Volume Of Intravenous Fluid Research Articles

Effect of timing of norepinephrine administration on prognosis of patients with septic shock: A prospective cohort study

BackgroundSepsis and septic shock are major healthcare problems worldwide, associated with substantial mortality. Early administration of norepinephrine in septic shock patients has been associated with an increased survival rate, but the timing from septic shock to norepinephrine initiation is controversial. This study examined the associations between the timing of initial norepinephrine administration and clinical outcomes in adult patients with septic shock. MethodsThis prospective cohort study was conducted from September 2021 to June 2022 in an intensive care unit (ICU) of a tertiary general hospital. All enrolled patients were divided into early and late norepinephrine groups according to whether the time from the onset of septic shock to the first application of norepinephrine was >1 h. The primary outcome was 28-day mortality. Secondary outcomes included ICU length of stay (LOS), hospital LOS, time to achieve a mean arterial pressure (MAP) ≥65 mmHg, 24-h infusion volume, 6-h Lac clearance, mechanical ventilation days, and continuous renal replacement therapy (CRRT )ratio. Multivariable logistic regression analysis was used to evaluate the independent risk factors for 28-day mortality. ResultsThis study enrolled 120 patients, including 42 patients (35.0%) and 78 patients (65.0%) in the early and late norepinephrine groups, respectively. The 28-day mortality was lower in the early group than in the late group (28.6% vs. 47.4%, P=0.045). The median time to achieve MAP ≥65 mmHg was shorter in the early group than in the late group (1 h vs. 1.5 h, P=0.010). The median 24-h intravenous fluids volume in the early group was lower than that in the late group (40.7% vs. 14.9%, P=0.030). The median 6-h lactate (Lac) clearance rate in the early group was higher than that in the late group (40.7% vs. 14.9%, P=0.009). There were no significant differences between early and late groups by ICU LOS (P=0.748), hospital LOS (P=0.369), mechanical ventilation time (P=0.128), and CRRT ratio (P=0.637). The independent risk factors for 28-day mortality included being male (odds ratio [OR]=3.288, 95% confidence interval [CI]: 1.236 to 8.745, P = 0.017), time to norepinephrine initiation >1 h (OR=4.564, 95% CI: 1.382 to 15.079, P = 0.013), and time to achieve MAP ≥65 mmHg (OR=1.800, 95% CI: 1.171 to 2.767, P = 0.007). ConclusionsNorepinephrine initiation ≤1 h is associated with lower 28-day mortality in patients with septic shock. Early norepinephrine administration is also associated with a shorter time to achieve MAP ≥65 mmHg, lower 24-h intravenous fluids volume, and higher 6-h Lac clearance rate. Being male, time to achieve MAP ≥65 mmHg, and norepinephrine initiation >1 h are independent risk factors for 28-day mortality.Trial registration Chinese Clinical Trial Registry Identifier: ChiCTR2100044071.

Fluid Overload Syndrome in Patients Undergoing Holmium Laser Enucleation of the Prostate (HoLEP)

