Intravenous Fluids Research Articles

P.112: Intravenous fluid therapy for the acute general surgical patient.

P.112: Intravenous fluid therapy for the acute general surgical patient.

Is an acute overdose of zolpidem fatal?

Zolpidem, widely prescribed for short-term management of insomnia, is a non-benzodiazepine hypnotic agent. It carries a high potential for abuse and an elevated risk of suicide. Overdose generally results in mild central nervous system depression, though severe outcomes are possible when co-ingested with other CNS depressants. Standard treatments include gastric lavage, flumazenil administration, and intravenous fluids. This case report describes a 66-year-old female admitted after an apparent suicidal ingestion of approximately 200 mg of zolpidem. Upon admission, she was unconscious, with bradypnea and hypotension, scoring 5 on the Glasgow Coma Scale. Gastric lavage and N-acetylcysteine were administered due to elevated liver enzymes suggesting concomitant paracetamol poisoning, which was confirmed by urine tests. Flumazenil temporarily improved her condition, and she was subsequently transferred to the Intensive Care Unit for mechanical ventilation. Her clinical status stabilized, leading to extubation on the second day and transfer to the Psychiatry Unit. This case highlights the critical need for timely intervention and continuous monitoring in zolpidem overdose scenarios, particularly when polypharmacy is involved. In instances of respiratory failure following zolpidem overdose, it is imperative to investigate the potential co-ingestion of additional substances.

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.

Associations between pre-existing comorbidities and in-hospital cardiovascular events and mortality among COVID-19 patients in Bangladesh: a secondary analysis of a prospective cohort study

ObjectiveTo identify the associations of in-hospital cardiovascular events and mortality with pre-existing comorbidities and cardiovascular disease (CVD) risk factors among COVID-19 patients in Bangladesh without vaccine availability.DesignA secondary analysis of...

Sequential recruitment of body fluid spaces for increasing volumes of crystalloid fluid.

The interstitial space harbours two fluid compartments linked serially to the plasma. This study explores conditions that lead to fluid accumulation in the most secluded compartment, termed the "third space". Retrospective data was collected from 326 experiments in which intravenous crystalloid fluid was administered to conscious volunteers as well as a small group of anaesthetized patients. The urinary excretion and plasma dilution derived from haemoglobin served as input variables in nine population volume kinetic analyses representing subtly different settings. An infusion of 250-500mL of Ringer's solution expanded only the central fluid space (plasma), whereas the infusion of 500-1,000mL extended into a rapidly exchanging interstitial fluid space. When more than 1L was infused over 30min, it was distributed across plasma and both interstitial fluid compartments. The remote space, characterized by slow turnover, abruptly accommodated fluid upon accumulation of 700-800mL in the rapidly exchanging space, equivalent to an 11%-13% volume increase. However, larger expansion was necessary to trigger this event in a perioperative setting. The plasma half-life of crystalloid fluid was 25 times longer when 2,000-2,700mL expanded all three fluid compartments compared to when only 250-500mL expanded the central space (14h versus 30min). As the volume of crystalloid fluid increases, it apparently occupies a larger proportion of the interstitial space. When more than 1L is administered at a high rate, there is expansion of a remote "third space", which considerably extends the intravascular half-life.

Fluid bolus in suspected Sepsis patients with Hyperlactatemia (FISH): Study protocol for an open-labeled, randomized controlled trial

Background: The adequate preload was the goal of hemodynamic optimization for sepsis resuscitation. The fluid strategy in the early phase of sepsis is unclear. Objective: To investigate the efficacy of a fluid bolus to prevent new-onset hypotension in suspected sepsis patients with hyperlactatemia (Point-of-care serum lactate 2-4 mmol/L). Methods: The Fluid Bolus in Suspected Sepsis Patients with Hyperlactatemia Trial (FISH) is a single-center, open-label randomized controlled trial. Participants will be patients suspected of having sepsis with hyperlactatemia (Point-of-care serum lactate 2-4 mmol/L) in the emergency department of Srinagarind Hospital, Thailand. Eligible patients will be randomized (1:1) to one of the study arms using block randomization. They will be placed in either the fluid bolus group (intervention, 30 mL/kg within 3 hours) or the standard care group (control). The primary outcome is new-onset hypotension within 24 hours after randomization. Secondary outcomes include lactate clearance, ∆SOFA at 72-hours, organ failure, and support ‘free days’ to day 28, 28-day mortality. Hypothesis: We hypothesize that a fluid bolus will prevent new-onset hypotension in suspected sepsis patients with hyperlactatemia (point-of-care serum lactate 2-4 mmol/L). Discussion: The optimal strategy for intravenous fluid therapy in a patient suspected of sepsis with hyperlactatemia is unknown. This is the first randomized trial examining fluid strategy in the early phase of sepsis with mild hyperlactatemia. Trial registration: TCTR20230502003

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

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

Moderate IV Fluid Resuscitation Is Associated With Decreased Sepsis Mortality.

