Intravenous Fluid Therapy Research Articles

Intravenous fluid therapy in hospitalized adult dengue patients without shock: Impact on subsequent severe dengue and potential adverse effects.

There is a lack of evidence on the optimal administration of intravenous (IV) fluids in hospitalized adult dengue patients without compensated and hypotensive shock. This study utilized a well-established cohort of dengue patients to compare risks of progressing to severe dengue (SD) over time for patients who were administered IV fluid versus others who were not. We included adult patients (n = 4781) who were hospitalized for dengue infection from 2005 to 2008. Cases were patients who developed SD (n = 689) and controls were patients who did not up until discharge (n = 4092). We estimated the hazardratios (HRs) and risk of SD over time between groups administered different volumes of IV fluids versus the no IV fluid comparison group using Cox models with time-dependent covariates. The doubly-robust estimation approach was used to control for the propensity of fluid administration given clinical characteristics of patients. Subgroup analyses by age, sex, and dengue warning signs before IV fluid administration were conducted. High (>2000 mL/day) IV fluids volume was associated with a higher risk of development of SD for those who had warning signs (HR: 1.77 [1.05-2.97], p: 0.0713) and for those below 55 years old (HR: 1.53 [1.04-2.25], p: 0.0713). Low (<1000 mL/day) IV fluids volume was protective against SD for patients without warning signs (HR: 0.757 [0.578-0.990], p: 0.0883), no lethargy (HR: 0.770 [0.600-0.998], p: 0.0847), and females (HR: 0.711 [0.516-0.980], p: 0.0804). Over the course of hospitalization, there were no significant differences in IV fluid administration and SD risk in most subgroups, except in those who experienced lethargy and were administered IV fluid volume or quantity. Administering high volumes of IV fluids may be associated with an increased risk of SD during hospitalization for adult dengue patients without shock. Judicious use of IV fluids as supportive therapy is warranted.

Improving management of intravenous maintenance fluids in the emergency department of a university hospital.

Intravenous (IV) fluid therapy is a known source of iatrogenic complications. Guideline implementation can be used to educate and guide physicians on adequate fluid management. In the emergency department (ED), a complex and interruption-driven environment, workload is high and active documentation is required to facilitate audits of fluid management quality. Fluid management was evaluated in the ED records of adult non-critically ill patients admitted to a tertiary care center before (PRE: 1/12/2016-31/3/2017) and after (POST: 1/12/2018-31/3/2019) implementation of an educational intervention aiming to optimize IV fluid therapy in November 2018. First, the appropriateness of the 24-hour IV maintenance fluid prescription was evaluated, as prescribed by the emergency physician. Second, factors associated with appropriate prescribing were assessed, as well as the quality of fluid management documentation practice. Prescription appropriateness and documentation quality were evaluated retrospectively using a structured audit instrument and additional review by experts. A total of 237 patients (2.3%) were included in the PRE-intervention group and 253 patients (2.4%) in the POST-intervention group. The expert panel evaluated 214 prescriptions in 82.3% of patients (PRE: 99, POST: 115), and appropriateness increased significantly (19.2% vs. 61.2%, p=0.002). A higher odds of an appropriate IV maintenance fluid prescription was determined, attributed to the intervention (adjOR=2.580; 95% CI 1.363-4.884) and in patients having a prehospital intervention (adjOR=1.914, 95% CI 1.022-3.586). Appropriateness of fluid management documentation did not significantly improve after the implementation of the intervention (15.6% vs. 16.2%, p=0.858). The IV fluid prescriptions' appropriateness was significantly higher after guideline implementation. However, documentation quality of fluid management was poor in the studied ED records. Active stewardship programs are warranted to further monitor fluid management quality in the ED.

On-farm calf assessment and practical fluid therapy

Large animal practitioners are faced with varying levels of dehydration in neonatal cattle. The goal of this talk will be to describe and formulate fluid therapy plans using intravenous catheter placement in varying circumstances in an ambulatory setting. Determining route of fluid administration and intrave­nous catherization techniques will be reviewed. Following this presentation, the practitioner will be able to identify the proper use intravenous catherization and fluid therapy plans in clini­cal cases to be administered on farm.