Introduction: Fluid overload syndrome is a potentially serious complication that can arise during holmium laser prostate enucleation (HoLEP) surgery. This minimally invasive surgical technique is used to treat benign prostatic hyperplasia (BPH) and is known for efficacy and safety. Fluid overload occurs when the patient receives excessive volume of intravenous fluids during the surgical procedure. This can occur due to a variety of factors, such as inadequate fluid administration by the medical team, excessive fluid absorption during irrigation, or systemic absorption of solutions used during surgery. Material And Methods: A descriptive, observational, single-center and retrospective study was performed in patients undergoing prostatic enucleation with Holmium laser (HoLEP) who developed water overload syndrome, between April 2023-2024 in the Hospital Juarez of Mexico. The demographic data and the dependent variables will be tested for normality according to the Kolmogorov-Smirnov test with Lilliefors correction. If the data are normally distributed, factorial ANOVA will be used for more than two independent samples where the Bonferroni test will be used post Hoc for the multiple pairwise comparison in a parametric manner, considering p<0.05 as statistically significant; if the data are not normally distributed, the Kruskal- Wallis test will be used for more than two independent samples where the Dunn's test will be used post hoc for the multiple pairwise comparison in a non-parametric way, considering p<0.05 as statistically significant. Results: We analyzed 142 files of patients who underwent HoLEP, of which only 49 met the expected inclusion criteria. Of the remaining 49 files, 100% were men with a median age 69 years (58-79 years), weight 62 kg (58-78 kg), height 1.67 m (1.55-1.74 m), BMI 22.1 kg/m2 (21.7-25.8 kg/m2) and body surface area 1.69 m2 (1.61-1.71 m2). The hemodynamic and gasometrical variables were recorded at the anesthesia beginning, at 30, 60, 90, 120, 150 minutes and at the anesthesia end: At 60 minutes after Holmium enucleation the hemodynamic variables: systolic blood pressure 116 mm Hg (110-119 mm Hg), Diastolic blood pressure 63.5 mm Hg (56.5-67 mm Hg), Mean arterial blood pressure 81 mm Hg (76.3-83.3 mm Hg), Heart Rate 68.6 beats/minute (62.6-73.6 beats/minute), Pulse Variability 4.45% (1.7-7.2%) and Plethysmographic variability 5.2% (2.2-8.2%). As for the gasometrical variables: pH 7.34±0.02, CO2 partial pressure 32.24±1.80 mm Hg, O2 partial pressure 61.61±1.80 mm Hg, Arterial Bicarbonate 17.84±1.26 mmol/L, Base deficit -3.95±0.53 mmol/L, Arterial Sodium 135.78±1.41 mmol/L, Arterial Potassium 3.02±0.15 mmol/L, Arterial Chlorine 103.97±1.95 mmol/L, Arterial Lactate 1.76±0.22 mmol/L and Coefficient p50 26.59±0.98 mm Hg. After statistical analysis with Kruskal-Wallis and Dunn-Bonferroni method, the hemodynamic and gasometrical changes occurring after 60 minutes are statistically significant (p<0.05). Discusion: In this cohort of patients with fluid overload, they respond to myocardial fiber distension to a variable degree by increasing cardiac output and stroke volume until dysfunction occurs due to myocardial insufficiency. Myocardial depression in turn produces microvascular dysfunction with alterations in the regulatory functions of the endothelium. This behavior is demonstrated by changes in systolic, diastolic, and average blood pressure that compensate for fluid overload within the first 90 minutes of surgery. Few studies have reported the clinical outcomes of patients undergoing HoLEP, with hemodynamic behavior variables being the least described. If this fluid infusion is continued through prostatic reabsorption of sodium chloride, heart failure occurs due to activation of the sympathetic nervous system accompanied by a greater predisposition to ventricular and supraventricular arrhythmias, which in our study occurred from a median of 71.5 Lt of NaCl and with a utilization rate of 0.27-0.49 lt/min. Conclusions: Fluid overload syndrome due to HoLEP is a rarely diagnosed entity that leads to the appearance of hyperchloremic metabolic acidosis after 90 minutes of enucleation that can appear in up to 23.6% of patients, with an average of fluids infused of NaCl from 43.9 liters and in prostate resections from 48 gr. The rapid identification of this fluid overload syndrome will allow negative assessments, administration of drugs such as diuretics and even the diagnosis of ischemia-reperfusion that can be harmful in patients with previous renal failure.

Baseline Characteristics of Adult Patients Treated and Never Treated with Teduglutide in a Multinational Short Bowel Syndrome and Intestinal Failure Registry.

The Short Bowel Syndrome (SBS) Registry (NCT01990040) is a multinational real-world study evaluating the long-term safety of teduglutide in patients with SBS and intestinal failure (SBS-IF) in routine clinical practice. This paper describes the study methodology and baseline characteristics of adult patients who have (ever-treated) or have never (never-treated) received teduglutide. A total of 1411 adult patients (679 ever-treated; 732 never-treated) were enrolled at 124 sites across 17 countries. The mean (standard deviation [SD]) age at enrollment was 55.4 (15.46) years, and 60.2% of patients were women. Crohn's disease was the most common cause of major intestinal resection in both ever-treated (34.1%) and never-treated patients (20.4%). A similar proportion of ever-treated and never-treated patients had a prior history of colorectal polyps (2.7% vs. 3.6%), whereas proportionally fewer ever-treated patients reported a history of colorectal cancer (1.8% vs. 6.2%) or any malignancy (17.7% vs. 30.0%) than never-treated patients. Never-treated patients received a numerically greater mean (SD) volume of parenteral nutrition and/or intravenous fluids than ever-treated patients (12.4 [8.02] vs. 10.1 [6.64] L/week). Ever-treated patients received a mean teduglutide dosage of 0.05 mg/kg/day. This is the first report of patient baseline characteristics from the SBS Registry, and the largest cohort of patients with SBS-IF to date. Overall, ever-treated and never-treated patients had similar baseline characteristics. Differences between treatment groups may reflect variations in patient selection and degree of monitoring.

Intraoperative goal-directed fluid management and postoperative brain edema in patients having high-grade gliomas resections: a randomized trial.