Significant practice variation exists in the amount of resuscitative IV fluid given to patients with sepsis. Current research suggests equipoise between a tightly restrictive or more liberal strategy but data is lacking on a wider range of resuscitation practices. We sought to examine the relationship between a wide range of fluid resuscitation practices and sepsis mortality and then identify the primary driver of this practice variation. Retrospective analysis of the Premier Healthcare Database. Six hundred twelve U.S. hospitals. Patients with sepsis and septic shock admitted from the emergency department to the ICU from January 1, 2016, to December 31, 2019. The volume of resuscitative IV fluid administered before the end of hospital day- 1 and mortality. In total, 190,682 patients with sepsis and septic shock were included in the analysis. Based upon patient characteristics and illness severity, we predicted that physicians should prescribe patients with sepsis a narrow mean range of IV fluid (95% range, 3.6-4.5 L). Instead, we observed wide variation in the mean IV fluids administered (95% range, 1.7-7.4 L). After splitting the patients into five groups based upon attending physician practice, we observed patients in the moderate group (4.0 L; interquartile range [IQR], 2.4-5.1 L) experienced a 2.5% reduction in risk-adjusted mortality compared with either the very low (1.6 L; IQR, 1.0-2.5 L) or very high (6.1 L; IQR, 4.0-9.0 L) fluid groups p < 0.01). An analysis of within- and between-hospital IV fluid resuscitation practices showed that physician variation within hospitals instead of practice differences between hospitals accounts for the observed variation. Individual physician practice drives excess variation in the amount of IV fluid given to patients with sepsis. A moderate approach to IV fluid resuscitation is associated with decreased sepsis mortality and should be tested in future randomized controlled trials.

An in vitro study for reducing the cytotoxicity and dose dumping risk of remdesivir via entrapment in nanostructured lipid carriers

The aim of this study was to synthesize and evaluate nanostructured lipid carriers (NLCs) loaded with Remdesivir (RDV) to control its side effects in COVID-19 patients. Due to the low solubility and short half-life of RDV in the blood, an injectable formulation was prepared using sulphobutylether-beta-cyclodextrin. However, it can accumulate in the kidney and cause renal impairment. NLCs improve the parenteral delivery of hydrophobic drugs such as RDV by increasing drug solubility and bioavailability. For the synthesis of RDV-NLCs, the aqueous phase containing Tween 80 was injected into the lipid phase under rapid stirring and was sonicated. The experimental conditions were optimized using Box-Behnken design and Design Expert software. The optimum formulation contained a total lipid of 2.13%, a total surfactant of 1%, and a hot bath time of 71 min. The optimum formulation showed particle size, polydispersity index, zeta potential, and entrapment efficiency values of 151.0 ± 1.7 nm (from 149.1 to 152.1), 0.4 ± 0.1 (from 0.3 to 0.5), −43.8 ± 1.2 mV (from −42.4 to −44.7), and 81.34 ± 1.57% (from 79.52 to 82.33%), respectively. RDV-NLCs showed acceptable stability for 30 days at 25 ℃ and were compatible with commonly used intravenous infusion fluids for 48 h. FE-SEM images of RDV-NLC showed spherical particles with a mean diameter of 207 nm. The NLC-RDV formulation showed a sustained release of RDV with a low risk of dose-dumping, minimizing potential side effects. In addition, RDV in the form of RDV-NLC causes less cytotoxicity to healthy normal kidney cells, which is expected to reduce renal impairment in COVID-19 patients.

Machine Learning for Patient-Based Real-Time Quality Control (PBRTQC), Analytical and Preanalytical Error Detection in Clinical Laboratory.

The rapidly evolving field of machine learning (ML), along with artificial intelligence in a broad sense, is revolutionising many areas of healthcare, including laboratory medicine. The amalgamation of the fields of ML and patient-based real-time quality control (PBRTQC) processes could improve the traditional PBRTQC and error detection algorithms in the laboratory. This narrative review discusses published studies on using ML for the detection of systematic errors, non-systematic errors, and combinations of different types of errors in clinical laboratories. The studies discussed used ML for detecting bias, the requirement for re-calibration, samples contaminated with intravenous fluid or EDTA, delayed sample analysis, wrong-blood-in-tube errors, interference or a combination of different types of errors, by comparing the performance of ML models with human validators or traditional PBRTQC algorithms. Advantages, limitations, the creation of standardised ML models, ethical and regulatory aspects and potential future developments have also been discussed in brief.

