydration, the patient was discharged on day three of hospitalization with a plan for outpatient endocrinology follow up in preparation for future parathyroidectomy. Conclusion There is no previous case report describing severe hypercalcemia in the third trimester of pregnancy managed conservatively solely with hydration. Calcitonin has been attempted but use is limited secondary to tachyphylaxis. Additionally, some case reports suggest cinacalcet use but this drug crosses the placenta. In this unique and complicated case of severe hypercalcemia diagnosed in the third trimester of pregnancy, conservative management with intensive oral and intravenous fluid rehydration was safe and effective in lowering serum calcium levels and therefore conducive to a positive pregnancy outcome. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

Successful Treatment of Refractory Ulcerative Proctitis in a Pediatric Patient Using Topical Tacrolimus

Successful Treatment of Refractory Ulcerative Proctitis in a Pediatric Patient Using Topical Tacrolimus

SAT-134 SOCIOECONOMIC STATUS AND TREATMENT OUTCOMES OF HOSPITALIZED PATIENTS WITH CHRONIC KIDNEY DISEASE IN NIGERIA - THE BURDEN OF THE DISEASE

Patients with chronic kidney disease (CKD) often require hospitalization for deterioration or disease complication. This hospitalization represents an addition to the high burden of CKD especially in the developing countries. Early recognition with targeted pre-emptive treatment measures of the factors responsible for admission should reduce the frequency or duration of hospitalization in these patients. This prospective study evaluated hospitalized CKD patients with emphasis on patients' admission records, treatment given, duration and estimated cost of hospitalization. Patients were followed up to end point which was either discharge home or death. Socioeconomic class was defined in accordance with the modified Kuppuswamy scale. One hundred and sixty five patients (101 males and 64 females) were studied; 68% were in the low socioeconomic class (SE) while 7.3% fell in the high socioeconomic class; the remaining were in the middle SE class. Ninety five (57.6%) patients’ responsibility for cost of hospitalization was borne by relations other than biological parents, while in 22.4% of patients the cost was borne by self. Biological parents were responsible for cost of hospitalization in 8.5% of patients. In 5 (3.0%) of patients cost of hospitalization was borne by a government agency/employer. The two major etiological diagnosis of CKD in these patients were hypertensive nephropathy (56.3%) and combined diabetic/hypertensive nephropathy (20.8%). Ten causes were identified as reasons for admission; in some patients multiple reasons were responsible. The causes were, in order of frequency: severe uremia (61%), severe anemia (48.8%), fluid retention (39.6%), pulmonary edema (22.5%), and severe hypertension (21.3%), UTI (9.8%), febrile episodes (9.1%), heart failure (8.5%), gastroenteritis (6.1%) and dehydration (1.8%). Hospitalization duration was ≤ 7days in 68 (44.2%) patients, 8-21 days in 73 (47.4%) patients and more than 28 days in 6 (3.9%) patients. During admission, 122 (74.0%) patients had hemodialysis treatment, 95 (57.6%) had blood transfusion, and 54 (32.7%) had IV fluid infusion for rehydration. The outcome of hospitalization was favorable in 120 (72.7%) patients who improved and were discharged home, while it was unfavourable in 22 (27.3%) who either deteriorated and were discharged or died during hospitalization. Some mandatory treatment procedures like dialysis, blood transfusion, and intravenous fluid rehydration significantly added to the cost of hospitalization. Majority of patients with CKD in Nigeria are in the low socioeconomic class. The outcome of hospitalization in the patients was favorable in majority of the patients studied. However, as the cost of hospitalization represents an addition to the high burden of CKD on these patients’ resources, prompt attention to the identified causes of admission would go a long way in reducing this burden.

Thirst-guided participant-controlled intravenous fluid rehydration: a single blind, randomised crossover study

