Intravenous Fluid Requirements Research Articles

Effects of intravenous Tranexamic Acid on bleeding during burn surgery: a double-blinded randomized clinical trial

Blood loss during burn surgeries significantly contributes to morbidity and mortality. Tranexamic Acid (TXA), an antifibrinolytic agent, is hypothesized to reduce intraoperative bleeding. This double-blinded, randomized clinical trial aimed to assess the efficacy of systemic TXA in severe burn patients (total body surface area [TBSA] >20%) undergoing surgery. The study evaluated the impact of TXA on surgical bleeding, operating room (OR) time, intravenous (IV) fluid requirements, length of hospital stay (LOS), and overall patient outcomes. A total of 94 patients, with equal distribution in age, sex, and TBSA, were randomly assigned into two groups (47 each). We administered TXA as a 10mg/kg loading dose followed by a 1mg/kg/h infusion during surgery. Results demonstrated significant reductions in blood loss (P-value: 0.043), total IV fluid volume (P-value: 0.021), OR time (P-value: 0.002), LOS (P-value: 0.0001), and transfusion necessity (P-value: 0.024) in the TXA group. Notably, women and patients without inhalation injuries exhibited better responses to TXA treatment, and graft survival was lower in the TXA group. The study concludes that IV TXA administration during burn surgeries can effectively reduce bleeding, minimize IV fluid and blood transfusion needs, and shorten surgery duration, enhancing overall surgical outcomes.

Balanced Crystalloid (Sterofundin) vs. Normal Saline for Diabetic Ketoacidosis: A Prospective Intervention Trial with Historical Controls.

Fluid therapy with normal saline (NS) in diabetic ketoacidosis (DKA) can cause hyperchloremic acidosis and delay DKA resolution. Balanced crystalloids may address this concern, though results with Ringer lactate and Plasma-Lyte have been mixed. This study aimed to compare the effectiveness of Sterofundin (SF) vs. NS in the management of DKA. A prospective, intervention trial with historical controls was conducted at the Postgraduate Institute of Medical Education and Research, Chandigarh, India. Patients aged 13 years or older with DKA were enrolled. The primary outcome was the time taken to DKA resolution, with a predefined superiority margin of a one-fourth reduction in resolution time. Secondary outcomes included total intravenous fluid and short-acting regular insulin requirements, the need for 0.45% saline, hospital stay duration, and in-hospital mortality. A total of 150 patients (mean age 36.8 years, 56.7% males) were included, with 75 receiving SF (intervention group) and 75 receiving NS (historical control group). The SF group showed a significantly shorter mean time to DKA resolution (13.8 ± 6.0 hours) compared to the NS group (18.1 ± 5.5 hours; P < 0.001). SF patients required less total intravenous fluid (4500 mL vs. 6000 mL; P = 0.004), less insulin (98 units vs. 112 units; P = 0.017), and had a lower need for 0.45% saline (8% vs. 74.3%; P < 0.001). Patients receiving SF had shorter hospital stays (4 [IQR 3-5] days vs. 4 [IQR 4-6] days; P = 0.020). Mortality rates were similar between the groups (SF: 9.3%, NS: 8.1%; P = 0.791). SF may be a superior alternative to NS for fluid therapy in DKA.

The Angiopoietin-Tie-2 Axis in Children and Young Adults with Dengue Virus Infection in the Philippines.

Dengue virus (DENV) infection is associated with plasma leakage, which may progress to shock. The angiopoietin (Ang)-tyrosine kinase with immunoglobulin and epidermal growth factor homology domain 2 (Tie-2) axis regulates endothelial permeability. We examined the clinical utility of Ang-1, Ang-2, and the Ang-2-to-Ang-1 ratio for prediction of progression to severe DENV in a prospective cohort study of children and young adults (age 1 to <26 years) with DENV infection. Ang-1, Ang-2, Tie-2 were measured at presentation to an outpatient clinic in the Philippines from stored plasma by multiplex Luminex® assay. Patients were followed prospectively to document the clinical course (hospitalization, length of stay, intravenous fluid resuscitation, and transfer to a higher level facility). We included 244 patients (median age 9 years, 40% female). At presentation, 63 patients (26%) had uncomplicated dengue, 179 (73%) had dengue with warning signs, and 2 (0.82%) had severe dengue. One hundred eighty-one patients (74%) were hospitalized. Ang-1 levels were lower and Ang-2 higher in patients who required hospitalization. Ang-2-to-Ang-1 ratio >1 was associated with a relative risk of hospitalization of 1.20 (95% CI: 1.03-1.36, P = 0.016). A higher Ang-2-to-Ang-1 ratio was associated with longer length of hospital stay, higher frequency of transfer to a higher level facility, larger intravenous fluid requirement, hemoconcentration, and thrombocytopenia. Angiopoietin-2 was correlated with procalcitonin (Kendall's τ = 0.17, P = 0.00012), a marker of systemic inflammation, as well as soluble vascular cell adhesion molecule-1 (τ = 0.22, P <0.0001) and Endoglin (τ = 0.14, P = 0.0017), markers of endothelial activation. In conclusion, altered Ang-2-to-Ang-1 ratio can be detected early in the course of DENV infection and predicts clinically meaningful events (hospitalization, length of stay, and fluid resuscitation).