Unintentionally retained lap sponge mimicking an ovarian cyst two years after Caesarean section in a 37-year old patient: case report of a rare “never event” in Sudan

IntroductionThis case report reports an unusual occurrence of gossypiboma, which refers to the accidental retention of surgical materials like sponges in the peritoneal cavity. The term is derived from “gossypium” (cotton) and “boma” (place of concealment). Its incidence varies with surgical type, posing diagnostic challenges due to nonspecific symptoms and equivocal imaging. Despite its rarity, gossypiboma poses significant risks, including intestinal obstruction and abscess formation.Case presentationA 37-year-old woman with ten previous pregnancies and an emergent caesarean section presented with abdominal pain. Examination and ultrasound suggested an ovarian cyst. During surgery, a 10 × 10 cm gauze-filled mass adherent to the ovary and jejunum was found. Postoperatively, she recovered well with no complications. The patient was treated with intravenous fluids and antibiotics for five days post-surgery and recovered without any complications. She was discharged from the hospital five days after the procedure.ConclusionTo the best of our knowledge, this is the first reported case of gossypiboma in Sudan in 2024, highlighting diagnostic challenges and the need for preventive protocols. Root cause analysis of accidents, enhanced training, application of advanced technologies and a collaborative culture in the operating room can prevent the occurrence of such incidents. This case underscores the importance of meticulous surgical protocols and continuous improvement in safety measures to prevent retained surgical items, ensuring patient safety and optimal outcomes.

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

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

Fluid Management in Critically Ill Children: Single-Center Retrospective Comparison of Trauma and Postoperative Patients, 2020-2022.

Injury and surgery both represent well-defined starting points of a predictable inflammatory response, but the consequent response to IV fluids has not been studied. We aimed to review and compare our single-center fluid management strategies in these two populations. Retrospective cohort study from January 2020 to July 2022. The primary outcome was total IV fluid volume administered. Net fluid balances and select clinical outcomes were also evaluated. Single tertiary academic center and level 1 pediatric trauma center in New York. A dataset of critically ill trauma and surgical patients aged 0-18 years who were admitted to the PICU, 2020-2022. Trauma patients had at least moderate traumatic injuries (Injury Severity Score ≥ 9) and surgical patients had at least a 1-hour operation time. None. We identified 25 trauma and 115 surgical patients. During the first 5 days of hospitalization, we did not identify an association between grouping and total IV fluids administered and fluid balance in the prehospital, emergency department, and operating room (p = 0.90 and p = 0.79), even when adjusted for weight (p = 0.96). Time trend graphs of net fluid balance and IV fluid administered illustrated analogous fluid requirement and response with the transition from net positive to net negative fluid balance between 48 and 72 hours. There was an association between total IV fluid and ventilator requirement (p = 0.003). Critically ill pediatric trauma and postoperative patients seem to have similar fluid management and balance after injury or surgery. In our opinion, these two critically ill populations could be combined in large prospective studies on optimal fluid therapy in critically ill children.

Ensuring Neurosurgical Equity: Setup for Safe Ventricular Endoscopy and Predictors of Clinical Outcome in a Resource-Limited Health Care System

Background/ObjectiveNeuroendoscopic surgeries require specialized equipment, which may not be universally available or equitably distributed in most neurosurgical units of resource-limited healthcare systems. This review reports on the use of locally available resources to perform safe ventricular endoscopic surgeries in patients with hydrocephalus and cystic craniopharyngioma, in a resource-limited health care system. MethodsThis study, described the use of locally available resources to perform intraventricular endoscopic surgeries, and retrospectively reviewed a three-year outcome of these surgeries, The authors, used a 24Fr, 2-way Foley's catheter, that served as an endoscopic working sheet. A transparent 9mm naso-tracheal tube, that served as a retractor and a peel-away sheet. An intravenous fluid (IVF) giving set, was used for irrigation, and a metallic stylet of External ventricular drain(EVD) was used for third ventricular floor or cyst wall fenestration. ResultsTwenty-one intraventricular endoscopic surgeries were performed, consisting; of endoscopic third ventriculostomy (ETV), septostomies, cystostomies, and intraventricular biopsies. Mortality occurred in four patients, with one of the mortality, directly related to intraoperative hemorrhage. Most (3/21) of the complications were post-operative CSF leakage and partial wound dehiscence. Of the 17 surviving patients, the ETV success rate was 82.4% (14/17). Logistic regression analysis revealed that the patient's age, etiology, ETV success score (ETVSS) and procedure performed were not predictive of ETV success or mortality. ConclusionsPatients accessing neurosurgical care in resource-limited healthcare systems can benefit from safe and successful intraventricular endoscopy. However, this may require the innovative use of locally available resources that can be adapted to local neurosurgical needs.

