Large Amounts Of Fluid Research Articles

Fine-needle aspiration for periprosthetic fluid removal after implantation of a remote internal-port tissue expander

BackgroundUse of internal filling ports in tissue expander–based reconstructions are advantageous because of easier self-care, lower infection rates, and fewer instances of capsule formation. The appearance of periprosthetic fluid accumulation after internal-port tissue expander implantation is a common complication that warrants treatment. In this study, we introduced a noninvasive method using fine-needle aspiration (FNA) to remove fluids accumulated after implantation of a remote internal-port tissue expander. MethodsIn this study, 245 patients who underwent implantation of remote internal-port tissue expanders in our hospital from July 1, 2012, to July 1, 2019, were included and divided into two groups. In the control group, patients underwent tissue expander implantation before July 1, 2016, and large quantities of fluids were removed with surgical aspiration procedures in most cases. In the FNA group, the patients underwent implantation after July 1, 2016, and large quantities of fluids were removed first with the FNA procedure. Patients’ demographic data, indications for FNA application, and related complications were collected and analyzed. ResultsOverall, 395 expanders were placed in 245 patients. Postoperative management was similar in both groups. Fluids were managed with 23 expanders in the control group and with 31 expanders in the FNA group. There was no difference in the fluid aspiration rate between the two groups. The surgical aspiration rate was 11.1% (23/208) in the control group. The success rate of FNA was 90.3% (28/31). In the FNA group, the surgical aspiration rate was 1.6% (3/187), which was significantly lower than that in the control group. There were no significant differences in complications between the two groups. ConclusionFNA can be used for periprosthetic fluid removal after the implantation of a remote internal-port tissue expander in most cases. This method is more convenient and safer than surgical aspiration for the postoperative management of internal-port tissue expander implantation.

Impact of Fluid Resuscitation Regimes in Relative Risk of Mortality in Burned Patients

Background; Some studies have supported the opinion that patients who get greater volumes of resuscitation fluids are at a higher chance of edema, complications, and probably bad outcomes. In the results of the International Society of Burn Injuries approximately half (49.5%) added colloid before 24h.
 This study aims to analyze the relative risk for mortality comparing resuscitation in the first 24 hours with Parkland and resuscitation with the use of Colloids. 
 Material and Methods; This was an observational prospective cohort study conducted in the Service of Burns of the University Hospital Centre "Mother Teresa" in Tirana (UHCT), Albania. The study includes adult patients with critical burns > 40% TBSA, hospitalized in the Intensive Care Unit of the service during the period 2014 to 2019. Resuscitation in the first 24 hours is done with Ringer Lactate according to Parkland and with Ringer Lactate with the addition of colloids after 12 hours.
 Results; The data for organ dysfunction and organ insufficiency were the same in the two groups without statistical significance. Mortality in the RL group was 48% (24 deaths of 50 patients) while in the RL + Colloid rehydrated group was 46% (23 deaths of 50 patients). Patients which have 40-60% burns and are rehydrated with RL + Colloids have a risk of death 0.4 times less than those rehydrated with RL.
 Conclusions; Resuscitation with Ringer lactate and Colloids in the first 24 hours of thermal damage is a rehydration alternative for the treatment of burn shock. This therapy especially helps patients with major burns > 40% TBSA who during rehydration require large amounts of fluids and are associated with severe plasma hypoalbuminemia. Number Need to Treat (NNT benefit) is 10 so 1 in 10 patients can benefit in lowering the risk of death with RL + Colloid rehydration.

Torkildsen shunt as an option for hydrocephalus associated with optic pathway glioma

Hydrocephalus caused by optic pathway glioma (OPG) is most often treated with a ventriculoperitoneal shunt (VPS), but this treatment may present complications such as ascites. Hence, ventriculocisternal shunt is an option worth considering. This article reports a case in which it was decided to place a ventriculocisternal or Torkildsen shunt in a patient with hydrocephalus caused by OPG. Case Report: A 12-year-old girl, amaurotic, with a VPS due to hydrocephalus caused by an OPG, reported to the emergency room with abdominal distension and pain and difficulty in walking. Computed tomography of the abdomen was performed, and a large amount of fluid was evidenced in the peritoneal cavity (ascites). Liver and kidney functions were normal. In the surgical procedure, the distal extremity of the ventriculoperitoneal catheter was exposed, and 3 L of ascites fluid of cerebrospinal origin was drained. After 10 days of antibiotic therapy, a ventriculocisternal or Torkildsen shunt was placed. After 4 years of follow-up, the patient has no complaints. Discussion: Arne Torkildsen was the first to perform a ventriculocisternal shunt in 1937; it is indicated in cases of hydrocephalus with obstruction of the aqueduct or third ventricle. In OPG, increased protein levels in CSF and the use of platinum-based chemotherapy agents would explain the development of ascites after VPS placement. In these cases of hydrocephalus with third ventricle tumor infiltrating the hypothalamus, the ventriculocisternal shunt can be used as an option in specific cases.