Prolonged magnesium sulfate infusion as adjuvant analgesia in postoperative transplant patients in the pediatric ICU: Preliminary results of a feasibility study

AbstractThe opioid crisis has emphasized identification of opioid‐sparing analgesics. This study was designed as a prospective trial with retrospective control group to determine feasibility for implementing a high‐dose prolonged magnesium sulfate infusion for adjuvant analgesia in the pediatric intensive care unit. Approval was granted for study of children receiving total pancreatectomy with islet cell autotransplantation and liver transplantation ages 3–18 years. Study exclusions were pregnancy, neuromuscular disease, hypersensitivity, preoperative creatinine &gt;1.5 times upper limit normal, arrhythmia or pacemaker presence, and clinician concern. Eleven patients were enrolled between January 2020 and December 2022. Magnesium sulfate bolus (50 mg/kg) followed by intravenous infusion (15 mg/kg/h) was initiated in the operating room and extended postoperatively (maximum 48 h). Serum magnesium levels were monitored serially. To prioritize safety, infusion dose was decreased by 5 mg/kg/h for levels greater than 3.5 mg/dL. Clinical team otherwise followed standard multimodal pain practice. Primary outcome was oral morphine equivalent per kg per day during intensive care course (maximum 7 days). Secondary outcomes focused primarily on magnesium safety, including hemodynamic variables, electrolyte variables, respiratory support, and opioid‐related side effects. There were no serious adverse events. Treatment group trended toward slightly higher intravenous fluid requirement (~1 bolus), however no increase in blood product. Treatment and control groups were otherwise comparable in targeted outcomes and overall adverse event profile. Use of a high‐dose magnesium sulfate infusion protocol for analgesic postoperative use in select transplant recipients appears feasible for continued optimization of study in the PICU.

Evaluation of the role of repeated inferior vena cava sonography in estimating first 24 h fluid requirement in resuscitation of major blunt trauma patients in emergency department Suez Canal University Hospital

IntroductionThe assessment of hemodynamic status in polytrauma patients is an important principle of the primary survey of trauma patients, and screening for ongoing hemorrhage and assessing the efficacy of resuscitation is vital in avoiding preventable death and significant morbidity in these patients. Invasive procedures may lead to various complications and the IVC ultrasound measurements are increasingly recognized as a potential noninvasive replacement or a source of adjunct information.Aimof this studyThe study aimed to determine if repeated ultrasound assessment of the inferior vena cava (diameter, collapsibility (IVC- CI) in major trauma patients presenting with collapsible IVC before resuscitation and after the first hour of resuscitation will predict total intravenous fluid requirements at first 24 h.Patients & methodsThe current study was conducted on 120 patients presented to the emergency department with Major blunt trauma (having significant injury to two or more ISS body regions or an ISS greater than 15). The patients(cases) group (shocked group) (60) patients with signs of shock such as decreased blood pressure < 90/60 mmHg or a more than 30% decrease from the baseline systolic pressure, heart rate > 100 b/m, cold, clammy skin, capillary refill > 2 s and their shock index above0.9. The control group (non-shocked group) (60) patients with normal blood pressure and heart rate, no other signs of shock (normal capillary refill, warm skin), and (shock index ≤ 0.9). Patients were evaluated at time 0 (baseline), 1 h after resucitation, and 24 h after 1st hour for:(blood pressure, pulse, RR, SO2, capillary refill time, MABP, IVCci, IVCmax, IVCmin).ResultsAmong 120 Major blunt trauma patients, 98 males (81.7%) and 22 females (18.3%) were included in this analysis; hypovolemic shocked patients (60 patients) were divided into two main groups according to IVC diameter after the first hour of resuscitation; IVC repleted were 32 patients (53.3%) while 28 patients (46.7%) were IVC non-repleted. In our study population, there were statistically significant differences between repleted and non-repleted IVC cases regarding IVCD, DIVC min, IVCCI (on arrival) (after 1 h) (after 24 h of 1st hour of resuscitation) ( p-value < 0.05) and DIVC Max (on arrival) (after 1 h) (p-value < 0.001). There is no statistically significant difference (p-value = 0.075) between repleted and non-repleted cases regarding DIVC Max (after 24 h).In our study, we found that IVCci0 at a cut-off point > 38.5 has a sensitivity of 80.0% and Specificity of 85.71% with AUC 0.971 and a good 95% CI (0.938 – 1.0), which means that IVCci of 38.6% or more can indicate fluid responsiveness. We also found that IVCci 1 h (after fluid resuscitation) at cut-off point > 28.6 has a sensitivity of 80.0% and Specificity of 75% with AUC 0.886 and good 95% CI (0.803 – 0.968), which means that IVCci of 28.5% or less can indicate fluid unresponsiveness after 1st hour of resuscitation. We found no statistically significant difference between repleted and non-repleted cases regarding fluid requirement and amount of blood transfusion at 1st hour of resuscitation (p-value = 0.104).ConclusionRepeated bedside ultrasonography of IVCD, and IVCci before and after the first hour of resuscitation could be an excellent reliable invasive tool that can be used in estimating the First 24 h of fluid requirement in Major blunt trauma patients and assessment of fluid status.