Development and Validation of a Policy Tree Approach for Optimizing Intravenous Fluids in Critically Ill Patients with Sepsis and Acute Kidney Injury.

Intravenous fluids are mainstay of management of acute kidney injury (AKI) after sepsis but can cause fluid overload. Recent literature shows that restrictive fluid strategy may be beneficial in some patients with AKI, however, identifying these patients is challenging. We aimed to develop and validate a machine learning algorithm to identify patients who would benefit from a restrictive fluid strategy. We included patients with sepsis who developed AKI within 48 hours of ICU admission and defined restrictive fluid strategy as receiving <500mL fluids within 24 hours after AKI. Our primary outcome was early AKI reversal within 48 hours of AKI onset, and secondary outcomes included sustained AKI reversal and major adverse kidney events (MAKE) at discharge. We used a causal forest, a machine learning algorithm to estimate individual treatment effects and policy tree algorithm to identify patients who would benefit by restrictive fluid strategy. We developed the algorithm in MIMIC-IV and validated it in eICU database. Among 2,091 patients in the external validation cohort, policy tree recommended restrictive fluids for 88.2%. Among these, patients who received restrictive fluids demonstrated significantly higher rate of early AKI reversal (48.2% vs 39.6%, p<0.001), sustained AKI reversal (36.7% vs 27.4%, p<0.001) and lower rates of MAKE by discharge (29.3% vs 35.1%, p=0.019). These results were consistent in adjusted analysis. Policy tree based on causal machine learning can identify septic patients with AKI who benefit from a restrictive fluid strategy. This approach needs to be validated in prospective trials.

Survival status and predictors of mortality among severely acute malnourished under-5 children admitted to stabilisation centers in selected government hospitals in Addis Ababa, Ethiopia, 2022: a retrospective cohort study

ObjectiveThis study aims to assess the survival status and predictors of mortality among under-5 children with severe acute malnutrition in Addis Ababa, Ethiopia.DesignA retrospective cohort study was employed on randomly...

Revisiting the fluid requirement during the critical phase of dengue: Does it actually follow a bell-shaped curve?&amp;nbsp;

Plasma leakage due to a transient increase in capillary permeability is the hallmark of dengue haemorrhagic fever. There is no specific antiviral agent for dengue. Therefore, the mainstay of management during the plasma leakage phase is the judicious use of intravenous fluid to ensure adequate organ perfusion and to prevent fluid overload. The current practice guidelines for dengue are empirical. They are mostly based on expert opinions. The rates and amounts of fluid to be administered during the critical phase of the disease have not been studied in randomised controlled trials. It is hypothesised that the rate of fluid leakage during the critical phase follows a bell-shaped curve. Based on this concept, both WHO and Sri Lankan guidelines recommend starting fluid at a lower rate, increasing the rate until the midpoint of the CP, and gradually reducing the infusion rate thereafter. However, the authors believe that the more fluid you give during the critical phase, the more will leak out into the third space. Thus increasing the complications of fluid overload without improving the effective plasma volume. Therefore, administering fluids at an escalating rate may be superfluous and could result in fluid overload.

WHO/INRUD Drug Prescribing Indicators in the Emergency Ward of a Teaching Hospital, South East of Iran

Background: Rational drug use is an important issue in all healthcare settings. Core drug use indicators have been developed by World Health Organization/ International Network for Rational Use of Drugs (WHO/INRUD). The prescribing indicators measure healthcare providers’ performance in five key areas of drug usage. The aim of this study was to evaluate WHO/INRUD indicators of prescribing in emergency ward of a teaching hospital. Methods: This descriptive cross-sectional study was carried out in Emergency Ward of teaching hospital from March 2022 – March 2023. A standard prescribing indicators form was utilized to collect the required data using WHO drug prescribing indicators. Besides the rate of intravenous fluids and narcotic analgesics administration was evaluated. Index of rational drug prescribing (IRDP) was also calculated for each month and the mean of 12 IRDPs represent the emergency ward IRDP. Descriptive statistics were used for analysis. Results: Antibiotics were prescribed in 34% of studied prescriptions and ceftriaxone was the most widely used antibiotic (33.8%). Index of rational drug prescribing (IRDP) was 0.73 for polypharmacy, 0.93 for generic name prescribing, 0.88 for antibiotic prescribing, 0.1 for injectable drug use and 1 for formulary-based drug prescription. Total IRDP for the emergency ward was 3.64 (from optimal value of 5). IV fluids and narcotics were prescribed in 61.1% and 8.3% of studied prescription respectively. Conclusion: We concluded that although our overall IRDP value is below the WHO standard but it is about other neighbor countries. Our condition regarding IV drug administration showed a huge difference with WHO standards. It shows we need more input and regulations in this regard.

