Intravenous Fluid Infusion Research Articles

Effect of Slower vs Faster Intravenous Fluid Bolus Rates on Mortality in Critically Ill Patients

Slower intravenous fluid infusion rates could reduce the formation of tissue edema and organ dysfunction in critically ill patients; however, there are no data to support different infusion rates during fluid challenges for important outcomes such as mortality.To determine the effect of a slower infusion rate vs control infusion rate on 90-day survival in patients in the intensive care unit (ICU).Unblinded randomized factorial clinical trial in 75 ICUs in Brazil, involving 11 052 patients requiring at least 1 fluid challenge and with 1 risk factor for worse outcomes were randomized from May 29, 2017, to March 2, 2020. Follow-up was concluded on October 29, 2020. Patients were randomized to 2 different infusion rates (reported in this article) and 2 different fluid types (balanced fluids or saline, reported separately).Patients were randomized to receive fluid challenges at 2 different infusion rates; 5538 to the slower rate (333 mL/h) and 5514 to the control group (999 mL/h). Patients were also randomized to receive balanced solution or 0.9% saline using a factorial design.The primary end point was 90-day survival.Of all randomized patients, 10 520 (95.2%) were analyzed (mean age, 61.1 years [SD, 17.0 years]; 44.2% were women) after excluding duplicates and consent withdrawals. Patients assigned to the slower rate received a mean of 1162 mL on the first day vs 1252 mL for the control group. By day 90, 1406 of 5276 patients (26.6%) in the slower rate group had died vs 1414 of 5244 (27.0%) in the control group (adjusted hazard ratio, 1.03; 95% CI, 0.96-1.11; P = .46). There was no significant interaction between fluid type and infusion rate (P = .98).Among patients in the intensive care unit requiring fluid challenges, infusing at a slower rate compared with a faster rate did not reduce 90-day mortality. These findings do not support the use of a slower infusion rate.ClinicalTrials.gov Identifier: NCT02875873.

Adrenal crisis and mortality rate in adrenal insufficiency and congenital adrenal hyperplasia.

Primary adrenal insufficiency (PAI) is characterized by the inability of the adrenal cortex to produce sufficient amounts of glucocorticoids and/or mineralocorticoids. Addison's disease (AD) and congenital adrenal hyperplasia (CAH) are the most frequent disorders in adults and children, respectively. Despite the diagnostic advances and the availability of glucocorticoid and mineralocorticoid replacements, adrenal crisis (AC) is still a potentially lethal condition contributing to the increased mortality, not only during the first year of life, but also throughout life. Failure in increasing glucocorticoid doses during acute stress, when greater amounts of glucocorticoids are required, can lead to AC and an increase morbimortality rate of PAI. Considering a mortality rate of 0.5 per 100 patient years, up to 1,500 deaths from AC are expected in Brazil in the coming decade, which represents an alarming situation. The major clinical features are hypotension and volume depletion. Nonspecific symptoms such as fatigue, lack of energy, anorexia, nausea, vomiting, and abdominal pain are common. The main precipitating factors are gastrointestinal diseases, other infectious disease, stressful events (e.g., major pain, surgery, strenuous physical activity, heat, and pregnancy), and withdrawal of glucocorticoid therapy. Suspected AC requires immediate therapeutic action with intravenous (iv) hydrocortisone, fluid infusion, monitoring support, and antibiotics if necessary. AC is best prevented through patient education, precocious identification and by adjusting the glucocorticoid dosage in stressor situations. The emergency card, warning about acute glucocorticoid replacement, has high value in reducing the morbidity and mortality of AC.

Risk Factors of Delayed Recovery of Gastrointestinal Function After Ileostomy Reversal for Rectal Cancer Patients.