Bilateral renal dysplasia in a ferret (Mustela putorius furo)

AbstractRenal dysplasia is a histological diagnosis characterised by disorganised architecture of the renal cortex and medulla with disrupted nephron differentiation and primitive ducts surrounded by collarettes of the mesenchymal tissue. This condition has been reported once previously in ferrets as a component of multiple congenital abnormalities of the urogenital tract. A 1.5‐year‐old, male, neutered ferret was presented after being found minimally responsive under a fallen shelf in its enclosure. The ferret was obtunded, with mild intermittent muscle tremors and severe dehydration. Survey radiographs, including thoracic and abdominal ventrodorsal and right and left lateral views, were performed to assess for general trauma. The right renal silhouette was normal in size, and the left was moderately reduced. The capsular margins of both renal silhouettes were moderately undulating and mildly indistinct with perirenal retroperitoneal striations. No signs of trauma or other abnormalities were identified. Whole blood biochemical analysis demonstrated elevated creatinine, elevated blood urea nitrogen, hypernatraemia, hypercalcaemia, hyperphosphataemia and hyperproteinemia characterised by hyperalbuminemia and haemoconcentration. The hypernatraemia and mentation failed to improve with intravenous fluid therapy, and the ferret was euthanased. Bilateral renal dysplasia was confirmed via gross postmortem examination and histopathology.

Ventricular bigeminy associated with myocardial ischemia in a dog with a colonic torsion: a case report

BackgroundVentricular bigeminy due to myocardial ischemia has been reported in humans as well as in canine patients with obstructive gastrointestinal diseases. This is the first case report of ventricular bigeminy in a dog with a colonic torsion that resolved after fluid resuscitation and restoration of myocardial perfusion.Case presentationAn 11-year-old, male neutered mixed breed dog presented with a one day history of vomiting, tenesmus, and lethargy. Physical examination identified an irregular heart rhythm and intermittent pulse deficits. A ventricular arrhythmia represented by ventricular premature complexes (VPCs) organized in bigeminy, was appreciated on a 3-lead electrocardiogram (ECG) with a single lead (II) view. Abdominal radiographs confirmed a colonic torsion. Prior to anesthetic induction, ventricular bigeminy was non responsive to fentanyl or lidocaine. The patient was anesthetized and intravascular volume deficit was identified by dampened plethysmographic wave amplitude (plethysomographic variability), audible softening of the Doppler sound, and more pronounced pulse deficits. Fluid resuscitation was achieved with a combination of intravenous crystalloid and colloid fluid therapy comprising 7.2% hypertonic saline and 6% hetastarch. The patient’s cardiac rhythm converted to normal sinus after fluid resuscitation. The colonic torsion was surgically corrected. The patient recovered well from anesthesia and was ultimately discharged from the hospital 5 days later.ConclusionsThe present case report highlights that myocardial ischemia can lead to ventricular arrythmias, such as ventricular bigeminy. This is the first documented case of ventricular bigeminy in the canine patient with a colonic torsion. Assessment of patient volume status and appropriate fluid resuscitation along with continuous electrocardiogram (ECG) monitoring are vital to patient stability under general anesthesia.

Effects of restrictive fluid therapy on the time to resolution of hyperlactatemia in ICU patients with septic shock. A secondary post hoc analysis of the CLASSIC randomized trial