Patients with high-grade gliomas often have severe brain edema. Goal-directed fluid management protects neurological function, but whether reduces postoperative brain edema remains unknown. Patients having elective resection of supratentorial malignant gliomas were randomly assigned to goal-directed versus routine fluid management. Patients assigned to goal-directed management group were given 3mL kg-1 hydroxyethyl starch solution when stroke volume variation exceeded 15% for 5 minutes. Fluid was managed per routine by attending anesthesiologists in reference patients. The primary outcome was cerebral edema volume after surgery as assessed by computerized tomography. A total of 480 eligible patients were randomly assigned to the goal-directed (n = 240) or the routine fluid management group (n = 240). The amounts of crystalloid (5.4 vs. 7.0ml kg-1 hour-1, P < 0.001), colloid (1.1 vs. 1.7ml kg-1 hour-1, P < 0.001), and overall fluid balance (0.3 vs. 1.9ml kg-1 hour-1, P < 0.001) were significantly lower in goal-directed fluid management. There was no significant difference in postoperative brain edema volume between groups (36.0cm3 vs. 38.9cm3, mean difference: 0.18cm3, 95% CI: -5.7 to 5.9). Goal-directed patients had lower intraoperative dural tension (risk ratio: 0.63, 95% CI: 0.50 to 0.80, P < 0.001). There was no significant difference in Karnofsky Performance Status between the two groups at 30 days after surgery. Goal-directed fluid therapy substantially reduced intravenous fluid volumes, but did not reduce postoperative brain edema in patients having brain tumor resections.

Comparison of Early and Late Norepinephrine Administration in Patients With Septic Shock: A Systematic Review and Meta-Analysis

BACKGROUNDVasopressor administration at an appropriate time is crucial but the optimal timing remains controversial. RESEARCH QUESTIONDoes early versus late norepinephrine (NE) administration impact the prognosis of septic shock? STUDY DESIGN AND METHODSSearches were conducted on PubMed, EMBASE, the Cochrane Library, and KMBASE. We included studies of adults with sepsis and categorized patients into early and late NE group according to specific time points or differences in norepinephrine use protocols. The primary outcome was overall mortality. The secondary outcomes included length of stay in the intensive care unit, days free from ventilator use, days free from renal replacement therapy, days free from vasopressor use, adverse events, and total fluid volume. RESULTSTwelve studies (4 randomized controlled trials [RCTs], 8 observational) comprising 7,281 patients were analyzed. For overall mortality, no significant difference was found between the early NE group and late NE group in RCTs (odds ratio [OR], 0.70; 95% confidence interval [CI], 0.41–1.19) or observational studies (OR, 0.83; 95% CI, 0.54–1.29). In the two RCTs without a restrictive fluid strategy that prioritized vasopressors and lower intravenous fluid volumes, the early NE group showed significantly lower mortality than the late NE group (OR 0.49, 95%, CI, 0.25–0.96). The early NE group demonstrated more mechanical ventilator–free days in observational studies (MD, 4.06; 95% CI, 2.82–5.30). The incidence of pulmonary edema was lower in the early NE group in the three RCTs that reported this outcome (OR 0.43; 95% CI, 0.25–0.74). No differences were found in the other secondary outcomes. INTERPRETATIONOverall mortality did not differ significantly between early and late NE administration for septic shock. However, early NE administration appeared to reduce pulmonary edema incidence, and mortality improvement was observed in studies without fluid restriction interventions, favoring early NE use.

The effect of restrictive compared to liberal intravenous fluid volume on hypotension in adults undergoing major abdominal surgery

In a cardiac output (CO) sub-study of the Restrictive versus Liberal Fluid Therapy in Major Abdominal Surgery (RELIEF) trial, it was shown that restrictive fluid management was associated with lower cardiac index at the end of surgery. However, the association of the fluid protocol with intraoperative blood pressure was less clear. This paper primarily compares rates of hypotension between the two fluid regimens. The haemodynamic effects of these protocols may increase our understanding of perioperative fluid prescription. Using a data set of arterial pressure and cardiac output measurements, this observational cohort study primarily compares intraoperative hypotension rates defined by a mean arterial pressure < 65 mmHg between liberal and restrictive fluid protocols. Secondary analyses explore predictors of invasive mean arterial pressure and doppler-derived cardiac output, including fluid volume regimens and surgical duration. 105 patients had a combined total of 835 haemodynamic data capture events from the beginning to the end of the surgery. Here we report that a restrictive regimen is not associated with a greater proportion of participants who experience at least one episode of hypotension than the liberal regimen 64.1% vs. 61.5% (mean difference 2.6%, 95% CI − 15.9% to 21%, p = 0.78). Duration of surgery was associated with an increased risk of hypotension (OR 1.05, 1 to 1.1, p = 0.038). A fluid restriction protocol compared to liberal fluid administration is not associated with lower blood pressure.

Establishing a Benchmark for Iatrogenic Hemodilution and Blood Transfusion in Long-Segment Spine Fusion Surgery.