Major Pelvic Ring Injuries: Fewer Transfusions Without Deaths from Bleeding During the Last Decade

BackgroundPelvic fracture-associated bleeding can be difficult to control with historically high mortality rates. The impact of resuscitation advancements for trauma patients with unstable pelvic ring injuries is unknown. We hypothesized that the time elapsed since introduction of our protocol would be associated with decreased blood transfusion requirements.MethodsA level 1 trauma center’s prospective pelvic fracture database was reviewed from 01/01/2009–31/12/2018. All patients with unstable pelvic ring injuries initially presenting to our institution were included. Adjusted regression analysis was performed on the overall cohort and separately for patients in traumatic shock (TS). The primary outcome was 24 h packed red blood cell (PRBC) requirements. Secondary outcomes were 24 h plasma, cryoprecipitate, platelet and intravenous fluid (IVF) requirements, length of stay and mortality.ResultsPatients with mechanically unstable pelvic ring injuries (n = 144, median [Q1–Q3] age 44 [28–55] years, 74% male) received a median (Q1–Q3) of 0 (0–4) units PRBC within 24 h, with TS patients (n = 47, 42 [28–60] years, 74% male) receiving 6 (4–9) units PRBC. There was no decrease in 24 h PRBC requirements for the overall cohort (years; IRR = 0.91, 95% CI 0.83–1.01; p = 0.07). TS patients had decreases in 24 h PRBC (years; IRR = 0.90, 95%CI 0.84–0.96; p = 0.002), plasma (IRR = 0.92, 95%CI 0.85–0.99; p = 0.019), cryoprecipitate (IRR = 0.88, 95%CI 0.81–0.95; p = 0.001) and IVF (IRR = 0.94, 95%CI 0.90–0.98; p = 0.004). There were 5 deaths (5/144, 3.5%) with no deaths due to acute hemorrhage.ConclusionsOver this 10-year period, there was no hemorrhage-related mortality among patients presenting with pelvic fractures. Crystalloid and transfusion requirements decreased for patients presenting with traumatic shock.

Does Serum Zinc Level Affect Severity of Acute Gastroenteritis Among Pre-School Thai Children?

IntroductionAcute gastroenteritis (AGE) is a common problem causing significant mortality and morbidity among children. In clinical settings, zinc deficiency leads to diminished resistance to infectious disorders including acute gastroenteritis, especially in the pediatric populations.PurposeThis study aimed to identify the possible effect of body zinc depletion on the severity of acute gastroenteritis among children. The parameters included dehydration status estimated by Modified Vesikari Score (MVS), laboratory findings, amount of intravenous (IV) fluid requirement, need of medications, as well as a clinical course of illness.Materials and MethodsWe conducted a prospective observational study with 107 children 3 months to 5 years old with AGE that were admitted to an inpatient unit. A comparison was made between children with normal (≥80 μg/dL: n=79 cases) and low serum zinc levels (<80 μg/dL, n=28 cases).ResultsThe definite zinc deficiency (<60 μg/dL) was demonstrated only in 3.7% of cases. The severity of dehydration, classified by MVS, reveals a significantly higher increase in children with low serum zinc levels (12.13 ± 2.4 vs 13.14 ± 1.86 points, p < 0.045). Additionally, the children with low serum zinc levels had a significantly higher number of prolonged vomiting episodes more than 24 hours (42.4% vs 72%, p = 0.013) and three cases of post-gastroenteritis complications, which are prolonged fever and persistent diarrhea, were identified only among patients with low zinc levels (p = 0.003). However, there was no significant difference in IV fluid requirement, a need for medications, as well as the duration of hospitalization between the groups.ConclusionA significantly higher dehydration score, which was assessed by MVS, was demonstrated in the participants with low serum zinc levels. Furthermore, the number of children with prolonged vomiting as well as the evidence of post-gastroenteritis complications was also significantly higher in this group.