Maintenance intravenous fluid therapy in infants with sepsis and hyponatremia: a clinical trial

BackgroundThis study aimed to compare the effect of two methods of maintenance intravenous fluid therapy on hyponatremia in hospitalized infants with sepsis.MethodsIn a double-blinded randomized clinical trial, 60 term infants with sepsis were enrolled. Blood samples were taken to determine sodium, potassium, Creatinine, and BUN levels before the initiation of treatment. Urine samples were taken to assess specific gravity and urinary output. Infants in the intervention group received half saline in 10% dextrose and infants in the control group were assigned to receive the conventional solution as maintenance. The above indicators were re-evaluated 24 and 48 h after the initiation of treatment. Two groups were compared concerning the incidence of hyponatremia, and other criteria such as urinary output and urinary specific gravity, blood urea nitrogen (BUN), and creatinine levels.ResultsHyponatremia was more common in the control group. Sodium levels were significantly higher in half saline recipients 24 h (137.83 ± 2.86 vs. 134.37 ± 1.91 mmol/L), and 48 h (138.10 ± 2.41 vs. 133.66 ± 1.98 mmol/L) after treatment (P < 0.001). Although BUN in the intervention group was significantly higher in comparison to the control group, the difference in urinary output, urine specific gravity, potassium, and Creatinine levels were not significant in the two groups.ConclusionsThe use of a half-saline solution as maintenance fluid reduces the risk of hyponatremia after 48 h when compared to 0.18%NaCl.Trial registrationThis has been registered at Iranian Registry of Clinical Trials (Retrospectively registered, Registration date: 2017-10-12, identifier: IRCT2017053034223N1, https://irct.behdasht.gov.ir/trial/26204).

Epidemiology of headache presentations to United States emergency departments from 2016 to 2023

IntroductionHeadaches are a common condition seen in the Emergency Department (ED), with numerous trials focused on improving care for these patients. However, there is limited recent large-scale, robust data available on the incidence, admission rates, evaluation, and treatment in the ED setting. MethodsThis was a cross-sectional study of ED presentations for headache from 1/1/2016 to 12/31/2023 using the Epic Cosmos national database. All ED visits with headache-relevant ICD-10 coding were included. Outcomes included percentage of total ED visits, admission rates, computed tomography (CT) brain imaging, lumbar puncture (LP) performance, and medication administration. Medications were analyzed by class (NSAIDs, acetaminophen, dopamine antagonists, diphenhydramine, opioids, intravenous fluids, caffeine, and magnesium sulfate). Subgroup analyses were performed by specific types of dopamine antagonists. ResultsOf 188,482,644 ED encounters, 6,007,090 (3.2%) were due to headache. Of these, 246,082 (4.1%) were admitted. Nearly half (46.6%) of patients received at least one CT. Rates of CT head without contrast increased from 38.2% to 47.9% over time, while rates of CT angiography rose from 2.8% to 10.2%. 1.4% of all patients received an LP, with rates decreasing from 1.8% to 1.1% over time. The most common medication was NSAIDs (45.3%), followed by dopamine antagonists (44.8%), diphenhydramine (38.1%), acetaminophen (24.8%), opioids (16.3%), magnesium sulfate (0.2%), and caffeine (0.1%). 50.8% of patients received intravenous fluids. Rates of opioids declined over time, while dopamine antagonists, acetaminophen, and intravenous fluid administration increased. ConclusionHeadaches represent a common reason for ED presentation, with approximately 4% of patients being admitted. Imaging is frequently performed, with rises in CT without contrast and CT angiography rates over time, while LP rates have been declining. NSAIDs remain the most common medication given, with opioids declining over time while non-opioid agents such as dopamine antagonists have increased. These findings can help inform health policy initiatives, such as those focused on radiologic imaging and evidence-based medication administration.