PurposeThe aim of this study was to examine the effects of intravenous (IV) fluid restriction on time to resolution of hyperlactatemia in septic shock. Hyperlactatemia in sepsis is associated with worse outcome. Sepsis guidelines suggest targeting lactate clearance to guide fluid therapy despite the complexity of hyperlactatemia and the potential harm of fluid overload.MethodsWe conducted a post hoc analysis of serial plasma lactate concentrations in a sub-cohort of 777 patients from the international multicenter clinical CLASSIC trial (restriction of intravenous fluids in intensive care unit (ICU) patients with septic shock). Adult ICU patients with septic shock had been randomized to restrictive (n = 385) or standard (n = 392) intravenous fluid therapy. The primary outcome, time to resolution of hyperlactatemia, was analyzed with a competing-risks regression model. Death and discharge were competing outcomes, and administrative censoring was imposed 72 h after randomization if hyperlactatemia persisted. The regression analysis was adjusted for the same stratification variables and covariates as in the original CLASSIC trial analysis.ResultsThe hazard ratios (HRs) for the cumulative probability of resolution of hyperlactatemia, in the restrictive vs the standard group, in the unadjusted analysis, with time split, were 0.94 (confidence interval (CI) 0.78–1.14) at day 1 and 1.21 (0.89–1.65) at day 2–3. The adjusted analyses were consistent with the unadjusted results.ConclusionIn this post hoc retrospective analysis of a multicenter randomized controlled trial (RCT), a restrictive intravenous fluid strategy did not seem to affect the time to resolution of hyperlactatemia in adult ICU patients with septic shock.

Acute severe renal failure in a patient receiving apixaban: a case report

Because there is little clinical experience with apixaban in patients with severe renal impairment and non-valvular atrial fibrillation, the European Medicines Agency does not advise using it to prevent strokes in these patients. However, only a small number of pharmacokinetic and pharmacodynamic investigations showed how crucially different elimination pathways contribute to the clearance of apixaban. A 74-year-old male patient who was receiving apixaban treatment for stroke prevention in atrial fibrillation was referred to our hospital because of acute severe renal failure brought on by dehydration and abnormally elevated apixaban plasma levels. The patient was treated only with intravenous fluid therapy; serum creatinine recovered slowly over the course of six days, but plasma apixaban levels recovered quickly. No bleeding events have been recorded. Our experience demonstrates the safety profile of apixaban in cases of severe renal failure, but it also emphasizes the need for more research to confirm this evidence.

A preliminary study of ecosmart intra venous system on patients’ comfort

Intravenous fluid therapy may cause discomfort to patients most of the time. More research and innovation are needed to develop infusion devices to provide a more comfortable feeling for patients receiving the therapy. This preliminary study analyzed the effect of economical and smart (ecosmart) infusion systems on comfort in healthy adults. The one-group post-test-only design was used in this pre-experimental investigation. A range of ages, gender, body weight, body temperature, and normal blood pressure selected participants. An independently created, valid, and reliable tool was used to measure comfort. Data analysis employed a t-test on a single sample. Fifteen nursing students are participating as sampling objects. The average comfort score for the study's participants was 11.2 (SD = 2.5967; p &lt; 0.05). The result indicates that the participants are at ease using the ecosmart system. The respondents' sense of comfort related to the instrument showed comfort or relaxation.&#x0D; Keywords: Nursing care; ecosmart; comfort; patient-centered care; hospital; fluid therapy

Therapeutic Benefits of N-Acetylcysteine in the Management of Contrast-Induced Nephropathy

Abstract Objective This study aimed to assess the beneficial effects of N-acetylcysteine (NAC) in the treatment of contrast-induced nephropathy (CIN). Materials and Methods A prospective study was conducted in the department of cardiology of a tertiary health care hospital. A sample of 100 patients who had developed CIN through coronary angioplasty were categorized into two groups: one group treated with intravenous fluids (IVF) monotherapy and the other group treated with the combination of IVF and NAC therapy. Statistical Analysis The data were analyzed using statistical software SPSS software version 26 and statistical significance was set at p &lt; 0.05. Independent t-test and paired t-test were used to analyze the parameters. Results The rate of incidence of CIN was found to be 10%. We observed that the IVF + NAC combination therapy significantly decreases the serum creatinine compared to IVF monotherapy (p = 0.004). Both therapies show similar treatment outcomes with no significant difference (p = 0.556) in the case of estimated glomerular filtration rate (eGFR). Based on creatinine clearance, the results show adding NAC does not impact any additional benefits (p = 000). The duration of hospital stay of the NAC group was reduced significantly (p = 0.000). Conclusion At present, we found that the treatment outcomes which we analyzed based on factors such as serum creatinine, eGFR, and creatinine clearance, are too inconsistent to conclude the beneficial effect of NAC in the management of CIN.