The effectiveness of buccal Vitamin D replacement in patients requiring home parenteral nutrition.

Patients with intestinal failure requiring home parenteral nutrition are at risk of vitamin D and other micronutrient deficiencies. Conventional enteral replacement of Vitamin D may not be sufficient for this patient group. This study examines whether buccal Vitamin D provides an alternative, effective route for supplementing Vitamin D in patients with intestinal failure. A retrospective review of patients who received buccal Vitamin D replacement between 1st January 2013 and 1st January 2020at our hospital in Northern England was carried out. Demographics were recorded as were patients' daily intravenous fluid requirements using standard ESPEN definitions. Serum Vitamin D levels were recorded prior to buccal replacement and then at a minimum interval of 3 months after commencement. A cost comparison of a 6 month course of this preparation was also made with an equivalent duration of replacement using oral cholecalciferol capsules. 17 patients were identified. The mean level of Vitamin D prior to replacement was 28.4nmol/l with 65% of patients classed as Vitamin D deficient (<25nmol/l) prior to replacement. The average duration of buccal replacement prior to a repeat level was 5 months. Following buccal Vitamin D replacement no patients were classed as Vitamin D deficient with all levels ≥25nmol/l and a mean of 62.3nmol/l. There was a statistically significant increase in post buccal replacement serum Vitamin D concentrations (p=0.001). Using costings from our hospital pharmacy a 6 month course of this buccal Vitamin D preparation was 38% less expensive than 6 months of replacement with oral cholecalciferol capsules. This study shows that in patients with intestinal failure on home parenteral nutrition, buccal Vitamin D is both a use and cost-effective method of replacement.

Clinical Outcome of Septic Patients With Heart Failure With Preserved Ejection Fraction Presenting to the Emergency Department of a Tertiary Hospital: A Retrospective Cohort Study.

Background: Patients with heart failure with preserved ejection fraction (HFpEF) may be at a higher risk of mortality from sepsis than patients without heart failure.Objective: The aim of this study is to compare sepsis-related morbidity and mortality between patients with HFpEF and patients without heart failure presenting to the emergency department (ED) of a tertiary medical center.Design: Single-center retrospective cohort study conducted at an academic ED between January 1, 2015 and December 31, 2018.Patients: Patients with a diagnosis of sepsis were included.Main Measures: Bivariate and multivariate analyses were performed to look at differences in demographics, infection, and treatment parameters as well as outcomes of patients with sepsis. The primary outcome of the study was in-hospital mortality. Secondary outcomes included ED mortality, lengths of stay, and treatment differences between both groups.Key Results: A total of 1,092 patients presented with sepsis to the ED, of which 305 (27.93%) had HFpEF. There was no significant difference in in-hospital mortality between the two groups (40.7% vs. 37.4%; p = 0.314). However, there was a significant increase in ED mortality for septic HFpEF patients compared to non-heart failure patients (2.4 vs. 0.4%; p = 0.003). Septic HFpEF patients presenting to the ED were older than non-heart failure patients (76.84 vs. 68.44 years old; p < 0.0001). On the other hand, there was no significant increase in the use of vasopressors in the first 24 h between both groups. There was a significantly higher rate of intubation in the first 48 h for septic HFpEF patients (17.5 vs. 8.9%; p < 0.0001). Finally, there was significantly less intravenous fluid requirement at 6 h (1.94 L vs. 2.41L; p < 0.0001) and 24 h (3.11 L vs. 3.54L; p = 0.004) for septic patients with HFpEF compared to non-heart failure patients.Conclusion: Septic HFpEF patients experienced an increase in ED mortality, intubation, and steroid use compared to septic non-heart failure patients.

Evaluation of Hypotensive Prevention Effect of Intramuscular Glycopyrrolate in Spinal Anaesthesia of Elderly TURP Patients: A Randomized Control Trial

Objective: Spinal anesthesia is one of the options for transurethral resection of the prostate (TURP) patients. However, due to patient old age, risk factors, and the procedure itself, hemodynamic instability is common and hazardous. Glycopyrrolate, an anticholinergic drug, has been used in many indications, including in hypotensive prevention in cesarean section patients undergoing spinal anesthesia. The study aims to evaluate the hypotensive prevention effect of the drug in elderly (&gt;60 years) spinal anesthesia TURP patients.Methods: Prospective randomized control trial of 62 elderly who indicated to TURP from December 2019 to January 2020. American Society of anaesthesiologists (ASA) classification of more than three, glycopyrrolate's contra-indication and unable to take spinal anesthesia, were exclusion criteria. 0.2 milligram (mg) intramuscular glycopyrrolate 15 minutes before spinal anesthesia was the primary testing process. Data were collected concurrently with hemodynamic parameters, which were recorded as a baseline and every five munites up to 60 minutes. The analysis was done with both single and repeated measure analysis.Results: Hypotensive incidence was significantly less in the glycopyrrolate group(38.7 vs. 74.2%). Intravenous fluid and vasopressor requirements were also lower. All hemodynamic parameters were higher in the treatment group, except heart rate, which was not different among the groups.Conclusion: Intra-muscular glycopyrrolate could prevent spinal anesthesia-related hypotension without a difference in heart rate in elderly TURP patients in our data.