Jewish Holiday “Tu Bishvat” or Two Cases of Small Bowel Obstruction with Dried Apricot

Introduction: Small bowel obstruction caused by bezoars is rare. One of the causes of phytobezoars is dried fruits. We present two cases of small bowel obstruction caused by dried apricots during Jewish holiday “Tu BiShvat”. Case Presentation: Two men, 54 and 86 years old hospitalized with acute abdomen attributed to small bowel obstruction. In the first case - intoxicated patient, due to suspicion of mesenteric ischemia underwent laparotomy. A lead point caused obstruction was found and after enterotomy whole dried apricot was removed. The patient swallowed it whole three days before hospitalization. In the second case, edentulous patient with small bowel obstruction and peritonitis underwent laparotomy. The cause of obstruction was a dried apricot swallowed whole by the patient. Discussion: Presentation of bezoar with features of acute surgical abdomen is extremely rare, accounting for only 1% of the patients. The expansion of phytobezoar that is high in cellulose content can absorb a large amount of fluid causing an obstruction of the small bowel. The treatment of small bowel obstruction caused by bezoars varies from dissolving with cellulase, papain and even Coca-Cola, followed by endoscopic and surgical removal. Conclusion: A high level of suspicion needs to exist in the presence of a history of eating dried fruit, which can cause gastrointestinal obstruction. Especially on background gastric bypass surgery and inadequate mastication.

An Innovative Technique for Fluid Infiltration Using Double-Bent Needle.

Local infiltration of tumescent fluid and saline is required in various surgical procedures such as liposuction and hair transplant surgery. The use of small-caliber needles requires more time and power for injection, especially in the superficial planes of the skin.1 The use of large-caliber needles has a few drawbacks. These include painful infiltration and lack of control of the volume injected. Moreover, there are high chances of needle injections into the vessels, and intravascular injections may occasionally result. Various techniques have been developed to avoid the complication. One technique is to use blunt needles or cannulas or short needles. Another is to bend the needle and keep the full length of the needle parallel to the skin to avoid injuring deeper structures (Fig. 1).Fig. 1.: Single-bent (above) and double-bent (below) needles.We have developed a new technique in which large-caliber needles can be used to inject larger volumes without any fear of injuring deeper structures or risking intravascular injections, as described below. [See Video 1 (online), which demonstrates how to make a double-bent needle.] {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 1.","caption":"Method for making a double-bent needle.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_elkyvaex"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} Hold the needle in the needle holder at about 3 to 4 mm from the tip, with the eye of needle facing up. Bend the needle at a right angle in a counterclockwise direction to create the first bend (point A) (Fig. 1, above). Hold the needle at about 2 to 3 mm proximal to point A and bend in a clockwise position at a right angle to create the second bend (point B) (Fig. 1, below). The direction of the distal part can be adjusted as well (Fig. 1, below). The use of a bent needle is not new in the medical literature. The bent needle is used in dentistry for intraoral nerve blocks and for supraclavicular regional blocks.2,3 The bent needle with broken tip is also used in plastic surgical procedures for irrigation. Similarly, the double-bent needle has been used in intraocular injections as well.4 We have developed this new technique to inject large amounts of fluid without any fear of intravascular injection, especially in the subcutaneous plane. In order to maximize safety, the eye at the bevel is faced upward. [See Video 2 (online), which shows application of the double-bent needle.] The bending of the needle at two points also decreases the lumen of the needle, which decreases the flow rate as well. The part between the two bend serves as depth control. {"href":"Single Video Player","role":"media-player-id","content-type":"play-in-place","position":"float","orientation":"portrait","label":"Video 2.","caption":"Clinical application of double-bent needle.","object-id":[{"pub-id-type":"doi","id":""},{"pub-id-type":"other","content-type":"media-stream-id","id":"1_8mnc7h8g"},{"pub-id-type":"other","content-type":"media-source","id":"Kaltura"}]} Avoid a second attempt to bend or twist the needle, as that may weaken the needle and it may break and can cause needle tip impaction. DISCLOSURE The authors have no financial interest to declare in relation to the content of this article.