PurposeThe aim of this study was to identify the risk factors associated with delayed recovery of gastrointestinal function after ileostomy reversal for rectal cancer patients.MethodsIn this retrospective study, the data of rectal cancer patients who underwent ileostomy reversal from January 2018 to December 2019 at the Sixth Affiliated Hospital of Sun Yat-sen University were assessed to investigate potential risk factors of delayed flatus after ileostomy reversal.ResultsA total of 282 patients were eligible for this study. Postoperative first flatus time ranged from 1 to 9 days, of which 58.8% patients presented with delayed flatus that was longer than 3 days. Univariate analysis showed that delayed postoperative flatus was significantly associated with the length of postoperative hospital stay (P<0.001) and postoperative complications (P=0.037). Multivariate analysis showed that intravenous fluid infusion at postoperative day 1 (POD1) (OR=1.001, 95% CI: 1.001–1.002, P=0.001) and duration of stoma ≥6 months (OR=2.005, 95% CI:1.155–3.657, P=0.014) were independent risk factors for delayed flatus.ConclusionIncreased intravenous fluid infusion at POD1 and duration of stoma ≥6 months were related to delayed recovery of gastrointestinal function after ileostomy reversal for rectal cancer patients.

819-P: Comparison of Two Nurse-Driven Adult Diabetic Ketoacidosis (DKA) Treatment Protocols Using a Single Bag vs. Simultaneous Two-Bag Maintenance Intravenous Fluids

Objective: Evaluate safety and efficacy of a novel, simultaneous 2-bag (2B) maintenance intravenous fluid (IVF) DKA protocol compared with a conventional, single 1-bag (1B) protocol in adults. Methods: Retrospective, observational review of patients treated with a DKA protocol from March-June 2017 (1B group) and March-June 2019 (2B group). One bag (1B) protocol: individual infusion of 1B IVF of ½ NS, ½ NS + KCL, D5W, OR D5W + KCL. Two bag (2B) protocol: simultaneous IVF infusion of 2B of D10W + KCL AND ½ NS + KCL. Safety endpoints of hypoglycemia, hyperkalemia, hypokalemia as well as efficacy endpoints of DKA resolution, incidence of rebound hyperglycemia, and hospital length of stay (LOS) were evaluated. Results: A total of 605 patients were included (1B: n=204; 2B: n=401). Both groups had similar baseline characteristics except a higher baseline beta-hydroxybutyrate level in the 2B group than 1B (3.2 vs. 2.4; P=0.02) and differences in distribution of Body Mass Index (BMI) categories. Safety: Significantly fewer patients had hypoglycemia (BG &amp;lt;70 mg/dL) in the 2B group than 1B (15% vs. 22%, P=0.04), but severe hypoglycemia (BG &amp;lt; 40 mg/dL) was not different (0.5% vs. 1.5%, P=0.3). Incidence of hyperkalemia (K &amp;gt; 5.2 mEq/L) was significantly lower in the 2B group than 1B (10% vs. 21%, P&amp;lt;0.01), but hypokalemia (K &amp;lt; 3.3 mEq/L) was not different (21% vs. 24%, P=0.4). Efficacy: Median time to DKA resolution was similar between the 2B and 1B (15.0 vs. 15.6 hours, P=0.6). Rebound hyperglycemia (BG &amp;gt; 250 mg/dL) was less in 2B than 1B (29% vs. 44%, P&amp;lt;0.01). The 2B group had a trend of decreased LOS, but the difference was not statically significant (3.7 vs. 4.3 days, P=0.06). Conclusion: In adult patients with DKA, a 2-bag protocol performed better in hypoglycemia, hyperkalemia, and rebound hyperglycemia without changing time to DKA resolution or LOS. In addition, the 2-bag protocol offered simplicity by decreasing the number of IVF bag options for the nurse. Disclosure R. Halfon: Stock/Shareholder; Spouse/Partner; Pfizer Inc. D. Dreucean: None. M. Sirimaturos: None. A. R. Sadhu: None.

Quantifying the Impact of Infusion Alerts and Alarms on Nursing Workflows: A Retrospective Analysis.