A phase II study of enterade in neuroendocrine tumor (NET) patients with quality-of-life limiting bowel movement frequency.

TPS634 Background: BM frequency in NET pts is a major cause of morbidity. Though typically associated with serotonin excess in pts with carcinoid syndrome (CS), it can also occur in pts without CS due to etiologies such as short bowel syndrome, bile acid malabsorption, steatorrhea from somatostatin analogs (SSAs) and complications from chemotherapy/immunotherapy/biologics. Enterade is an oral rehydration solution, comprised of 5 amino acids, which has demonstrated pre-clinical and clinical potential to improve small intestinal resorption, thereby offering a potential treatment for limiting BM frequency in NET pts. Methods: We are conducting a phase II parallel cohort study in CS and non-CS NET pts (NCT 4073017). To be eligible, pts must be experiencing an average of ≥ 4 daily BM while on standard-of-care (SOC) therapies (SSAs, anti-diarrheals). Pts will be categorized into CS or non-CS cohorts based upon biochemical evaluation which includes plasma 5-HIAA/24-hour urine 5-HIAA, VIP or gastrin levels. Eligible pts will undergo observation during weeks 1-4 (baseline period). During weeks 5-8, pts will consume Enterade twice per day (Enterade period) while during weeks 9-12, pts will stop Enterade and resume observation. Daily stool diaries for each pt will be assessed to compute differences in mean bowel movement number between baseline and Enterade periods. Endpoints: The primary endpoint of the study is reduction in BM frequency in individual pts between baseline and Enterade periods. Based on parameters utilized in a prior study, we will assume that the mean daily reduction in bowel movements from baseline is equal to 1.5 (standard deviation of change = 1.5) representing a large effect size = 1.0. A sample of 12 pts in each cohort will provide nearly 90% power to detect this effect size based on a one-sample t-test (α = .05). An additional 3 pts will be added to each cohort to account for potential dropouts. Key secondary study endpoints include differences in pt-reported QOL outcomes (FACIT-D), pt weight, intravenous fluid requirement and utilization of SOC anti-diarrheals between baseline and Enterade periods. Accrual for the study will be ensuing shortly. Clinical trial information: NCT04073017.

P108 TEDUGLUTIDE USE IN CROHN’S DISEASE: A CASE SERIES

Abstract Background Teduglutide is a glucagon-like peptide-2 (GLP-2) analogue with trophic effects on the intestinal mucosa to increase the absorptive surface area and enhance nutrient and fluid absorption of the small bowel (SB).1 It has been shown to reduce parenteral nutrition (PN) and intravenous fluid (IVF) requirements and is an important adjunct in the medical management of short bowel syndrome (SBS).1–2 Crohn’s disease (CD) is an important etiology of SBS but use of teduglutide in this population can be challenging. Aim The aim of this case series was to describe the use of teduglutide in CD patients. Methods A retrospective case series of all CD patients with SBS who used teduglutide at the Inflammatory Bowel Disease Center at Cedars-Sinai Medical Center. Age, duration of SBS, length of remaining SB and colonic continuity status were recorded. BMI, average daily PN kilocalories (kcal), and IVF requirements were recorded at the time of teduglutide initiation. The duration of teduglutide use was calculated. Teduglutide dose, dose adjustment history, reason for dose adjustment, and therapy complications were noted. Results 9 patients were included (5 male/4 female). Median age was 57 years (IQR 32). Median length of remaining small bowel was 60cm (IQR 27.5) and median duration of SBS was 8 years (IQR 9.83). Median BMI at teduglutide initiation was 18.66 (IQR 4.29) with a median duration of PN of 4.5 years (IQR 9.42) and median PN kcal/day of 971.43 (IQR 518). The median duration of teduglutide was 1.1 years (IQR 3.4). 4 patients (44%) had a teduglutide dose change. 2 patients had dose interval extended from daily to every other day to reduce injection burden. 1 patient developed obstructive symptoms on daily dosing, which resolved when the dose interval was extended to every other day. 1 patient had to stop therapy due to a small bowel obstruction requiring hospitalization. 8 patients (88%) were able to wean or stop PN/IVF with addition of teduglutide. 1 patient had to restart PN despite teduglutide therapy. Table 1. Discussion Teduglutide is effective in Crohn’s disease patients and facilitates weaning of PN and IVF requirements. Most patients tolerate the recommended dose with daily injections, but the dose interval can be extended to every other day to reduce obstructive symptoms or reduce the injection burden without affecting ability to wean PN/IVF. References

Ultrasonographic inferior vena cava diameter response to trauma resuscitation after 1 hour predicts 24-hour fluid requirement.