Local earthquake tomography of the source region of the 2018 Lombok earthquake sequence, Indonesia

SUMMARY We develop and present a 3-D seismic velocity model of the source region of the 2018 Lombok, Indonesia earthquakes by using local earthquake tomography. The data consist of 28 728 P- and 20 713 S-wave arrival times from 3259 events which were recorded by 20 local seismic stations. The results show that most of the significant earthquakes occur to the edge of high-velocity regions. We interpret these to represent coherent blocks of the Flores Oceanic Crust underthrusting Lombok. At depths shallower than the nucleation area of the largest earthquake, many triggered aftershocks are located within a low-velocity, high-Vp/Vs region which is probably a highly fractured fault zone with a large amount of fluid. This fault zone is parallel to the dip of the Flores Back Arc Thrust and probably ruptured during this earthquake sequence. A prominent low-velocity, high-Vp/Vs region is colocated with the northwest and southern flank of the Rinjani volcanic complex. This large aseismic region is probably related to a wide area of the crust containing fluids due to ongoing magma intrusion beneath the volcano. To the east of Rinjani Volcano a cooled intrusive complex was imaged. It is characterized by high-velocity and low-Vp/Vs, supported by the presence of a high Bouguer anomaly. We confirm the existence of the Sumbawa Strait Strike-Slip Fault and find it is characterized by an elongated low-velocity, high-Vp/Vs zone.

Slab Dehydration in Sumatra: Implications for Fast and Slow Earthquakes and Arc Magmatism

AbstractThe catastrophic 2004 Sumatra‐Andaman Mw9.1 earthquake associated with destructive tsunamis has characterized Sumatra as one of the most dangerous convergence zones. Nevertheless, the effects of the thermohydrous state on the strongly coupled megathrust of the incoming plate remain enigmatic. By using a three‐dimensional (3‐D) thermomechanical model to compute the temperature variation and the complicated phase transition process of the water‐bearing descending plate which generates unstable thrust slips, we find that Sumatran earthquakes at varying depths are likely under the control of the inter or intraplate hydrothermal regime, which occurs in or close to the petrological metamorphism transition area. The slab dehydration of the water‐rich mid‐ocean‐ridge basalts (MORB) and the ultramafic rocks in the oceanic lithosphere releases a large amount of fluid to the continental wedge and further facilitates arc magmatism. The fluids are prone to upwelling following the subduction channel along the plate interface and thus contribute to the clustering of earthquakes updip of the dehydration front beneath offshore Sumatra. Brittle failure and dehydration embrittlement at depth, along with the temperature differences caused by variant slab geometry, are conjectured to greatly influence the occurrence of fast and slow earthquakes in Sumatra.

Systemic capillary leak syndrome complicated by laryngeal edema after severe acute respiratory syndrome coronavirus 2 vaccination.