Smart infusion pumps affect workflows as they add alerts and alarms in an information-rich clinical environment where alarm fatigue is already a major concern. An analytic approach is needed to quantify the impact of these alerts and alarms on nursing workflows and patient safety. To analyze a detailed infusion dataset from a smart infusion pump system and identify contributing factors for infusion programming alerts, operational alarms, and alarm resolution times. We analyzed detailed infusion pump data across four hospitals in a health system for up to 1 year. The prevalence of alerts and alarms was grouped by infusion type and a selected list of 32 high-alert medications (HAMs). Logistic regression was used to explore the relationship between a set of risk factors and the occurrence of alerts and alarms. We used nonparametric tests to explore the relationship between alarm resolution times and a subset of predictor variables. The study dataset included 745,641 unique infusions with a total of 3,231,300 infusion events. Overall, 28.7% of all unique infusions had at least one operational alarm, and 2.1% of all unique infusions had at least one programming alert. Alarms averaged two per infusion, whereas at least one alert happened in every 48 unique infusions. Eight percent of alarms took over 4 minutes to resolve. Intravenous fluid infusions had the highest rate of error-state occurrence. HAMs had 1.64 more odds for alerts than the rest of the infusions. On average, HAMs had a higher alert rate than maintenance fluids. Infusion pump alerts and alarms impact clinical care, as alerts and alarms by design interrupt clinical workflow. Our study showcases how hospital system leadership teams can leverage infusion pump informatics to prioritize quality improvement and patient safety initiatives pertaining to infusion practices.

Nivolumab-induced hypophysitis followed by acute-onset type 1 diabetes with renal cell carcinoma: a\xa0case report

BackgroundImmune checkpoint inhibitors have recently become widely used for the management of advanced cancer patients. During the development of immune checkpoint inhibitors (ICPIs), it was quickly recognized that they are associated with autoimmune or autoinflammatory side effects. These toxicities are known as immune-related adverse events (irAEs): common endocrine irAEs include hypophysitis and thyroid dysfunction, and uncommon irAEs include type 1 diabetes mellitus (T1DM).Case presentationA 62-year-old Japanese man with metastatic renal cell carcinoma was treated with sunitinib followed by the 10th cycle of treatment with the ICPI nivolumab. He had already had thyroiditis and hypophysitis due to these anti-cancer drugs. On admission, he showed an extremely elevated plasma glucose level (601 mg/dl) and a low C-peptide level, and was diagnosed with acute T1DM. The patient was treated with intravenous fluid infusion and continuous insulin infusion. On the second day, he was switched to multiple daily injections of insulin therapy. Since these treatments, his blood glucose levels have been stable and he has been treated with an additional 10 ICPI treatments for renal cell carcinoma for over a year.ConclusionsTreatment with ICPIs is expected to increase in the future. There may be cases in which their use for cancer treatment is inevitable despite the side effects. As long as treatment with ICPI continues, multiple side effects can be expected in some cases. It is important to carefully observe the side effects that occur during ICPI treatment and to provide appropriate treatment for each side effect.

Comparative Clinical Effects of Early Pharyngostomy Alimentation and Intravenous Fluid Infusion following Oesophageal Transection and Anastomosis in Nigerian Breeds of Dogs