BackgroundDehydration is common in hospitals and is associated with increased mortality and morbidity. Clinical assessment and diagnostic measures of dehydration are unreliable. We sought to investigate the novel concept that individuals might control their own intravenous rehydration, guided by thirst. MethodsWe performed a single-blind, counterbalanced, randomised cross-over trial. Ten healthy male volunteers of mean age 26 (standard deviation [sd] 10.5) yr were dehydrated by 3–5% of their baseline body mass via exercising in the heat (35°C, 60% humidity). This was followed by a 4 h participant-controlled intravenous rehydration: individuals triggered up to six fluid boluses (4% dextrose in 0.18% sodium chloride) per hour in response to thirst. Participants undertook two blinded rehydration protocols which differed only by bolus volume: 50 ml (low volume [LV]) or 200 ml (high volume [HV]). Each hour during the rehydration phase, plasma osmolality (pOsm) was measured and thirst score recorded. Nude body mass was measured at baseline, after dehydration, and after the rehydration phase. ResultsIn both conditions, the mean dehydration-related body mass loss was 3.9%. Thirst score was strongly associated with pOsm (within-subject r=0.74) and demand for fluid decreased as pOsm corrected. In the HV condition, participants rapidly rehydrated themselves (mean fluid delivered 3060 vs 981 ml in the LV condition) to body mass and pOsm no different to their euhydrated state. ConclusionHealthy individuals appear able to rely on thirst to manage intravenous fluid intake. Future work must now focus on whether patient-controlled intravenous fluids could represent a paradigm shift in the management of hydration in the clinical setting. Clinical trial registrationNCT03932890

Acute pancreatitis- a clinical update

Acute pancreatitis is an acute inflammatory process of the pancreas that can range from mild interstitial pancreatitis to severe pancreatitis with pancreatic necrosis with variable involvement of regional tissues and remote organ systems. The incidence of pancreatitis varies in different countries and depends on causes e.g, gallstones, alcohol, metabolic factors and viral infections. Gall stones continue to be the leading cause of acute pancreatitis in most series. Alcohol, hypertriglyceridemia and drugs are also a common cause of acute pancreatitis. Gall stone pancreatitis is more common in women than in men. Alcohol is also a common cause of acute pancreatitis. Alcoholic pancreatitis is more common in men, and usually occurs in individuals with long standing alcohol abuse. The increased frequency of acute pancreatitis may be due to the rising incidence of obesity, a risk factor for the development of gallstones and by extension, gallstone pancreatitis. Acute pancreatitis occurs when there is abnormal activation of digestive enzymes within the pancreas. This occurs through inappropriate activation of inactive enzyme precursors called zymogens or proenzymes inside the pancreas, most notably trypsinogen. Acute pancreatitis is typically rapid in onset and most commonly encountered in its mild form. While mild cases are often successfully treated with conservative measures, such as fasting and aggressive intravenous fluid rehydration, severe cases may require admission to the intensive care unit or even surgery to deal with complications of the disease process. Acute pancreatitis may be accompanied by life threatening complications as well as significant morbidity and mortality despite treatment.Bang Med J (Khulna) 2017; 50 : 35-40

Emergency Department Treatment of Children With Diarrhea Who Attend Day Care: A Randomized Multidose Trial of a Lactobacillus helveticus and Lactobacillus rhamnosus Combination Probiotic.

Benefits associated with probiotic administration to children seeking emergency department care with diarrheal disease are unknown. In this 3-site, double-blind, placebo-controlled study, children aged 4 to 48 months with gastroenteritis were randomized to receive 5 days of placebo, low-dose (4 × 10(9) colony forming units per day), or high-dose (8 × 10(9) colony forming units per day) probiotic (Lactobacillus helveticus and Lactobacillus rhamnosus) in a 2:1:1 ratio. The primary outcome was day care absenteeism. The proportion of children missing a day of day care was 63% (39/62) and 61% (37/61) in the placebo and probiotic arms, respectively (95%CI -14.6% to 18.9%). The proportions experiencing unscheduled health care provider visits and intravenous fluid rehydration were 24% (15/62), 7% (4/62), and 30% (18/61), 5% (3/61) in the placebo and probiotic study arms, respectively (P = .52 and P = .65). None of the results differed based on probiotic dose. The probiotic evaluated did not reduce absenteeism. Since power was suboptimal, further evaluation is required.