Systemic capillary leak syndrome (SCLS) is a rare disease characterized by episodic exacerbation of hypovolemia, hemoconcentration, and hypoalbuminemia due to capillary hyperpermeability. Although the overall pathophysiology remains unknown, transient endothelial dysfunction is believed to be associated with the disease.1 Systemic capillary leak syndrome is diagnosed clinically, often requiring exclusion of other differential diagnoses such as sepsis, angioedema, and anaphylactic shock. Exacerbation of SCLS could be life-threatening, leading to hypovolemic shock and multiple organ dysfunction as well as compartment syndrome and thromboembolic events as complications.2 Herein, we describe a patient who had an exacerbation of SCLS requiring intensive care after receiving a second dose of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccine. A 60-year-old woman presented to the emergency department with a 1-day history of fever, dyspnea, and nausea. She received a series of SARS-CoV-2 vaccinations (BNT162b2; Pfizer-BioNTech), two shots given 3 weeks apart, with the second dose given 2 days before the visit. Her medical history was relevant to a diagnosis of SCLS, with a life-threatening attack of capillary leakage, complicated by cardiac arrest, that required intensive care. Her vital signs at presentation were: body temperature, 37.1°C; blood pressure, 81/60 mmHg; pulse rate, 122 beats/min; respiratory rate, 16 breaths/min; and oxygen saturation, 97% with ambient air. She was also alert, with oriented consciousness. Laboratory results showed an increased hematocrit level of 47% and a hemoglobin level of 15.1 g/dl. Nasal swab polymerase chain reaction testing for SARS-CoV-2 yielded negative results, and imaging studies did not indicate an infection source. Although her hypotension and tachycardia temporarily resolved after a bolus of fluids, she continued to require a large amount of fluid, which made us consider SCLS possibly provoked by SARS-CoV-2 vaccination. She was admitted to the intensive care unit and required further resuscitative treatment with fluid and vasopressors. On hospital day 2, she developed hoarseness due to laryngeal edema and was intubated to secure her airway. During the first 24 hours, she received 12 L of fluids, but her hematocrit level and hypoalbuminemia worsened (Table 1). The increased fluid requirement gradually resolved after day 3, and she was extubated on day 6. She was discharged from the intensive care unit on day 10 and was discharged home on day 18. Adverse reactions to SARS-CoV-2 vaccination are usually local and mild; however, some serious reactions have been reported, including anaphylaxis, myocarditis, thromboembolic events, and Guillain-Barré syndrome.3 Recent published reports describe acute exacerbation of SCLS 1–2 days after SARS-CoV-2 vaccination and suggest the possibility of SCLS as an adverse vaccine reaction.4, 5 Although we could not fully investigate all possible causes that triggered the SCLS, we were unable to identify any cause other than recent vaccination. Thus, we suspect that exacerbation of SCLS is related to vaccination. Being a rare disease, SCLS may not be recognized or may be treated under a similar differential diagnosis. When patients present with hypovolemic shock from an unknown cause after SARS-CoV-2 vaccination, exacerbation of SCLS should be considered among the differential diagnoses. We would like to thank Editage for English language editing. Approval of the research protocol: N/A. Informed consent: The patient provided written consent for the publication. Registry and registration no. of the study/trial: N/A. Animal studies: N/A. Conflict of interest: None.

Analysis of two phase critical flow with a non-equilibrium model

Critical (choked) flow is a highly concerned phenomenon in safety analysis for nuclear energy. During the accident, a large amount of fluid with the aerosol in nuclear power plant (NPP), which are hazardous for environment, may be released accompanying the fluid discharge. The prediction of the amounts of discharge fluid is crucial for engineering design and emergency response in case of nuclear accidents. Unfortunately, the critical flow is difficult to predict especially when two phase flow exists. Based on the literature, a six-equation two phase critical model, which considers the interphase interaction terms for momentum, heat transfer and mass, was developed to allow the calculation of critical flow rates for steam-water mixtures. Certain constitutive correlations, which account for different flow regimes, were included into this model. New virtual mass force and the force for interfacial momentum transport were used in this model. The six equations used in this two phase critical flow model form a system of stiff ordinary differential equations (stiff ODEs), which were solved by using a variable step implicit Runge-Kutta procedure. Furthermore, the shooting method was used to split the given boundary value problem into several initial value problems, since the choked point of the discharge pipe for a given mass flow is not a-priori known (ODEs should be solved each time). The numerical results were then compared with the experimental data involving critical flows for different geometries (long pipe and orifice). It came out that the non-equilibrium model predicts well the critical flow rate, pressure distribution along the tube, and the tube outlet pressure. In addition, the errors made in the prediction of the critical flow are between −7% and + 4%, better than other models in literatures, most probably as a pay-back for the modification of the virtual mass force and of the force corresponding to the interfacial momentum transport. The choking process was understood more clearly by analyzing the main constitutive parameters, aspect with little payed attention in other works. This study contributes to a detailed understanding of the critical flow phenomenon and its results may be implemented into related code development (especially for system thermal hydraulics STH codes) and used for safety analysis.