5% Dextrose in Ringer's Lactate versus 5% Dextrose Normal Saline as Maintenance Intravenous Fluid Therapy in Children - A Randomised Controlled Trial.

To estimate the difference in serum chloride levels between children receiving 5% Dextrose in Ringer's Lactate (RLD5) vs. 5% Dextrose Normal Saline (DNS) and to estimate the incidence of dyselectrolytemia, hyperchloremic metabolic acidosis (HCMA), acute kidney injury (AKI) and all-cause mortality in both groups. A randomised controlled trial was conducted in non-critically ill children aged 6 mo to 14 y, admitted between August 2021 and July 2022, requiring intravenous fluids. A sample size of 140 was estimated and randomised, with controls receiving 5% DNS and the intervention group receiving RLD5. Kidney function tests and blood gas analysis were done at admission, 24 h and 48 h after starting the maintenance IV fluid, and outcomes were analysed at 24 h and 48 h. Data was collected using a pre-designed data collection form that included demographic and clinical profile details, and outcomes were analysed using SPSS Version 20 software. Seventy-one children per group were enrolled. The mean chloride difference between the two groups at 24 and 48h were 1.67 (p-value 0.03) and 2.78 (p-value 0.01), respectively. The incidence of AKI at 24h and 48h was 1.4% and 2.8% in the RLD5 group and 0% and 1.4% in the DNS group, respectively. At 24h and 48h, 2.8% and 2.8% of children had HCMA in the RLD5 group, and 14% and 4.2% had HCMA in the DNS group, respectively. There was no mortality in either group. Though clinically insignificant, there was a statistically significant difference in the serum chloride levels between the groups.

How to follow the guidelines, when the appropriate fluid is missing?

Intravenous maintenance fluid therapy (IV-MFT) is probably the most prescribed drug in paediatric hospital care. Recently paediatric societies have produced evidence-based practice guidelines that recommend the use of balanced isotonic fluid when prescribing IV-MFT in both acute and critical paediatric care. Unfortunately, the applicability of these guidelines could be called into question when a ready-to-use glucose-containing balanced isotonic fluid is not available. The main objective of this study was to describe the availability of glucose-containing balanced isotonic fluids in European and Middle Eastern paediatric acute and critical care settings. This work is an ancillary study of the survey dedicated to IV-MFT practices in the paediatric acute and critical care settings in Europe and Middle East, a cross-sectional electronic 27-item survey, emailed in April-May 2021 to paediatric critical care physicians across 34 European and Middle East countries. The survey was developed by an expert multi-professional panel within the European Society of Peadiatric and Neonatal Intensive Care (ESPNIC). Balanced isotonic fluid with glucose 5% was available for only 32/153 (21%) responders. Balanced isotonic fluid with glucose 5% was consistently available in the UK (90%) but not available in France, Greece, The Netherlands and Turkey. Conclusion: Ready-to-use isotonic balanced IV solutions containing glucose in sufficient amount exist but are inconsistently available throughout Europe. National and European Medication Safety Incentives should guarantee the availability of the most appropriate and safest IV-MFT solution for all children. What is Known: • Intravenous maintenance fluid therapy (IV-MFT) is probably the most prescribed drug in paediatric hospital care. • Balanced isotonic fluid is recommended when prescribing IV-MFT in both acute and critical paediatric care. What is New: • Balanced isotonic fluid with glucose 5% is available for less than 25% of the prescribers in Europe and the Middle East.Availability of balanced isotonic fluid with glucose 5% varies from one country to another but can also be inconsistent within the same country. • Clinicians who have access to a ready-to-use balanced isotonic fluid with glucose 5% are more likely to consider its use than clinicians who do not have access to such an IV solution.