Single-center retrospective cohort study. To identify risk factors for transfusion during long-segment thoracolumbar fusion surgery and benchmark cutoffs that could be used by the operative team to guide the use of transfusion. Perioperative transfusion for patients undergoing long-segment thoracolumbar fusion surgery is common. To date, no standardized intra- and perioperative management of transfusion administration has been defined. Patients who underwent thoracolumbar fusion surgeries of 8 or more levels between 2015 and 2020 were identified. Patient demographics, surgical details, anesthesia and critical care records, and laboratory data were compared between patients who received intraoperative and postoperative blood transfusions and those who did not. Univariate and multivariate propensity-matched analyses were performed to identify independent predictors for blood transfusion, and ordinal analysis was performed to identify possible benchmark cutoffs. Among 233 patients identified who underwent long-segment fusions, 133 (57.1%) received a blood transfusion. Multivariate propensity-matched logistic regression showed that intravenous (IV) fluid volume was an independent predictor for transfusion (transfusion group 8051mL vs. non-transfusion group 5070mL, P<0.01). Patients who received ≥4L total IV fluids were more likely to undergo transfusion than those who received <4L (93.2% vs. 50.7%, P<0.01). Those receiving total IV fluids at a rate ≥60mL/Kg (OR 10.45; 95% CI: 2.62-41.72, P<0.01) or intraoperative IV fluids at a rate ≥9mL/Kg/hr (OR 4.46; 95% CI: 1.39-14.32, P<0.01) were more likely to require transfusions. IV fluid administration is an independent predictor for blood transfusion after long-segment fusion surgery. Limiting IV fluid administration may prevent iatrogenic hemodilution and decrease transfusion rates. These data can be used to create perioperative protocols with the goal of decreasing transfusion rates when not indicated and allowing earlier administration when indicated.

Does Point-of-Care Ultrasound Affect Fluid Resuscitation Volume in Patients with Septic Shock: A Retrospective Review.

Fixed, large volume resuscitation with intravenous fluids (IVFs) in septic shock can cause inadvertent hypervolemia, increased medical interventions, and death when unguided by point-of-care ultrasound (POCUS). The primary study objective was to evaluate whether total IVF volume differs for emergency department (ED) septic shock patients receiving POCUS versus no POCUS. We conducted a retrospective observational cohort study from 7/1/2018 to 8/31/2021 of atraumatic adult ED patients with septic shock. We agreed upon a priori variables and defined septic shock as lactate ≥4 and hypotension (SBP <90 or MAP <65). A sample size of 300 patients would provide 85% power to detect an IVF difference of 500 milliliters between POCUS and non-POCUS cohorts. Data are reported as frequencies, median (IQR), and associations from bivariate logistic models. 304 patients met criteria and 26% (78/304) underwent POCUS. Cardiac POCUS demonstrated reduced ejection fraction in 15.4% of patients. Lung ultrasound showed normal findings in 53% of patients. The POCUS vs. non-POCUS cohorts had statistically significant differences for the following variables: higher median lactate (6.7 [IQR 5.2-8.7] vs. 5.6], p = 0.003), lower systolic blood pressure (77.5 [IQR 61-86] vs. 85.0, p < 0.001), more vasopressor use (51% vs. 34%, p = 0.006), and more positive pressure ventilation (38% vs. 24%, p = 0.017). However, there were no statistically significant differences between POCUS and non-POCUS cohorts in total IVF volume ml/kg (33.02 vs. 32.1, p = 0.47), new oxygen requirement (68% vs. 59%, p = 0.16), ED death (3% vs. 4%, p = 0.15), or hospital death (31% vs. 27%, p = 0.48). There were similar distributions of lactate, total fluids, and vasopressors in patients with CHF and severe renal failure. Among ED patients with septic shock, POCUS was more likely to be used in sicker patients. Patients who had POCUS were given similar volume of crystalloids although these patients were more critically ill. There were no differences in new oxygen requirement or mortality in the POCUS group compared to the non-POCUS group.

Associations Between Volume of Early Intravenous Fluid and Hospital Outcomes in Septic Patients With and Without Heart Failure: A Retrospective Cohort Study.