Thyrotoxicosis After a Massive Levothyroxine Ingestion in a 3-Year-Old Patient

Most children with exploratory levothyroxine ingestions remain asymptomatic or suffer only minor effects, and most patients can be managed in the home or with supportive care in the hospital. We present a case of a 3-year-old girl who was found after a witnessed massive ingestion of levothyroxine. The patient was initially seen in an emergency department and discharged in stable condition, only to return 4 days after ingestion with thyrotoxicosis, hypertension, tachycardia, 24 hours of persistent vomiting, and clinical and laboratory evidence of dehydration. On the day of hospital admission, her thyroid-stimulating hormone was 0.018 µIU/mL (reference range, 0.6-4.5 µIU/mL); free T4 (tetraiodothyronine) was greater than 6.0 ng/dL (reference range, 0.7-2.1 ng/dL); and T3 (triiodothyronine) total was 494 ng/dL (reference range, 100-200 ng/dL). During a 3-day hospital admission, she was managed with supportive care, including intravenous fluid rehydration and antiemetics, and was ultimately discharged in good condition. The patient was followed up until 2 months after ingestion and remained asymptomatic. Although most exploratory levothyroxine ingestions suffer little to no clinical effects, serious symptoms can occur. Because serious symptoms can occur in a delayed fashion, it is important for clinicians to give proper anticipatory guidance regarding home symptom monitoring, follow-up, and reasons to return to the emergency department when patients present for medical evaluation.

Case 1: Recurrent acute liver dysfunction in a 19-month-old boy

A male infant with an unremarkable family history and medical history presented initially at 12 months of age with vomiting and recurrent otitis media, which was treated successfully with antibiotics. At 16 months of age, he presented again to the emergency room with severe vomiting with hematemesis, in the context of a recurrent otitis under antibiotic treatment. A gastric lavage was performed and his clinical status improved rapidly following treatment with intravenous fluid rehydration and ranitidine. His coagulation profile revealed a mildly increased international normalized ratio (INR) of 1.63 (normal 0.8 to 1.3). On day 6 after the emergency room visit, the coagulopathy was found to have worsened, with his INR increasing to 2.66. Vitamin K therapy was empirically begun, and antibiotic therapy was discontinued. On day 10, the patient’s INR had decreased to 1.61, plasma ammonia level was 39 μM (normal 0 μM to 55 μM) and his hepatic profile showed transaminase elevation up to 767 IU/L for aspartate aminotransferase (normal 22 IU/L to 58 IU/L) and 1108 IU/L for alanine aminotransferase (normal 11 IU/L to 39 IU/L), and a mild increase in alkaline phosphatase and direct bilirubin. At this time, the patient was clinically well. Complementary investigations were performed. Ceruloplasmin and α1-antitrypsin levels were normal. Serology for Epstein-Barr virus, cytomegalovirus and hepatitis A, B and C viruses were negative, as were antinuclear, smooth muscle and antiliver kidney microsome-1 autoantibodies. Abdominal ultrasonography demonstrated an architecturally normal liver. Liver functions gradually normalized over the course of three weeks. It was suspected that the liver dysfunction was related to an idiosyncratic reaction to cephalosporins. At 19 months of age, the infant presented for a third time to the emergency room with vomiting, poor oral intake and lethargy. The patient exhibited tachycardia (heart rate 191 beats/min), tachypnea (respiratory rate 30 breaths/min, oxygen saturation 100%) and dehydration with cold extremities and prolonged capillary refill. He was afebrile. Capillary blood gas analysis showed pH 7.43, partial pressure of carbon dioxide 29 mmHg and a calculated bicarbonate level of 18.7 mM. His lactate levels and anion gap were normal, and his hepatic workup demonstrated a mildly elevated INR of 1.52 and normal transaminase levels. Because of the patient’s lethargy, his plasma ammonia level was tested and was found to be elevated (179 μM). Additional laboratory tests confirmed the diagnosis.

Descripción clínica y epidemiológica de un grave brote de salmonelosis transmitida por alimentos

Foodborne diseases have increased considerably. To report a foodborne outbreak, remarking the importance of early notification to activate the epidemiological surveillance system. During February 2011 we observed a Salmonella Enteritidis outbreak. 31.6% of the cases were seen in the same Emergency Care Unit where all required intravenous fluid rehydration, and 41.7% were hospitalized because of severe dehydration. In the Emergency Room 45.5% of cases required a second visit to be diagnosed correctly. Physicians under report the cases of this disease, delaying the activation of the epidemiological surveillance system. Besides providing good treatment to patients, physicians need to be qualified to recognize foodborne diseases and communicate early the suspicion of an outbreak to the epidemiological surveillance system in order to prevent new cases of disease in the community.