Experimental and computational study of the two-fluid nozzle spreading characteristics

Spray nozzles are widely used in processing industry for spreading evenly large amount of fluids. The expansion of fluid depends on the nozzle type, the parameters of the nozzle and the characteristics of the working fluids. The experiments were performed for five fluid types used in food/pharma/animal feed application (glycerol, soybean oil, molasses, hydroxypropyl methylcellulose, tara gum), three diameters of the nozzle (1 mm, 3 mm, 5 mm) and three fluid temperatures (40 °C, 50 °C and 60 °C). An experimentally validated numerical model was developed, based on laminar two-phase flow, investigating different liquids, assuming the ideal gas flow, applying the finite volume method and volume of the fluid model with interface tracking. The effects of liquid parameters, nozzle diameter and liquid temperature on the characteristics of the jet were also analysed by artificial neural network model. The nozzle diameter strongly influenced the spreading characteristics of the jet, while the temperature affected the liquid viscosity. The increase of the temperature also led to the augment of the spreading angle of the fluid passing from the nozzle and also the enhancement of the spaying liquid expansion.

Effect of Nano-fibril Cellulose (NFC) Filler towards the Swelling and Diffusion Behavior of Superabsorbent Polymer Composite

Superabsorbent polymers (SAP) exist as a three-dimensional network consisting of branched or linear chains that are chemically or physically crosslinked and possess the ability to retain large amounts of fluids. To be in coherence with the global demand for more biodegradable materials, nano-fibril cellulose (NFC) is introduced as fillers during the synthesis of SAP. The objective of this study is to investigate the effects of different amounts of NFC addition to swelling and diffusion behavior of the final product (SAP/NFC). Inverse suspension polymerization was employed to produce the NFC/SAP, in which acrylic acid (AA) was used as a monomer, acrylamide (AM) as co-monomer and N, N’-Methylenebis(acrylamide) (NNMBA) as the crosslinker. The reaction was conducted at temperature, 55°C for 3 hours. In water absorbency analysis, SAP with 0.006 wt% of NFC shows the highest water absorbency, up to 135%. Swelling kinetic study shows that all SAP exhibit second order of swelling kinetic, and obeys Fickian diffusion behavior. FTIR analysis confirmed the characteristic of SAP and the presence of NFC by identifying C=O, N-H, O=C-H, C-N, O-H, C-H, C=C, C-H, and C-OH bonds. The morphological study shows that the presence of NFC inhibits the formation of SAP in regular bead shape. In thermal stability analysis, SAP with 0.006 wt% of NFC shows the highest thermal stability compared to the other SAPs. It is concluded that the addition of 0.006 wt% NFC is the most optimum condition for cellulose-based SAP synthesis due to the highest water absorbency and thermal stability.

Long-term follow-up results of patients diagnosed with nonspecific pleuritis by video-assisted thoracoscopic surgery biopsy

IntroductionNon-specific pleuritis (NSP) is a fibrinous or inflammatory pleurisy that is not attributable to a benign or malign etiology. The long-term follow-up results of patients diagnosed with NSP following video- assisted thoracoscopic surgery (VATS) were investigated in this study.Material and methodsThis investigation focused on 593 patients with exudative pleural effusion who underwent VATS between 2011 and 2014. Of the 137 patients diagnosed with NSP, a total of 39 patients were excluded from the study.ResultsOut of the 98 patients, 78 were male (80%) with their mean age being 52.2 ±15.9 years. The mean follow-up period was 1919 ±744 days. Of these patients, 70 (71.4%) had no specific diagnosis, while 28 patients (28.6%) did have specific diagnoses. Malignancy was detected in seven (7.1%) of those with specific diagnoses, with most of the diagnoses of malignancy detected within the first 36 months. Malignant diseases included mesothelioma (n = 2), lung cancer (n = 2), chronic lymphocytic leukemia (n = 1), soft tissue sarcoma (n = 1), and multiple myeloma (n = 1). Chest radiographs of malignant patients showed that statistically significantly larger amounts of fluid (40% vs. 6.9%, p = 0.026), pleural plaque (20% vs. 1.1%, p = 0.020) and nodules (20% vs. 7.7%, p = 0.020) were detected compared to patients with a benign course.ConclusionsMost patients diagnosed with NSP after VATS had a benign disease course. There was a probability of malignancy, although it was low. Mesothelioma and other malignancies could be seen within the first 36 months after the biopsy. Apart from mesothelioma, other malignancies should also be considered, and further follow-up recommended for patients with a large amount of fluid, plaque and nodules found in the initial VATS images.