To evaluate the relationship between early IV fluid volume and hospital outcomes, including death in-hospital or discharge to hospice, in septic patients with and without heart failure (HF). A retrospective cohort study using logistic regression with restricted cubic splines to assess for nonlinear relationships between fluid volume and outcomes, stratified by HF status and adjusted for propensity to receive a given fluid volume in the first 6 hours. An ICU subgroup analysis was performed. Secondary outcomes of vasopressor use, mechanical ventilation, and length of stay in survivors were assessed. An urban university-based hospital. A total of 9613 adult patients were admitted from the emergency department from 2012 to 2021 that met electronic health record-based Sepsis-3 criteria. Preexisting HF diagnosis was identified by the International Classification of Diseases codes. None. There were 1449 admissions from patients with HF. The relationship between fluid volume and death or discharge to hospice was nonlinear in patients without HF, and approximately linear in patients with HF. Receiving 0-15 mL/kg in the first 6 hours was associated with lower likelihood of death or discharge to hospice compared with 30-45 mL/kg (odds ratio = 0.61; 95% CI, 0.41-0.90; p = 0.01) in HF patients, but no significant difference for non-HF patients. A similar pattern was identified in ICU admissions and some secondary outcomes. Volumes larger than 15-30 mL/kg for non-HF patients and 30-45 mL/kg for ICU-admitted non-HF patients were not associated with improved outcomes. Early fluid resuscitation showed distinct patterns of potential harm and benefit between patients with and without HF who met Sepsis-3 criteria. Restricted cubic splines analysis highlighted the importance of considering nonlinear fluid outcomes relationships and identified potential points of diminishing returns (15-30 mL/kg across all patients without HF and 30-45 mL/kg when admitted to the ICU). Receiving less than 15 mL/kg was associated with better outcomes in HF patients, suggesting small volumes may be appropriate in select patients. Future studies may benefit from investigating nonlinear fluid-outcome associations and a focus on other conditions like HF.

Effects of IV fluid restriction according to site-specific intensity of standard fluid treatment-protocol.

Variation in usual practice in fluid trials assessing lower versus higher volumes may affect overall comparisons. To address this, we will evaluate the effects of heterogeneity in treatment intensity in the Conservative versus Liberal Approach to Fluid Therapy of Septic Shock in Intensive Care trial. This will reflect the effects of differences in site-specific intensities of standard fluid treatment due to local practice preferences while considering participant characteristics. We will assess the effects of heterogeneity in treatment intensity across one primary (all-cause mortality) and three secondary outcomes (serious adverse events or reactions, days alive without life support and days alive out of hospital) after 90 days. We will classify sites based on the site-specific intensity of standard fluid treatment, defined as the mean differences in observed versus predicted intravenous fluid volumes in the first 24 h in the standard-fluid group while accounting for differences in participant characteristics. Predictions will be made using a machine learning model including 22 baseline predictors using the extreme gradient boosting algorithm. Subsequently, sites will be grouped into fluid treatment intensity subgroups containing at least 100 participants each. Subgroups differences will be assessed using hierarchical Bayesian regression models with weakly informative priors. We will present the full posterior distributions of relative (risk ratios and ratios of means) and absolute differences (risk differences and mean differences) in each subgroup. This study will provide data on the effects of heterogeneity in treatment intensity while accounting for patient characteristics in critically ill adult patients with septic shock. The European Clinical Trials Database (EudraCT): 2018-000404-42, ClinicalTrials. gov: NCT03668236.

Effect of Fluid Therapy in Early Morning on the Incidence of Post-Induction Hypotension During Non-Cardiac Surgery After Noon: A Single-Center Retrospective Study.

Post-induction hypotension (PIH) is a common clinical phenomenon linked to increased morbidity and mortality in various non-cardiac surgeries. Patients with surgery in the afternoon may have preoperative hypovolemia caused by prolonged fasting and dehydration, which increases the risk of hypotension during the induction period. However, studies on the fluid therapy in early morning combating PIH remain inadequate. Therefore, we aimed to investigate the influence of prophylactic high-volume fluid in the early morning of the operation day on the incidence of PIH during non-cardiac surgery after noon. We reviewed the medical records of patients who underwent non-cardiac surgery after noon between October 2021 and October 2022. The patients were divided into two groups based on whether they received a substantial volume of intravenous fluid (high-volume group) or not (low-volume group) in the early morning of the surgery day. We investigated the incidence of PIH and intraoperative hypotension (IOH) as well as the accumulated duration of PIH in the first 15 minutes. In total, 550 patients were included in the analysis. After propensity score matching, the incidence of PIH was 39.7% in the high-volume group and 54.1% in the low-volume group. Multivariate logistic regression analysis showed that patients in the high-volume group had lower incidence of hypotension after induction compared with the low-volume group (odds ratio, 0.55; 95% CI, 0.34-0.89; p = 0.016). The high-volume fluid infusion in the preoperative morning was significantly correlated with the decreased duration of PIH (p = 0.013), but no statistical difference was observed for the occurrence of IOH between the two groups (p = 0.075). The fluid therapy of more than or equal to 1000 mL in the early morning of the surgery day was associated with a decreased incidence of PIH compared with the low-volume group in patients undergoing non-cardiac surgery after noon.

Pediatric kidney care experience after the 2023 Türkiye earthquake.