Fluids and body composition during anesthesia in children and adolescents: A pilot study

The purpose of this study is to evaluate the intracellular and extracellular volume before and after anesthesia in order to ascertain their variations and determine the potential utility of this information in optimizing intraoperative fluid administration practices. A bioimpedance spectroscopy device (body composition monitor, BCM) was used to measure total body fluid volume, extracellular volume, and intracellular volume. BCM measurements were performed before and after general anesthesia in unselected healthy children and adolescents visiting the Pediatric Institute of Southern Switzerland for low-risk surgical procedures hydrated with an isotonic solution. In 100 children and adolescents aged 7.0 (4.8–11) years (median and interquartile range), the average total body water increased perioperatively with a delta value of 182 (0–383) mL/m2 from pre- to postoperatively, as well as the extracellular water content, which had a similar increase with a delta value of 169 (19–307) mL/m2. The changes in total body water and extracellular water content significantly correlated with the amount of fluids administered. The intracellular water content did not significantly change. Conclusion: Intraoperative administration of isotonic solutions results in a significant fluid accumulation in low-risk schoolchildren during general anesthesia. The results suggest that children without major health problems undergoing short procedures do not need any perioperative intravenous fluid therapy, because they are allowed to take clear fluids up to 1 h prior anesthesia. In future studies, the use of BCM measurements has the potential to be valuable in guiding intraoperative fluid therapy.What is Known:• Most children who undergo common surgical interventions or investigations requiring anesthesia are nowadays hydrated at a rate of 1700 mL/m2/day with an isotonic solution.• The use bioimpedance spectroscopy for the assessment of fluid status in healthy children has already been successfully validated.• The bioimpedance spectroscopy is already currently widely used in various nephrological settings to calculate fluid overload and determine patient’s optimal fluid status.What is New:• Routine intraoperative fluid administration results in a significant fluid accumulation during general anesthesia in low-risk surgical procedures.• This observation might be relevant for children and adolescents with conditions predisposing to fluid retention.• In future studies, the use of BCM measurements has the potential to be valuable in guiding intraoperative fluid therapy.

Analysis of blood composition by porcine breeding cycle.

Pigs for biomedical research are administered commercial fluids made for human consumption when they receive intravenous (IV) fluid therapy. Although pigs and humans have slightly different bodily fluid compositions, the composition shift happens at the same rate as their rapid growth. The study aimed to analyse the composition of porcine blood according to breeding cycle using a portable blood analyser and provides data for developing customized IV fluids for pigs. Pigs were sorted 25, 50, 100 and 120 days after birth, and sows were classified into candidate, pregnant and farrowing groups. A blood sample was collected from the external jugular vein and analysed using the EPOC blood analysis system using haematological, biochemical and gas parameters. There was no difference among pig groups by age, but hematocrit and haemoglobin amounts decreased in sows after farrowing, but their concentrations were higher as compared to pigs. Glucose gradually reduced as age increased in pigs and during pregnancy in sows. This study provided a comprehensive analysis of porcine blood composition by breeding cycle and highlighted the importance of glucose supplementation for IV fluid therapy in pigs.

Striking fear into students’ hearts: Unforeseen consequences of prescribing education