Validation of the Clinical Dehydration Scale for Children With Acute Gastroenteritis

We previously created a clinical dehydration scale. Our objective was to validate the clinical dehydration scale with a new cohort of patients with acute gastroenteritis who were assessed in a tertiary emergency department in a developed country. A prospective observational study was performed in an emergency department at a large pediatric tertiary center in Canada. Children 1 month to 5 years of age with symptoms of acute gastroenteritis who were assessed in the emergency department were enrolled consecutively during a 4-month period. The main outcome measures were length of stay, proportion of children receiving intravenous fluid rehydration, and proportions of children with abnormal serum pH values or bicarbonate levels. A total of 205 children were enrolled, with a mean age of 22.4 +/- 14.9 months; 103 (50%) were male. The distribution of severity categories was as follows: no dehydration (score of 0), n = 117 (57%); some dehydration (score of 1-4), n = 83 (41%); moderate/severe dehydration (score of 5-8), n = 5 (2%). The 3 dehydration categories were significantly different with respect to the validation hypotheses (length of stay, mean +/- SD: none, 245 +/- 181 minutes; some, 397 +/- 302 minutes; moderate/severe, 501 +/- 389 minutes; treatment with intravenous fluids: none, n =17, 15%; some, n = 41, 49%; moderate/severe, n = 4, 80%; number of vomiting episodes in the 7 days before the emergency department visit: none, 8.4 +/- 7.7 episodes; some, 13 +/- 10.7 episodes; moderate/severe, 30.2 +/- 14.8 episodes). The clinical dehydration scale and the 3 severity categories were valid for a prospectively enrolled cohort of patients who were assessed in our tertiary emergency department. The scoring system was valuable in predicting a longer length of stay and the need for intravenous fluid rehydration for children with symptoms of acute gastroenteritis.

Fluid Resuscitation in Malaria: The Need for New Randomised Clinical Trials

Very little clinical research has been conducted on how to manage children with severemalaria, despite it accounting for the deaths of around 1 million children each year in Africa alone. Antimalarial drugs remain the mainstay of treatment (and are the subject of several current or planned clinical trials), but there is increasing debate around aspects of supportive care and the treatment of complications. No aspect of care has been more controversial in recent years than the initial fluid management of children with severe malaria, particularly given the resourcepoor health-care context in which most such children are treated. The debate centres around the role of hypovolaemia (i.e., insufficient circulating blood volume) in the pathophysiology of severe malaria. Hypovolaemia has been incriminated as an important cause of metabolic acidosis, which has been shown repeatedly to be associated with a poor prognosis. The key question is whether hypovolaemia contributes to impaired tissue perfusion in severe malaria, contributing to the anaerobic glycolysis and consequent acidosis. Some studies of severe malaria in children have supported this hypothesis by providing indirect evidence (e.g., capillary refill time, central venous p r e s s u r e mea su r emen t s , r a i s e d creatinine, and clinical dehydration) that severely ill patients are commonly hypovolaemic on admission, and that this contributes to the severity of the disease [1,2]. In febrile children hypovolaemia often results from dehydration, but a detailed study in Gabon showed that the children with severe malaria investigated had only a mild or moderate degree of dehydration (as measured by total body water, not necessarily synonymous with hypovolaemia) [3]. So, should children with severe malaria all receive rapid intravenous fluid rehydration? And if so, with what fluid? Proponents of rapid fluid repletion cite the standards of care applied in resourcerich settings for severely ill children with bacterial sepsis, whilst those advocating caution argue that malaria should be considered differently, particularly given the haemodynamic and circulatory differences from sepsis and the concerns of precipitating or worsening pulmonary or cerebral oedema [2,4]. It is clear that clinical trials are the only way forward to resolve the debate. There have been several previously published intervention studies, all conducted by Maitland and the Kilifi team on the Kenyan coast, but to date all have been too small and heterogenous to provide conclusive answers.