Two earthquakes on 6 February 2023 destroyed 10 cities in Türkiye. We report our experience with pediatric victims during these catastrophes, with a focus on crush syndrome related-acute kidney injury (Crush-AKI) and death. Web-based software was prepared. Patient demographics, time under rubble (TUR), admission laboratory data, dialysis, and kidney and overall outcomes were recorded. A total of 903 injured children (median age 11.62years) were evaluated. Mean TUR was 13h (interquartile range 32.5, max 240h). Thirty-one of 32 patients with a TUR of >120h survived. The patient who was rescued after 10days survived. Two-thirds of the patients were given 50mEq/L sodium bicarbonate in 0.45% sodium chloride solution on admission day. Fifty-eight percent of patients were given intravenous fluid (IVF) at a volume of 2000-3000mL/m2 body surface area (BSA), 40% at 3000-4000mL/m2 BSA and only 2% at >4000mL/m2 BSA. A total of 425 patients had surgeries, and 48 suffered from major bleeding. Amputations were recorded in 96 patients. Eighty-two and 66 patients required ventilator and inotropic support, respectively. Crush-AKI developed in 314 patients (36% of all patients). In all, 189 patients were dialyzed. Age >15years, creatine phosphokinase (CK) ≥20950U/L, TUR ≥10h and the first-day IVF volume <3000-4000mL/m2 BSA were associated with Crush-AKI development. Twenty-two deaths were recorded, 20 of 22 occurring in patients with Crush-AKI and within the first 4days of admission. All patients admitted after 7days survived. These are the most extensive pediatric kidney disaster data obtained after an earthquake. Serum CK level was significantly associated with Crush-AKI at the levels of >20950U/L, but not with death. Adolescent age and initial IVF of less than 3000-4000mL/m2 BSA were also associated with Crush-AKI. Given that mildly injured victims can survive longer periods in the disaster field, we suggest uninterrupted rescue activity for at least 10days.

Risk factors of postoperative delirium following spine surgery: A meta-analysis of 50 cohort studies with 1.1 million participants

ObjectivesPostoperative delirium (POD) is considered to be a common complication of spine surgery. Although many studies have reported the risk factors associated with POD, the results remain unclear. Therefore, we performed a meta-analysis to identify risk factors for POD among patients following spinal surgery. MethodsWe systematically searched the PubMed, Embase and the Cochrane Library for relevant articles published from 2006 to February 1, 2023 that reported risk factors associated with the incidence of POD among patients undergoing spinal surgery. The Meta-Analysis of Observational Studies in Epidemiology (MOOSE) guidelines were followed, and random effects models were used to estimate pooled odds ratio (OR) estimates with 95 % confidence intervals (CIs) for each factor. The evidence from observational studies was classified according to Egger's P value, total sample size, and heterogeneity between studies. ResultsOf 11,329 citations screened, 50 cohort studies involving 1,182,719 participants met the inclusion criteria. High-quality evidence indicated that POD was associated with hypertension, diabetes mellitus, cardiovascular disease, pulmonary disease, older age (>65 years), patients experiencing substance use disorder (take drug ≥1 month), cerebrovascular disease, kidney disease, neurological disorder, parkinsonism, cervical surgery, surgical site infection, postoperative fever, postoperative urinary tract infection, and admission to the intensive care unit (ICU). Moderate-quality evidence indicated that POD was associated with depression, American Society of Anesthesiologists (ASA) fitness grade (>II), blood transfusion, abnormal potassium, electrolyte disorder, length of stay, inability to ambulate and intravenous fluid volume. ConclusionsConspicuous risk factors for POD were mainly patient- and surgery-related. These findings help clinicians identify high-risk patients with POD following spinal surgery and recognize the importance of early intervention.

Hemodynamic Resuscitation Characteristics of Emergency Department Patients with Sepsis and Hypotension who are and are not Admitted to ICU; a Prospective Cross-sectional Study.

There is an evidence-practice gap in the optimal timing and volume of intravenous fluid as well as vasopressor administration in managing patients with sepsis. This study aimed to explore current hemodynamic resuscitation practice in emergency department (ED) for patients with sepsis and hypotension. This is a sub-analysis of the prospective multicentre ARISE FLUIDS observational study, which was conducted in 70 EDs across Australia and New Zealand. Baseline characteristics, as well as ED management and outcome of sepsis patients were compared between patients who were and were not admitted to intensive care unit (ICU) or high dependency unit (HDU). A total of 587 patients with a median age of 65 years and even sex distribution (49% female) were available for analysis. Almost two-thirds of patients with sepsis (63.2%, n=371) were not admitted to ICU/HDU and were given lower intravenous (IV) fluid volumes over 24-hours, compared to those receiving critical care (4077ml vs. 5421ml, p<0.001). Patients not admitted to an ICU/HDU had a lower Acute Physiology And Chronic Health Evaluation (APACHE) II score (median 14 vs. 18, P<0.001) and serum lactate level (1.8 vs. 2.8 mmol/L, P<0.001) compared to those admitted to ICU/HDU and 5.9% received a vasopressor infusion in the first 24-hours. Females, patients aged <65 years, and those with urosepsis or sepsis of non-respiratory origin received a greater volume of IV fluids. Almost two-thirds of patients were not admitted to ICU/HDU. In patients not admitted to ICU/HDU, 1 in 17 received a vasopressor infusion during their ED or early hospital stay. Patients not admitted to ICU/HDU received less fluid in the first 24 hours than those who were. Greater resuscitation fluid volumes were independently associated with female sex, age <65 years, higher lactate levels, and urinary or non-respiratory source of sepsis.