Purpose Undergraduate medical education (UGME) has to prepare students to do safety-critical work (notably, to prescribe) immediately after qualifying. Despite hospitals depending on them, medical graduates consistently report feeling unprepared to prescribe and they sometimes harm patients. Research clarifying how to prepare students better could improve healthcare safety. Our aim was to explore how students experienced preparing for one of their commonest prescribing tasks: intravenous fluid therapy (IVFT). Methods Complexity assumptions guided the research, which used a qualitative methodology oriented towards hermeneutic phenomenology. The study design was an uncontrolled and unplanned complex intervention: judicial review of the iatrogenic death of five children due to hyponatraemia in our region had resulted in the recommendation that students’ education in ‘the implementation of important clinical guidelines’ relevant to fluid and electrolyte balance should be intensified. An opportunity sample of 40 final-year medical students drew and gave audio-recorded commentaries on rich pictures. We completed two template analyses: one of participants’ transcribed commentaries on the pictures and one using a novel heuristic to analyse the pictures themselves. We then reconciled the two analyses into a single template. Results There were four themes: affects, teaching and learning, contradictions, and the curriculum as a journey. To explore interconnections between themes, we chose the picture best exemplifying each of the four themes and interpreted the curriculum journey depicted in each of them. These interpretations were grounded in each participant’s picture, verbal account of the picture, and the aggregate findings of the template analysis. Participants’ experiences were influenced by the situated complexity of IVFT. Layered on top of that, contradictions, overlaps, and gaps within the curriculum introduced extraneous complexity. Confusion and apprehension resulted. Conclusions After spending five years preparing to prescribe IVFT, participants felt unprepared to do so. We conclude that intensive teaching had not achieved its avowed goal of improving students’ preparedness for safe practice. Merton’s seminal work on the ‘unanticipated consequences of purposive social action’ suggests that intensive teaching may even have contributed to their unpreparedness.

A Narrative Review on Diabetic Ketoacidosis in Children.

Diabetic ketoacidosis (DKA) is a life-threatening complication in children with diabetes mellitus. There are considerable differences in the management approaches for DKA between different countries. One of the main areas of differences between guidelines is the administration of fluid, with most guidelines adopting a restrictive approach. This is based on the concern over cerebral oedema, a lethal sequela allegedly to be caused by excessive fluid administration. However, in recent years, new clinical studies suggest that there is no causal relationship between intravenous fluid therapy and DKA-related cerebral injury. The British Society of Paediatric Endocrinology updated its guideline in 2020 to adopt a more permissive approach to fluid administration, which has sparked controversy among some paediatricians. The purpose of this article is to provide a narrative review on the management of DKA. A PubMed search was performed with clinical queries using the key term "diabetic ketoacidosis". The search strategy included randomized controlled trials, clinical trials, meta-analyses, observational studies, guidelines, and reviews. The search was restricted to English literature and the age range of 18 years and younger. Moreover, we reviewed and compared major guidelines. The management of DKA involves early recognition, accurate diagnosis, meticulous fluid and insulin treatment with close monitoring of blood glucose, ketones, electrolytes, renal function, and neurological status. There is still limited clinical evidence to support either a restrictive or permissive approach in the fluid management of paediatric DKA patients. Clinicians should exercise caution when applying different guidelines in their clinical practice, considering the specific circumstances of individual paediatric patients.

Knowledge and practice towards intravenous fluid therapy in children among nurses in the pediatrics emergency department of selected public hospitals

Morbidity and mortality in hospitalized patients can be increased due to errors that are caused by inadequate knowledge and unsatisfactory practice of intravenous (IV) fluid therapy among healthcare workers. The knowledge and practice of nurses are very critical to IV fluid therapy because they are the cornerstone of a subject. This study assessed nurse's knowledge and practice of IV fluid therapy. A cross-sectional study design was employed at four selected public hospitals in Addis Ababa, Ethiopia. Data were collected from 112 nurses using a structured questionnaire for knowledge and using an observational checklist for practice. Data were analyzed using SPSS version 26 computer programs. Most respondents (67%) were males; the mean age of respondents was 31.2 ± 4.3. Among participated nurses, 42% (95% CI 32.8, 51.2) and 56.3% (95% CI 47.1, 65.6) had inadequate knowledge and satisfactory practice regarding IV fluid therapy in children, respectively. A significant association was observed between nurses' intravenous fluid therapy knowledge and in-service training that nurses who had training on fluid therapy in children had 4 times adequate knowledge than those who had no training (P = 0.01), an educational qualification that master degree holders had 4.8 times adequate knowledge than first-degree holders (P = 0.04) and training institution that nurse who had taken training in governmental teaching institution had 4 times adequate knowledge than who had taken training in private teaching institution (P = 0.011). No statistically significant association was found between practice level and independent variables regarding IV fluid therapy. Nurses’ knowledge of IV fluid therapy was inadequate and practice was relatively satisfactory. Continuous education and training of nurses on IV fluid therapy should be conducted regularly to improve their knowledge and practice. Further research should be employed involving other hospitals and focusing on risk factors for knowledge and practice inadequacy that are not discussed in this study.