Identification of occult hypovolemia in trauma patients is difficult. We hypothesized that in acute trauma patients, the response of ultrasound-measured minimum inferior vena cava diameter (IVCDMIN), IVC Collapsibility Index (IVCCI), minimum internal jugular diameter (IJVDMIN) or IJV Collapsibility Index (IJVCI) after up to 1 hour of fluid resuscitation would predict 24-hour resuscitation intravenous fluid requirements (24FR). An NTI-funded, American Association for the Surgery of Trauma Multi-Institutional Trials Committee prospective, cohort trial was conducted at four Level I Trauma Centers. Major trauma patients were screened for an IVCD of 12 mm or less or IVCCI of 50% or less on initial focused assessment sonographic evaluations for trauma. A second IVCD was obtained 40 minutes to 60 minutes later, after standard-of-care fluid resuscitation. Patients whose second measured IVCD was less than 10 mm were deemed nonrepleted (NONREPLETED), those 10 mm or greater were repleted (REPLETED). Prehospital and initial resuscitation fluids and 24FR were recorded. Demographics, Injury Severity Score, arterial blood gasses, length of stay, interventions, and complications were recorded. Means were compared by ANOVA and categorical variables were compared via χ. Receiver operating characteristic curves analysis was used to compare the measures as 24FR predictors. There were 4,798 patients screened, 196 were identified with admission IVCD of 12 mm or IVCCI of 50% or less, 144 were enrolled. There were 86 REPLETED and 58 NONREPLETED. Demographics, initial hemodynamics, or laboratory measures were not significantly different. NONREPLETED had smaller IVCD (6.0 ± 3.7 mm vs. 14.2 ± 4.3 mm, p < 0.001) and higher IVCCI (41.7% ± 30.0% vs. 13.2% ± 12.7%, p < 0.001) but no significant difference in IJVD or IJVCCI. REPLETED had greater 24FR than NONREPLETED (2503 ± 1751 mL vs. 1,243 ± 1,130 mL, p = 0.003). Receiver operating characteristic analysis indicates IVCDMIN predicted 24FR (area under the curve [AUC], 0.74; 95% confidence interval [CI], 0.64-0.84; p < 0.001) as did IVCCI (AUC, 0.75; 95% CI, 0.65-0.85; p < 0.001) but not IJVDMIN (AUC, 0.48; 95% CI, 0.24-0.60; p = 0.747) or IJVCI (AUC, 0.54; 95% CI, 0.42-0.67; p = 0.591). Ultrasound assessed IVCDMIN and IVCCI response initial resuscitation predicts 24-hour fluid resuscitation requirements. Diagnostic tests or criteria, level II.

Use of prophylactic percutaneous endoscopic gastrostomy (pPEG) tube in head and neck cancer (HNC) patients and correlation of weight loss with treatment interruptions.

e17509 Background: HNC patients are at risk for weight loss which can cause treatment interruptions, and poorer outcomes. There is no consensus on optimal timing of PEG tube placement in HNC patients undergoing concurrent ChemoTherapy (CT) and RadioTherapy (RT). The aim of this study is to determine if pPEG tube would decrease weight loss (WL) in HNC patients. We also analyzed correlation between WL and CT interruptions (CTI), RT interruptions (RTI), and intravenous fluid requirements (IVFr). Methods: This is a prospective study. A total of 16 HNC patients undergoing concurrent CT, RT were included. Before treatment initiation, a PEG tube placement was recommended as a mode of nutrition. 13 patients chose to get pPEG tube and 3 refused. We collected data on weight at 0 and 2 months, CTI, RTI, and IVFr. CTI included missed as well as reduced chemotherapy doses. RTI included missed radiations. Statistical tests used - t-test, Levene’s test for equality of variances and point biserial correlation. Results: Median age - 63 years; Gender: 14 Male/2 Female; Tumor location - Oral cavity - 31.3%; Oropharynx - 43.7%; Larynx - 25%; Nasopharynx and Hypopharynx- 0%. Stages were - II (6.2%), III (37.5%) and IV (56.3%). 2 patients were non-smoker and 4 were Human Papilloma Virus positive. Mean WL(lb) in pPEG (n = 11) vs non-PEG (n = 3) group was 10.3 vs 20.3 (p = 0.045, one-tailed t-test). Average percentage of WL: PEG vs non-PEG - 5.8 vs 8.2; RTI vs not - 8.9 vs 5.3; CTI vs not - 6.9 vs 5.8; IVFr vs not - 6.8 vs 4.5 ( &gt; 7.5% WL over 3 months is significant (ADA/ASPEN)). CTI, RTI and IVFr were positively correlated to WL (correlation coefficient: 0.16; 0.32; 0.17 respectively). CTI and RTI in pPEG group were 23.1% and 38.5% respectively. CTI and RTI in non-PEG group were 33.3% and 66.7% respectively. 2 patients in pPEG group had average weight gain of 2.75 lb. Only 3 patients had PEG tube related complications - infections and clogging. Conclusions: pPEG tube decreases weight loss in locally advanced HNC patients. Patients with higher weight loss had more chemoradiation interruptions and IVFr. HNC patients undergoing concurrent CT, RT should be encouraged to maintain weight and get a PEG tube.