Intravenous fluid therapy and hospital outcomes for vaso-occlusive episodes in children, adolescents, and young adults with sickle cell disease.

While intravenous fluid (IVF) therapy in patients with sickle cell disease (SCD) admitted for a vaso-occlusive episode (VOE) can help reduce red blood cell sickling, clinical practice varies across institutions. We examined the relationship between IVF therapy and hospital length of stay (HLOS), as well as adverse events, such as acute chest syndrome (ACS), pediatric intensive care unit (PICU) transfer, and 28-day re-admission. This is a single-center retrospective analysis of SCD VOE hospitalizations between January 2015 and April 2020. Patients with SCD, age 0-30, with consecutive hospitalizations for VOE were included. For the first 3days of each admission, an "IVF ratio" was calculated by dividing actual IVF rate administered by weight-based maintenance IVF (mIVF) rate. A total of 617 hospitalizations for 161 patients were included. Mean HLOS was 5.7days, (SD 3.9), and mean IVF volume over the first 3days of admission was 139.6mL/kg/day (SD 57.8). Multivariate analysis showed that for each additional 0.5 times the mIVF rate, HLOS increased by 0.53day (p<.001; 95% confidence interval [CI]: 0.609-0.989), but there was no significant association between IVF therapy and adverse events. History of chronic pain was associated with increased odds of re-admission (OR 6.4; 95% CI: 3.93-10.52). Despite the theoretical potential for IVF therapy to slow down the sickling process, our findings suggest that increased IVF therapy was associated with prolonged HLOS, which places a burden on patients, families, and the health system.

Management of kidney injury in critically ill patients with earthquake-induced crush syndrome: A case series of 18 patients.

We evaluated 18 patients with crush syndrome who were admitted to the intensive care unit (ICU) after the great earthquake in February 2023 in Turkey. AKI occurred in 83% (n:15) of these patients after ICU admission (AKI-1; 16.6% [n:3], AKI-2; 16.6% [n:3], and AKI-3; 50% [n:9]). While the majority of patients who developed crush syndrome were treated with high volume intravenous hydration, only 33% (n:6) of all patients required renal replacement therapy. All patients who developed AKI had complete recovery in renal functions at the end of 2 months. There is no need for routine renal replacement therapy in the treatment of AKI, which is frequently seen in patients with crush syndrome. Most can be treated with high volumes of intravenous fluid.

Is aggressive intravenous fluid prescription the answer to reduce mortality in severe pancreatitis? The FLIP study: Fluid resuscitation in pancreatitis.

Acute pancreatitis is an emergency presentation, which can range from mild to life threatening. Intravenous fluids are the cornerstone of management. Although the WATERFALL trial described the optimal fluid rate in mild/moderate pancreatitis, this trial excluded patients with moderate-severe/severe pancreatitis. The aim of this study was to establish clinical practice regarding intravenous fluid administration in acute pancreatitis and assess its effect on mortality. Prospective multi-centre audit of patients with acute pancreatitis was conducted. Data were collected regarding intravenous fluid administration within 72 hours of admission. The primary outcome was 30-day mortality. Multivariable logistic regression was used to identify predictors of 30-day mortality. Those with severe pancreatitis received more fluid; median 5.7 L versus 4 L in 72 hours (p = 0.003). Participants with severe pancreatitis who died within 30 days received a median of 2,750 mL in the first 24 hours, compared to 4,000 mL in those who survived. The following factors were significant predictors of 30-day mortality: age, Glasgow score, C-reactive protein, ischaemic heart disease, and pancreatitis aetiology. Overall, volume of intravenous fluid was not associated with mortality. However, the effect of intravenous fluid volume on mortality differed significantly depending on pancreatitis severity. In severe pancreatitis, increased volume of intravenous fluid was associated with significant reductions in mortality (odds ratio = 0.655; 0.459-0.936; p = 0.020). In severe pancreatitis, more aggressive fluid prescription was associated with decreased mortality; however, this was not the case in milder disease. Further prospective trials guiding fluid resuscitation in severe pancreatitis are needed, as the impact of fluid on this population appears to differ from that in those with milder disease.