Efficacy and safety of phospholipid nanoparticles (VBI-S) in reversing intractable hypotension in patients with septic shock: a multicentre, open-label, repeated measures, phase 2a clinical pilot trial

Since the 1990's attempts to favorably modulate nitric oxide (NO) have been unsuccessful. We hypothesized that because NO is lipophilic it would preferentially localize into intravascularly infused hydrophobic nanoparticles, thereby reducing its bioavailability and adverse effects without inhibiting its production. We aimed to determine the efficacy and safety of intravenous infusion of a fluid comprised of hydrophobic phospholipid nanoparticles (VBI-S) that reversibly absorb NO in the treatment of hypotension of patients in severe septic shock. This is a multicentre, open-label, repeated measures, phase 2a clinical pilot trial done at six hospital centers in the USA. Patients in severe septic shock were enrolled after intravenous fluid therapy had failed to raise mean arterial blood pressure (MAP) to at least the generally accepted level of 65mmHg, requiring the use of vasopressors. The primary endpoint of this study is the proportion of patients in whom MAP increased by at least 10mmHg. VBI-S was administered intravenously to patients as boluses of 100ml, 200ml, 400ml, and 800ml at 999ml/min until the blood pressure goal was reached after which the infusion was stopped, and the MAP was recorded. All patients who received any volume of VBI-S were included in the primary and safety analysis. The study is registered with ClinicalTrials.gov, NCT04257136. Between February 17, 2020 and January 3, 2023, 20 eligible patients were enrolled in the study. In all 20 (100%) patients, the goal of increasing MAP by at least 10mmHg using VBI-S was achieved (p=0.0087, effect size=0.654). Mean VBI-S volume required to meet the primary goal was 561.0±372.3ml. The goal of lowering vasopressor dose was also achieved (p=0.0017). Within 48h or less after VBI-S, there was a statistically significant improvement in oxygenation, serum creatinine, clotting variables, procalcitonin, lactic acid, and the sequential organ failure assessment (SOFA) score. At 24h and 48h following administration of VBI-S, 12/15 (80%) and 9/12 (75%) patients developed hyperlipidemia, respectively. No severe adverse events of VBI-S were observed, and there were no treatment-related deaths. These preliminary findings suggest the safety and efficacy of VBI-S in treating hypotension in patients with septic shock. However, a definitive mortality benefit cannot be demonstrated without a randomized controlled study. The Naval Medical Research Command-Naval Advanced Medical Development program via the Medical Technology Enterprise Consortium.

Short anesthesia without intravenous fluid therapy in children: Results of a prospective non-interventional multicenter observational study.

The German guidelines recommend that intravenous fluid therapy should not be mandatorily performed in children with short fasting times undergoing short anesthesia, but there is a lack of clinical studies including a large number of pediatric patients. Therefore, we performed a prospective non-interventional multicenter observational study to evaluate the perioperative hemodynamic and metabolic stability of children undergoing short anesthesia without intravenous fluid therapy. The primary aim was to assess the incidence of hypotension and the secondary aim was to assess the real preoperative fasting times, the incidence of hypoglycemia and the impact on ketone bodies and acid-base balance. Children aged 1 month-18 years undergoing short anesthesia (<1 h) without intravenous fluid therapy were enrolled. Patient demographics, the surgical or diagnostic procedure performed, anesthesia, hemodynamic, laboratory data, and adverse events were documented using a standardized case report form. Four hundred and twenty seven children that were investigated at three pediatric centers from July 2021 to June 2022 (mean age 83.4 ± 58.9 months, body weight 27.9 ± 19.8 kg) were included in the analysis. The real preoperative fasting times were 14.2 ± 3.6 h for solids, 7.2 ± 3.5 h for milk and 5 ± 4.8 h for clear fluids. During the course of anesthesia, hypotension (<2.5th percentile) was detected in 3 of 427 cases (0.7%), hypoglycemia (glucose <3.0 mmol L-1) in 1 of 355 cases (0.3%), and ketosis (ketone bodies ≥0.6 mmol L-1) in 51 of 233 cases (21.9%). The occurrence of ketosis was associated with lower body weight (p <.001) and longer fasting times for solids or milk (p =.021), but not for clear fluids (p =.69). Our study supported the German guidelines recommendation that perioperative intravenous fluid therapy is not mandatory in children beyond the neonatal period with short pre- and postoperative fasting times undergoing short anesthesia (<1 h).