Twelve adult Nigerian breeds of dogs were used to compare the clinical responses of dogs alimented through pharyngostomy tubes (PGTs) with those maintained on intravenous infusion (50:50 mixture of Ringers lactate and 5% dextrose saline) during the first 14 days following oesophageal transection and anastomosis (OTA). The dogs were assigned to two groups (n=6), the pharyngostomy tube (PGT) group and the intravenous fluid infusion (IVF) group (n=6). Dogs in both groups underwent routine OTA. The PGT group was fed blanched processed dog food at 70g/kg body weight for 14 days through PGTs, while the IVF group was maintained on intravenous fluids at a dose of 70 mL/kg body weight daily also for 14 days post operatively. The postoperative complications observed in both groups showed that the mortality rate in the IVF group (83.3%) was significantly (P &lt; 0.05) higher than in the PGT group (16.7%). Vomiting and leakages at the site of oesophageal anastomosis did not differ significantly between the groups. Cervical swelling was observed in two dogs (33.3%) in the IVF group, while tenesmus and displacement of the tubes were recorded in 66.6% and 100% respectively of the dogs in the PGT group. It is concluded that feeding dogs which had undergone OTA through PGTs during the immediate postoperative period reduces their morbidity and mortality; and shortens the recovery period when compared with similar dogs maintained solely on intravenous fluids.&#x0D; Keywords: Oesophageal, Transection, Anastomosis, Pharyngostomy, Complications, Morbidity, Mortality.

WITHDRAWN: Smart intravenous infusion monitoring and controlling system using Internet of Things

As technology is progressing at a very high pace, it is imperative to occupy with the progress in medical science. The latest shift that is happening in the world as regards our health. In the current saline bottle monitoring system, the intravenous infusion of fluids by gravity flow is a common procedure in medical care facilities. It is of vital importance that the fluid for infusion is replaced with a fresh supply when the fluid bottle is empty. This requires regular inspection by a nurse. In some cases, a pressure difference between a vein of a patient and the saline bottle may cause a reverse flow of the fluid from the patient to the saline bottle, which may prove fatal to the patient. Thus, a need for a system for efficiently and effectively monitoring a fluid level in a saline bottle with minimum human intervention. This paper provides a solution to overcome these problems with the aid of the Internet, sensors can interact with each other via the whole Bio Medical instrument which is placed on the monitoring equipment. This system is easily adaptable for any type of fluid bottle regardless of its initial size and weight.

Optimal sepsis patient treatment using human-in-the-loop artificial intelligence

Sepsis is one of the leading causes of death in Intensive Care Units (ICU). The strategy for treating sepsis involves the infusion of intravenous (IV) fluids and administration of antibiotics. Determining the optimal quantity of IV fluids is a challenging problem due to the complexity of a patient’s physiology. In this study, we develop a data-driven optimization solution that derives the optimal quantity of IV fluids for individual patients. The proposed method minimizes the probability of severe outcomes by controlling the prescribed quantity of IV fluids and utilizes human-in-the-loop artificial intelligence. We demonstrate the performance of our model on 1122 ICU patients with sepsis diagnosis extracted from the MIMIC-III dataset. The results show that, on average, our model can reduce mortality by 22%. This study has the potential to help physicians synthesize optimal, patient-specific treatment strategies.