Randomized Clinical Trial of Abdominal Wound Catheters (AWC) versus Epidural Analgesia (EP) following Open Liver Resection (OLR): An Interim Analysis

Background: To compare outcomes following OLR between patients receiving EP vs AWC plus PCA (morphine). This is the mid-point analysis of a RCT powered to detect a difference in hospital length of stay. Methods: Patients undergoing OLR were randomized 1:1 to receive EP or AWC/PCA for 60 hours within an enhanced recovery protocol (ERAS). Postoperative variables recorded included pain scores and peak flow twice a day, need for ionotropic support, intravenous fluid requirements and length of stay amongst others. Results: Between April 2015 and January 2017 45 patients were randomized to EP (n=25) or WC (n=20). No differences were noted in pre-operative variables including age, sex, ASA grade, diagnosis, resection type and wound length. EP patients required more inotropic support in theatre (52% v 35%, ns), immediately postoperatively on day 0 (52% vs 20%, p=0.028 and day 1 (20% v 5%, ns). Accordingly, mean HDU stay was longer in patients with EP (1.6 days v 0.9, ns). No significant differences were noted in pain scores between the two groups except at Day 0 (EP 0 (0-8) vs WC 3 (0-6), p=0.004). Peak flow measurements, intravenous fluid requirements and overall length of stay were similar in both groups. Conclusion: The utilization of AWC was not inferior to EP in OLR. EP-associated hypotension translates into a greater need for ionotropic support when compared with WC following open liver resection. Whether this leads to a longer length of hospital stay remains to be seen.

Randomized clinical trial of abdominal wound catheters (AWC) versus epidural analgesia (EP) following open liver resection (OLR): an interim analysis

Background: To compare outcomes following OLR between patients receiving EP vs AWC plus PCA (morphine). This is the mid-point analysis of a RCT powered to detect a difference in hospital length of stay. Methods: Patients undergoing OLR were randomized 1:1 to receive EP or AWC/PCA for 60 hours within an enhanced recovery protocol (ERAS). Postoperative variables recorded included pain scores and peak flow twice a day, need for ionotropic support, intravenous fluid requirements and length of stay amongst others. Results: Between April 2015 and January 2017 45 patients were randomized to EP (n=25) or WC (n=20). No differences were noted in pre-operative variables including age, sex, ASA grade, diagnosis, resection type and wound length. EP patients required more inotropic support in theatre (52% v 35%, ns), immediately postoperatively on day 0 (52% vs 20%, p=0.028 and day 1 (20% v 5%, ns). Accordingly, mean HDU stay was longer in patients with EP (1.6 days v 0.9, ns). No significant differences were noted in pain scores between the two groups except at Day 0 (EP 0 (0-8) vs WC 3 (0-6), p=0.004). Peak flow measurements, intravenous fluid requirements and overall length of stay were similar in both groups. Conclusion: The utilization of AWC was not inferior to EP in OLR. EP-associated hypotension translates into a greater need for ionotropic support when compared with WC following open liver resection. Whether this leads to a longer length of hospital stay remains to be seen.

Comparable outcomes using propylene glycol-free melphalan for autologous stem cell transplantation in multiple myeloma.