Protective Effect of Subcutaneous Drains on Wound Infections in Kidney Transplantation

Wound infections following kidney transplantation are common, with a reported incidence of 5%-19%. In the first few days after surgery, these patients receive extremely high doses of immunosuppression and high volumes of intravenous fluids, and they represent a specific subgroup of surgical patients that may benefit from using prophylactic subcutaneous drains. We analyzed a nonrandomized series of 112 consecutive kidney transplants between January 2017 and December 2019: those who received a subcutaneous drain in addition to the standard retroperitoneal drain (SQ drain group) vs those with a retroperitoneal drain alone (standard group). The SQ drain group had a significantly higher median BMI (31.2 vs 25.8, P < .0001) and a trend towards more patients having diabetes and receiving thymoglobulin on induction. Nonetheless, 1/36 (3%) of patients in the SQ drain group had a documented wound infection requiring packing compared to the standard group 13/73 (17%) (P = .032). When multivariate regression analysis accounted for the potential confounders BMI, thymoglobulin use, and diabetes, the protective effect of the SQ drain was more significant (P = .001). An SQ drain may be a simple and inexpensive method to reduce the rate of wound complications in kidney transplant recipients; prospective studies are warranted.

Evaluation of Blood Lactate Concentrations as a Marker for Resuscitation and Prognosis in Patients with Major Burns

Background Severe burns require appropriate fluid management in the acute phase. A massive volume of intravenous fluid is usually required to ensure adequate end-organ perfusion. Lactate is a product of anaerobic metabolism. A high level of lactate in tissue is direct indication of tissue hypoxia. The correlation between serum lactate and clinical outcome has been well accepted in hemorrhagic and septic shock. However, studies on its use in predicting mortality and morbidity of major burn patients in particular is sparse. Early prediction of outcome in patients with major burn is very likely to aid suitable modification of management strategies. Objective To assess the role of serum lactate measurement as the predictor burn patient's outcome (survivors and non-survivors). Patients and Methods 30 patients with major burn (more than 20% of TBSA) were included. This includes operated/ non-operated patients. Of the 30 patients, 20 were males and 10 were females. All adult burned patients admitted within the first 24h post burn were included in the study. Patients admitted after 24h from the thermal injury, or those who were discharged or died 48h after admission were excluded. Results Serial blood lactate measures were better as a prognostic tool than isolated measure. Reduction or normalization of lactate levels 24 hours after admission was significantly associated with a higher probability of survival. This study confirms the prognostic value of serum lactate for mortality in patients with major burns as serial blood lactate measurements predict mortality in these patients. Conclusion Although many studies reiterate the importance of blood lactate and lactate clearance in predicting mortality in burn patients, the role of these markers in therapy titration is ambiguous. Overzealous fluid resuscitation can cause fluid overload and acute respiratory distress syndrome. little regional data are available to establish the importance of blood lactate. We have demonstrated the association of blood lactate in the first 36 hours of the burn injury with mortality. Further large multicenter prospective studies are required.

Effects of Teduglutide on Diarrhea in Pediatric Patients with Short Bowel Syndrome-Associated Intestinal Failure.

This post-hoc analysis evaluated the effect of teduglutide treatment on diarrhea in patients with short bowel syndrome-associated intestinal failure (SBS-IF). Data from 2 open-label, multicenter, phase 3 pediatric SBS-IF clinical trials of teduglutide (NCT01952080 and NCT02682381) were pooled where possible. The primary objective was to evaluate the change in stool consistency, frequency, and volume from baseline to weeks 12 and 24 of treatment in patients who received any teduglutide dose from both studies ("total teduglutide"). Safety assessments included gastrointestinal adverse event reporting. Overall, 101 patients were analyzed. Among the total teduglutide group (n = 87), there were significant changes from baseline to weeks 12 and 24 in mean (standard error) Bristol Stool Form Scale (BSFS) score [-1.8 (0.26; P < 0.0001) and -2.2 (0.27; P < 0.0001), respectively], parenteral nutrition and/or intravenous fluid (PN/IV) volume [-16.9 (1.7; P < 0.0001) and -20.1 (2.3; P < 0.0001) mL/kg/day, respectively], and enteral nutrition volume [9.2 (1.7; P < 0.0001) and 9.6 (2.3; P = 0.0002) mL/kg/day, respectively]. Among patients in the standard of care group (n = 14) there were numerical changes in BSFS score, and enteral nutrition volume at weeks 12 and 24; significant changes in PN/IV volume [-6.9 (1.5) mL/kg/day; P = 0.0041] were observed at 24 weeks, but not at 12 weeks. In this post-hoc analysis, short-term treatment with teduglutide was associated with improved stool consistency, as well as trends towards reductions in PN/IV requirements and advancements in enteral nutrition volume in children with SBS-IF. Further research assessing the impact of patient-level factors on stool characteristics when using teduglutide is warranted.