Options of severe preeclampsia treatment

Background. Preeclampsia (PE) occurs in 2-8 % of all pregnancies. Every day 210 women die from PE, and neonatal losses are even greater (1380 children per day). Fatal complications of severe PE include cerebral hemorrhage, cerebral edema, pulmonary edema, placental abruption, adrenal hemorrhage, dissecting aortic aneurysm, HELLP syndrome, disseminated intravascular coagulation syndrome. Excessive intravenous fluid infusion is one of the causes of pulmonary edema in PE.&#x0D; Objective. To describe the options of severe PE treatment.&#x0D; Materials and methods. Analysis of literature data on this issue.&#x0D; Results and discussion. The pathogenesis of PE is based on total damage to the vascular endothelium, which leads to an increase in its permeability, including for albumin molecules. Plasma protein loss is accompanied by a drop in oncotic blood pressure and fluid leakage into the interstitial space. Thus, in patients with PE there is an associated disturbance of fluid and electrolyte balance: along with intravascular dehydration there is extravascular hyperhydration. Infusion therapy (IT) allows to overcome this imbalance and to increase the colloid-osmotic pressure. According to modern views, a restricted IT regimen improves the effects of PE treatment. There are two ways to correct this disorder: an increase in oncotic blood pressure due to infusion of albumin (indicated in case of blood albumin levels &lt;25 g/L) and the administration of osmotically active drugs, such as Reosorbilact (“Yuria-Pharm”). The latter option prevents the loss of fluid from the vascular bed and promotes its return to the vessels from the intercellular space. The total fluid volume should be limited to physiological needs, taking into account pathological losses (not more than 1 ml/kg/h). The maximum IT volume should not exceed 800 ml per day. The drugs of choice for IT before delivery are balanced isotonic saline solutions and solutions containing 6 % sorbitol. Fresh-frozen plasma is not recommended for the correction of colloid-oncotic pressure. Influence on the redistribution of fluid in the interstitial space without the introduction of significant volumes of infusion solutions is the main principle of low-volume IT. Recommendations for the administration of Reosorbilact comply with this principle. The low osmolarity of Reosorbilact and its ability to improve the osmotic properties of blood justify the use of this drug in women with PE.&#x0D; Conclusions. 1. PE occurs in 2-8 % of all pregnancies. 2. Excessive intravenous fluid infusion is one of the causes of pulmonary edema in PE. 3. Restricted IT mode improves the consequences of PE treatment. 4. Osmotically active drugs (Reosorbilact) are prescribed for this purpose.

Case Report : Severe Hypernatremia following treatment for Hyperosmolar Hyperglycaemic State : A pragmatic approach used to manage hypernatremia

The Hyperosmolar Hyperglycaemia State (HHS) is an endocrine emergency with a mortality rate between 10 and 50%. The mainstay for the treatment of this condition is vigorous IV fluid replacement with close monitoring of blood glucose, serum osmolality, and electrolytes. However, after initial resuscitation, patients can develop hypernatremia and raised serum osmolality, which have deleterious consequences. While hypernatremia in HHS can be treated with infusions of 0.45% saline or 5% dextrose, alternate measures such as intravenous (IV) hypotonic fluid infusion [e.g. 0.18% sodium chloride (NaCl) containing 4% dextrose and 0.15% potassium chloride (KCl)], or free water administration through a nasogastric (NG) tube can be used. We report the case of a 70-year-old man, who was initially admitted to a medical high care ward (MHC) with HHS, and was transferred to the ICU 72 hours later with an altered level of consciousness and severe hypernatremia. His treatment consisted in an IV hypotonic 0.18% NaCl infusion containing 4% dextrose and 0.15% KCl. He also received free water through a NG tube at a rate that was calculated to correct natremia at an average rate of 0.55 meq L-1 hr-1 over 72 hours. A multipronged approach was instituted to manage this patient, including, in addition to natremia correction, blood glucose control with insulin, appropriate IV antibiotics to treat infected foot ulcers, adequate analgesic medications, low-molecular-weight- heparin (LMWH) for thromboprophylaxis, proton- pump inhibitors, and continuation of patient’s ongoing antidepressant drugs at the time of his Glasgow Coma Score improvement. This case report demonstrates the feasibility and success of IV hypotonic fluid (0.18% NaCl - 4% dextrose - 0.15% KCl), alongside NG free water for correcting sodium levels with lower fluid volumes than would have been otherwise required if corrected with 0.45% saline. This treatment seems to be a reasonable choice for correcting sodium levels and osmolality in HHS patients who present with hypernatremia after an initial resuscitation, insofar as it avoids fluid overload and provides dextrose as an energy substrate, in addition to potassium ions. However, while correcting natremia with hypotonic fluid, other aspects of management should not be ignored.

Abstract 17170: Does Cardiopulmonary Bypass Provide Adequate End-Organ Perfusion?