Systemic capillary leak syndrome presenting as recurrent shock

To report a case of systemic capillary leak syndrome (SCLS) in a child. Case report. Pediatric intensive care unit. A 6-yr-old girl was admitted twice to the pediatric intensive care unit, at a 10-month interval, in severe shock with important edema. The patient presented with acute symptoms of abdominal pain, vomiting, and syncope in the hour preceding the shock. During both episodes necessary management included aggressive intravenous fluid rehydration, mechanical ventilation, and use of inotropes/vasopressors. Suspicion of a lower limb fasciitis necessitated surgical exploration, but pathology reports were negative on both occasions revealing only subcutaneous tissue edema. The patient recovered within 24 hrs on both episodes. Investigation ruled out cardiogenic shock and septic shock due to bacterial etiology. On the first episode, a nasopharyngeal aspirate was positive for influenza A (H3N2) by both viral immunofluorescence and culture. The presumed diagnosis was toxic shock syndrome associated with influenza virus. On the second episode, all bacterial and virology cultures remained negative. Hypovolemic shock was suspected, but there was no history of dehydration, bleeding, or gastrointestinal losses (persistent vomiting or diarrhea). Noninfectious causes of hypovolemic shock with edema were ruled out, leading us to believe that she suffered from SCLS. Although well described in the adult literature, there have been few reports of SCLS in pediatric patients. SCLS should be considered in the differential diagnosis of recurrent hypovolemic shock without identifiable cause. The only therapeutic intervention is to obtain vascular access when initial manifestations occur and give aggressive fluid reanimation.

INTRAVENOUS VERSUS ORAL REHYDRATION DURING A BRIEF PERIOD: STRESS HORMONE RESPONSES TO SUBSEQUENT EXHAUSTIVE EXERCISE IN THE HEAT

1614 The purpose of this study was to determine if intravenous fluid rehydration (RHY), versus oral RHY, during a brief period (20 min) differentially affects plasma ACTH, cortisol, and norepinephrine concentrations during subsequent exhaustive exercise in the heat. It was hypothesized that these hormonal variables at exhaustion would show unique perturbations due to the different modes of RHY. Following dehydration (DHY) to −4% of body weight eight nonacclimated highly trained males (Age- 23.5 ± 1.2 years, VO2peak- 61.4 ± 0.8ml·kg·min−1, % body fat- 13.5 ± 0.6%) cycled to exhaustion at 74% VO2peak in 36.8°C on three different occasions. These included: 1) CONTROL, no fluid was provided during the RHY period, 2) DRINK, oral RHY (0.45% NaCl) was provided equal to 50% of the prior DHY, and 3) IV, intravenous infusion (0.45% NaCl) was provided equal to 50% of the prior DHY. Thus, in the two RHY treatments, subjects began exercise at −2% DHY, while in the CONTROL trial subjects began exercise at −4% DHY. Exercise time to exhaustion was not different (p = 0.08) between the DRINK (34.86 ± 4.01 min) and IV (29.48 ± 3.50 min) trials, but both were longer (p < 0.05) than the CONTROL (18.95 ± 2.73 min) trial. No differences (p > 0.05) were found for any of the hormone measures among trials. For all trials the following within responses were reported. Post-exercise (POE) plasma ACTH values were higher (p < 0.05) than post-DHY and pre-exercise (PRE) values. Plasma cortisol PRE was lower (p < 0.05) compared to post-DHY and POE values. POE plasma norepinephrine values were higher (p < 0.05) compared to post-DHY and PRE values. Thus, the endocrine responses at exhaustion were similar regardless of hydration state and mode of RHY, but RHY prolonged the time to exhaustion. Supported by General Nutrition Corp. & Univ. of Conn. Research Foundation

Hypercalcemia of malignancy in the palliative care patient: A treatment strategy

Hypercalcemia of malignancy is most commonly due to the effects of parathyroid hormone-related peptide, which acts as a humoral factor to cause generalized osteoclast-mediated bone resorption and reabsorption of calcium by the kidney tubule, and may also act as a local resorptive factor adjacent to bone metastases. Local resorptive mechanisms are less common causes of malignant hypercalcemia than previously believed. Treatment begins with intravenous fluid rehydration, followed by a furosemide diuresis and the bisphosphonate pamidronate, 60–90 mg, intravenously. Gallium nitrate is an efficacious but inconvenient alternative to pamidronate. Calcitonin combined with pamidronate is a reasonable initial therapy for severe hypercalcemia to hasten normalization of the serum calcium. Steroids should be reserved for hypercalcemia due to tumor production of 1,25 dihydroxyvitamin D, or for steroid-responsive malignancies. Oral or parenteral bisphosphonates can be used to maintain normocalcemia. In addition to improving the morbidity of acute hypercalcemia, bisphosphonate therapy has been shown to reduce bone pain and pathological fractures in patients with bone metastases, and calcitonin also has a potent analgesic effect in these patients. Treatment for hypercalcemia should therefore be considered in the majority of patients in the palliative care setting.