Autologous stem cell transplantation (ASCT) remains a mainstay in the treatment of multiple myeloma (MM). While the procedure is generally safe, toxicities associated with high-dose melphalan conditioning are common and significantly affect patient quality of life. Recently, a propylene glycol-free melphalan formulation (PG-free MEL; Evomela®) was approved by the United States Food and Drug Administration as an ASCT conditioning regimen for MM. PG-free MEL is more soluble and stable than propylene glycol-solubilized melphalan (PG-solubilized MEL; Alkeran®). As such, there is speculation that it could decrease toxicities and increase the efficacy of ASCT. We compared the outcomes of patients conditioned with PG-free MEL (n=216) to PG-solubilized MEL (n=200) at our institution. The baseline characteristics were similar between the two groups. After Day +0, there were no differences in terms of hospitalizations, neutropenic fevers, intravenous granisetron requirement, World Health Organization grade ≥2 oral/esophageal mucositis, intravenous fluid requirement, or narcotic requirement. However, PG-free MEL patients had a higher incidence of diarrhea, which was mostly C. difficile-negative (82% vs. 71%, P=0.015*). Day +100 hematologic responses and progression-free survival after ASCT were comparable. In summary, we demonstrate that switching to PG-free MEL did not significantly reduce short-term complications of ASCT or improve outcomes in MM.

Outcomes of patients with systolic heart failure presenting with sepsis to the emergency department of a tertiary hospital: a retrospective chart review study from Lebanon

ObjectivesPatients with congestive heart failure (CHF) may be at a higher risk of mortality from sepsis than patients without CHF due to insufficient cardiovascular reserves during systemic infections. The aim...

Effectiveness of a fluid chart in outpatient management of suspected dengue fever: A pilot study.

IntroductionDengue infection is the fastest spreading mosquito-borne viral disease in the world. One of the complications of dengue is dehydration which, if not carefully monitored and treated, may lead to shock, particularly in those with dengue haemorrhagic fever. WHO has recommended oral fluid intake of five glasses or more for adults who are suspected to have dengue fever. However, there have been no published studies looking at self-care intervention measures to improve oral fluid intake among patients suspected of dengue fever.ObjectiveTo assess the feasibility and effectiveness of using a fluid chart to improve oral fluid intake in patients with suspected dengue fever in a primary care setting.MethodsThis feasibility study used a randomized controlled study design. The data was collected over two months at a primary care clinic in a teaching hospital. The inclusion criteria were: age > 12 years, patients who were suspected to have dengue fever based on the assessment by the primary healthcare clinician, fever for > three days, and thrombocytopenia (platelets < 150 x 109/L). Both groups received a dengue home care card. The intervention group received the fluid chart and a cup (200ml). Baseline clinical and laboratory data, 24-hour fluid recall (control group), and fluid chart were collected. The main outcomes were: hospitalization rates, intravenous fluid requirement and total oral fluid intake.FindingsAmong the 138 participants who were included in the final analysis, there were fewer hospital admissions in the intervention group (n = 7, 10.0%) than the control group (n = 12, 17.6%) (p = 0.192). Similarly, fewer patients (n = 9, 12.9%) in the intervention group required intravenous fluid compared to the control group (n = 15, 22.1%), (p = 0.154). There was an increase in the amount of daily oral fluid intake in the intervention group (about 3,000 ml) compared to the control group (about 2,500 ml, p = 0.521). However, these differences did not reach statistical significance.ConclusionThis is a feasible and acceptable study to perform in a primary care setting. The fluid chart is a simple, inexpensive tool that may reduce hospitalization and intravenous fluid requirement in suspected dengue patients. A randomized controlled trial with larger sample size is needed to determine this conclusively.Trial registrationInternational Standard Randomized Controlled Trial Number (ISRCTN) Registry ISRCTN25394628 http://www.isrctn.com/ISRCTN25394628

Effect of Oral Zinc Supplementation on Persistent Diarrhea

To study the effect of oral zinc supplementation on duration of persistent diarrhea and need for unscheduled intravenous (IV) fluid requirement after initial dehydration correction. To study the etiological spectrum of persistent diarrhea in hospitalized children. A double blind randomized placebo controlled trial was done in children from 3 months to 5 years of age admitted to Lok Nayak Hospital, New Delhi, India, with persistent diarrhea. Thirty cases of persistent diarrhea received oral zinc supplementation while placebo (similar in taste and colour) was administered orally to other thirty control cases of persistent diarrhea. Children having gastrointestinal stomas and congenital anomalies were excluded. Passage of first formed stool and need for unscheduled IV fluid administration was recorded. Mean duration of diarrhea (defined as first formed stool), after admission, in zinc group was 38.69 ± 13.944 hours (mean ± SD) with range of 11-76 hours as compared with placebo group where duration was 71.50 ± 22.045 hours (mean ± SD) with range of 46-144 hours. This was significant with p value <0.001 & 95 % CI=23.3-42.366. The need for unscheduled IV fluid administration was not significantly different in 2 groups (43.3% in placebo group as compared to 36.7% in zinc group with p value=0.396). In 17 cases out of 60, etiological diagnosis could be reached. The results indicate that there is significant reduction of diarrhea duration in persistent diarrhea by oral zinc supplementation.