Introduction: Our clinical experience in cardiac surgery teaches us that a subset of patients show signs of unexplained end-organ hypoperfusion after an otherwise unremarkable procedure. The objective of this study is to comprehensively examine cardiopulmonary bypass (CPB) management parameters and end-organ perfusion. Hypothesis: Despite advancements in CPB management, CPB does not provide adequate end-organ perfusion. Methods: Retrospective analysis was performed using data from 1462 cardiac operations performed from 2/2019 to 4/2020, excluding circulatory arrest and non-CPB cases. CPB management parameters included cardiac index (CI), mean arterial pressure (MAP), vasopressor-phenylephrine use, lines and bladder temperatures, hemoglobin (Hgb), indexed oxygen delivery (iDO 2 ), and intravenous fluid infusion. End-organ perfusion markers included lactate levels, mixed venous oxygen saturation (SvO 2 ), oxygen consumption (VO 2 ), and arterial pH. Results were expressed as means with first standard deviation. Results: During CPB, CI, MAP, iDO 2 and Hgb were 2.2 ± 0.4 l/min/m 2 , 67 ± 16 mmHg, 270 ± 71 ml/min/m 2 , and 9.3 ± 1.6 g/dl respectively (Figure 1). Phenylephrine cumulative dose increased with CPB duration, 11 ± 9 mg at 1h and 20 ± 15 mg at 2h. Fluid administration showed similar trend. Core mean temperature was maintained with nadir being 33.5 ± 3.4°C. SvO 2 rapidly increased with institution of CPB, peaking at 85%, and then slowly declined. Inversely, VO 2 dropped and then slowly increased. Lactate continuously increased with duration of CPB. Conclusions: Our findings suggest that despite hemodynamic values being maintained at goal by continuously high vasopressor use and fluid administration during CPB, tissue perfusion was inadequate.Our study suggests that, using data-driven approaches, it may be time to revisit the assumptions regarding all aspects of managing CPB.

Strategies to Aid Identification of Apheresis PowerFlow Ports: A Case Report

IntroductionThe PowerFlow implantable apheresis intravenous port is a venous access device for therapeutic apheresis procedures. In this case review article, we identify key similarities and differences between apheresis PowerFlow ports and traditional ports. We also list strategies that emergency departments can implement to aid in correct port identification. MethodsUsing a case review format, we describe the clinical presentation of a 33-year-old female with neuromyelitis optica who was evaluated in the emergency department for an acute exacerbation. She had a history of outpatient apheresis procedures that made use of bilateral PowerFlow ports. Mistaken for a conventional port, the right PowerFlow port was accessed with a Huber needle rather than the appropriate catheter-over-needle device. On infusion of intravenous fluids, the patient experienced pain and swelling. Ultimately, the port malfunctioned and was eventually replaced. ResultsA subsequent root cause analysis identified opportunities for education and aids to improve port identification. To this end, strategies were implemented to appropriately identify the PowerFlow port using at least 2 of the following methods: (1) look in the patient’s chart for record of an implantable apheresis intravenous port; (2) check the port identification card, bracelet, or keychain issued at insertion; (3) palpate the port to look for the rounded top and hollow concave entry point; and (4) use x-ray or fluoroscopy to identify radiopaque port markers. ConclusionWhen a patient with a history of apheresis procedures presents with an implanted port, steps should be taken to ensure correct identification and access.

Nutritional Status Assessment in ICU Patients Using Ultrasound Imaging of Muscles and Subcutaneous Fat