Post hospital admission blood lactate measurements are associated with mortality but not neurologic morbidity in children with cerebral malaria.

In children with cerebral malaria (CM) admission blood lactate has previously guided intravenous fluid therapy and been validated as a prognostic biomarker associated with death. The usefulness of post-admission measurements of blood lactate in children with CM is less clear. The strength of association between blood lactate and neurological sequelae in CM survivors, as well as the optimal duration of post-admission measurements of blood lactate to identify children at higher risk of adverse outcomes is unknown. A retrospective cohort study of 1674 Malawian children with CM hospitalized from 2000 to 2018 who had blood lactate measurements every 6h for the first 24h after admission was performed. The strength of association between admission lactate or values measured at any time point in the first 24h post-admission and outcomes (mortality and neurological morbidity in survivors) was estimated. The duration of time after admission that lactate remained a valid prognostic biomarker was assessed. When lactate is analysed as a continuous variable, children with CM who have higher values at admission have a 1.05-fold higher odds (95% CI 0.99-1.11) of death compared to those with lower lactate values. Children with higher blood lactate at 6h have 1.16-fold higher odds (95% CI 1.09-1.23) of death, compared to those with lower values. If lactate levels are dichotomized into hyperlactataemic (lactate > 5.0 mmol/L) or not, the strength of association between admission lactate and mortality increases (OR = 2.49, 95% CI 1.47-4.22). Blood lactate levels obtained after 18h post-admission are not associated with outcomes. Similarly, the change in lactate concentrations through time during the first 24h of hospital admission is not associated with outcomes. Blood lactate during hospitalization is not associated with adverse neurologic outcomes in CM survivors. In children with CM, blood lactate is associated with death but not neurologic morbidity in survivors. To comprehensively estimate prognosis, blood lactate in children with CM should be assessed at admission and for 18h afterwards.

Postoperative fluid therapy in enhanced recovery after surgery for pancreaticoduodenectomy.

Optimal intravenous fluid management during the perioperative period for patients undergoing pancreaticoduodenectomy (PD) within the framework of enhanced recovery after surgery (ERAS) is unclear. Studies have indicated that excessive total body salt and water can contribute to the development of oedema, leading to increased morbidity and extended hospital stays. This study aimed to assess the effects of an intravenous therapy regimen during postoperative day (POD) 0 to 2 in PD patients within ERAS. A retrospective interventional cohort study was conducted, and it involved all PD patients before and after implementation of ERAS (2009-2017). In the ERAS group, a targeted maintenance fluid regimen of 20 mL/kg/day with a sodium requirement of 0.5 mmoL/kg/day was administered. Outcome measures included the mmol of sodium and chloride administered, length of stay, and morbidity (postoperative pancreatic fistula, POPF; acute kidney injury, AKI; ileus). The study included 169 patients, with a mean age of 64 ± 11.3 years. Following implementation of the intravenous fluid therapy protocol, there was a significant reduction in chloride and sodium loading. However, in the multivariable analysis, chloride administered (mmoL/kg) did not independently influence the length of stay; or rates of POPF, ileus, or AKI (p > 0.05). The findings suggested that a postoperative intravenous fluid therapy regimen did not significantly impact morbidity. Notably, there was a trend towards reduced length of stay within an increasingly comorbid patient cohort. This targeted fluid regimen appears to be safe for PD patients within the ERAS program. Further prospective research is needed to explore this area.