Ultrasound imaging of muscles and subcutaneous fat has been used in recent years to assess the nutritional status, but there are no common approaches for selecting muscles for it.The aim of the study was to examine the variability of thickness of different muscles and subcutaneous fat using ultrasonography to identify optimal cutaneous and muscle landmarks for the assessment of nutritional status.Materials and methods. It was a prospective observational study with participation of 14 patients. All patients underwent ultrasound examination of thickness of the following muscles: m. rectus femoris; m. tibialis anterior; m. biceps brachii; m. deltoideus and m. sternocleidomastoideus, as well as the thickness of skin and subcutaneous fat over the muscles. The ultrasound assessment was done on admission to ICU, on days 7, 14, 21, 28, 42. On days 7, 14 and 21 the intravenous load test of 1000 ml of 0.9% sodium chloride solution was performed. On days 5 and 10 the test with the patients in the lateral decubitus position was carried out.Results. We found that m. tibialis anterior changed its size when patients were turned laterally by 2%, m. deltoideus by 6%, m. sternocleidomastoideus by 10%, m. rectus femoris by 20.5%, and m. biceps brachii by 26%. After infusion of 1,000 ml of 0,9% sodium chloride solution, the variability of m. tibialis anterior size was 2%, m. deltoideus 2%, m. sternocleidomastoideus 6%, m. biceps brachii 8%, m. rectus femoris 12%.The thickness of subcutaneous fat over m. biceps brachii and m. rectus femoris changed more than the anteroposterior size of the muscles (P&lt;0.05).Conclusion. The m. deltoideus and m. tibialis anterior are optimal for ultrasound assessment of the nutritional status because their size is less affected by the patient's positioning and infusion therapy. Intravenous fluid infusion increases the variability of subcutaneous fat thickness.

Clinical Efficacy of 50% Glucose Infusion in Restoring Intradialytic Hypotension

Objective Intradialytic hypotension complicates up to 30% of all dialysis treatments and is linked to increased morbidity and mortality. Intravenous fluid infusion is effective to restore blood pressure, yet the optimal replacement fluid remains unclear. This study aimed to evaluate the clinical efficacy of 50% glucose as the treatment for intradialytic hypotension in maintenance hemodialysis (MHD) patients. Methods Thirty-five MHD patients with intradialytic hypotension from February 2019 to March 2020 were enrolled in this study. The control group (n=17) received 100-200ml normal saline infusion, while the experimental group (n=18) received 100-200ml 50% glucose infusion. The blood pressure before and after hemodialysis was compared to determine the efficacy rate of the treatments. Results The efficacy rate of the experimental group was significantly higher than that of the control group (efficacy rate: 94.4% vs 64.7%, p=0.028). Patients in the experimental group restored their blood pressure faster than those in the control group (time to relief of symptoms: 12±6.5 vs 7.6±2.9 mins, p=0.014), indicating that 50% glucose infusion are more effective than the isotonic saline in treating intradialytic hypotension. Conclusions Compared with isotonic normal saline, 50% glucose might be a better option for the treatment of hypotension during hemodialysis.

Megacolon Concurrent with Perineal Hernia in a Male Rough Collie

Perineal hernia occurs frequently in aged collies as a result of weakening of the pelvic diaphragmatic muscle or its total failure, thereby allowing displacement of abdominal contents into the perineum. Surgical management include subtotal colectomy, colotomy, internal obturator muscle transposition and perineal herniorrhaphy. This report highlights a case of perineal hernia associated with megacolon as well as its successful management in a dog. A seven years old, male Rough Collie was presented with a complaint of right perineal swelling that has lasted for a week as well as inappetance and absence of defecation. Physical examination was unremarkable except for 3% dehydration and a firm, large perineal non-reducible swelling. Plain abdominal radiography revealed perineal hernia with megacolon. Serum chemistry showed azotaemia. Emergency surgical intervention involving colotomy, perineal herniorrhaphy with incisional colopexy were conducted. Post-operative care included ceftriaxone injection at 50mg/kg intramuscularly, intravenous fluid infusion, one week fasting, daily wound dressing, Nutriplus® gel supplementation and administration of recovery diet post-fasting. Thus, surgical management using traditional perineal herniorrhaphy, colotomy with colopexy was effective in correcting the perineal hernia with megacolon.

Vitamin C in Home Parenteral Nutrition: A Need for Monitoring.

To date, there are no recommendations about screening plasma vitamin C concentration and adjust its supplementation in patients on long-term home parenteral nutrition (HPN). The aim of this study was to evaluate vitamin C status and determine if a commercial multivitamin preparation (CMVP) containing 125 mg of vitamin C is sufficient in stable patients on HPN. All clinically stable patients receiving HPN or an intravenous fluid infusion at least two times per week for at least 6 months, hospitalized for nutritional assessment, were retrospectively included, for a total of 186 patients. We found that 29% of the patients had vitamin C insufficiency (i.e., <25 µmol/L). In univariate analysis, C-reactive protein (CRP) (p = 0.002) and intake of only 125 mg of vitamin C (p = 0.001) were negatively associated with vitamin C levels, and duration of follow-up in our referral center (p = 0.009) was positively associated with vitamin C levels. In multivariate analysis, only CRP (p = 0.001) and intake of 125 mg of vitamin C (p < 0.0001) were independently associated with low plasma vitamin C concentration. Patients receiving only CMVP with a low plasma vitamin C level significantly received personal compounded HPN (p = 0.008) and presented an inflammatory syndrome (p = 0.002). Vitamin C insufficiency is frequent in individuals undergoing home parenteral nutrition; therefore, there is a need to monitor plasma vitamin C levels, especially in patients on HPN with an inflammatory syndrome and only on CMVP.

The impact of intra-arrest hypothermia.

To address the impact of therapeutic hypothermia induced already during cardiopulmonary resuscitation (i.e. intra-arrest cooling) and its association with neurologic functional outcome. Intra-arrest cooling is superior than post-ROSC cooling to mitigate brain injuries in experimental models of cardiac arrest. The delayed initiation of hypothermia in human studies may not have adequately addressed the underlying pathophysiology of ischemia and reperfusion. The assessment of early initiation of cooling has been complicated by increased rate of hemodynamic adverse events caused by infusion of cold intravenous fluids. These adverse events have been more deleterious in patients with initial shockable rhythms. A recent randomized study shows that an alternative intra-arrest cooling method using trans-nasal evaporative cooling was well tolerated and effective to shorten time to target temperature. However, the neurologic outcomes (CPC 1-2 at 90 days) in favor of intra-arrest cooling compared to hospital cooling (34.8% vs 25.9%, P = 0.11) in patients with initial shockable rhythms did not reach statistical significance. Therapeutic intra-arrest hypothermia can be initiated safely at the scene of the arrest using transnasal evaporative cooling. The potential beneficial effect of intra-arrest cooling on neurologic recovery in patients with initial shockable rhythms should be explored further.

Rapid Detection of Microbial Contamination in Intravenous Fluids by ATP-Based Monitoring System.

In this study, we investigated four clinical cases of microbial contamination of in-use intravenous infusion fluid, detected by measuring "Adenosine triphosphate (ATP) + adenosine monophosphate (AMP)" ("ATP+AMP") levels. High "ATP+AMP" values correlate with microbial contamination, and by utilizing these values as indicator for microbial contamination possibility, we were able to rapidly detect the contamination and recommend replacement of catheters and administration sets. In three out of four cases, changing the infusion fluid led to improvement in the condition of the patients. "ATP+AMP" levels can be used to confirm microbial contamination of in-use intravenous infusion fluids, as it is fast (several minites) and convenient to measure them.

Efficacy of Forced-air Warming and Warmed Intravenous Fluid for Prevention of Hypothermia and Shivering During Caesarean Delivery Under Spinal Anaesthesia: A Randomized Controlled Trial

(Eur J Anaesthesiol. 2019;36:442–448) Perioperative hypothermia and shivering are common in women undergoing cesarean delivery. Several complications have been associated with perioperative hypothermia, including surgical site infection and coagulopathy. During cesarean delivery maternal hypothermia may also lead to hypothermia in the newborn. The purpose of this prospective, randomized, controlled trial was to assess the effectiveness of preanesthetic forced-air warming combined with warmed intravenous (IV) fluid infusion to prevent maternal hypothermia and shivering in women receiving spinal anesthesia for undergoing cesarean delivery.