Agarose/κ-carrageenan-based hydrogel film enriched with natural plant extracts for the treatment of cutaneous wounds

Hydrogels for complex and chronic wound dressings must be conformable, absorb and retain wound exudates and maintain hydration. They can incorporate and release bioactive molecules that can accelerate the healing process. Wound dressings have to be in contact with the wound and epidermis, even for long periods, without causing adverse effects. Hydrogel dressing formulations based on biopolymers derived from terrestrial or marine flora can be relatively inexpensive and well tolerated. In the present article hydrogel films composed by agarose (1.0 wt%), κ-carrageenan at three different concentrations (0.5, 1.0 and 1.5 wt%) and glycerol (3.0 wt%) were prepared without recourse to crosslinking agents, and characterized for their mechanical properties, morphology, swelling and erosion behavior. The films resulted highly elastic and able to absorb and retain large amounts of fluids without losing their integrity. One of the films was loaded with the aqueous extract from Cryphaea heteromalla (Hedw.) D. Mohr for its antioxidant properties. Absence of cytotoxicity and ability to reduce the oxidative stress were demonstrated on NIH-3T3 fibroblast cell cultures. These results encourage further biological evaluations to assess their impact on the healing process.

Abstract 359: Cardiac-specific Deletion of Prohibitin-1 Leads to Fetal Demise, Gross Mitochondrial Abnormalities and Heart Failure in Adolescent Mice

Prohibitins (PHB1, 2) are lipid raft-associated proteins which form a multimeric, alternating ring-like structure in cellular membranes, and are particularly abundant in mitochondria and plasma membranes, but have also been found in nuclei. These pleiotropic proteins are associated with numerous signaling pathways responsible for cell differentiation, growth, and metabolism. In mitochondria, PHBs are thought to act as scaffold-like chaperone proteins responsible for stabilizing enzymes responsible for electron transport and oxidative phosphorylation (OXPHOS), minimizing reactive oxygen species (ROS), and coordinating fission/fusion. However, the extent to which PHB1 regulates mitochondria and electromechanical function of the heart, is not known. We established a cardiac-specific PHB1-deficient mouse strain by crossing floxxed phb1 mice with mice expressing Cre recombinase under control of myosin heavy chain (MHC) promoter. The vast majority of cardiac-specific PHB1-deficient mice (cPHB1ko) died in utero during pregnancy (E12-E15). Uterine sonography of the expired cPHB1ko embryos showed significantly decreased crown-rump length and increased placenta thickness with large amount of fluids, restricted uterine artery flow and detachment between amnion and chorion compared with normal embryos (P < 0.001). The few that were born develop severe dilated cardiomyopathy, resulting in mortality by 8-9 weeks of age. Heart weight/body weight ratio is ~2-fold greater in the KO mice vs. WT. Echocardiography reveals severely enlarged right atria and ventricles in cPHB1ko mice, corresponding to significantly decreased ejection faction (EF), increased end diastolic volume (EDV) and end systolic volume (ESV) compared to wild-type littermates (P < 0.05). In mitochondria, cPHB1ko mice have derangements in OXPHOS as evidenced by decreased pyruvate and palmitoylcarnitine-supported respiration and ATP production. Moreover, both the rate of calcium uptake (P = 0.05) and the total calcium retention capacity (P < 0.01) were diminished in the KO mice. These preliminary findings implicate PHB1 as a critical regulator of myocardial development and function, due in part to its role in maintaining OXPHOS and controlling metabolism.

Multidisciplinary approach in the treatment of a newborn child with chylotorax

Chylothorax in children is a fairly rare but at the same time serious pathology. Accumulation of a large amount of fluid in the pleural cavity leads to the development of respiratory, cardiovascular failure, and even death. In some children, this process can be initiated even before birth. The main components in the treatment of chylothorax are as follows: conservative measures aimed at reducing the amount of chyle, paracentesis, and drainage of the pleural cavity, mini-invasive surgery. To date, universal approaches to the management of patients with chylothorax have not been fully developed, there are no common diagnostic algorithms, terms, and optimal treatment tactics. There are only a few publications on this issue in literature, which are descriptive in nature and based on a small number of observations. The low prevalence of chylothorax in newborn infants, different etiology, various pathogenetic mechanisms of the disease make it difficult to conduct large-scale randomized trials in this area that would fully meet the modern requirements of evidence-based medicine. In this article, the authors demonstrate a multidisciplinary approach to treating a child with congenital chylothorax.

Early Positive Fluid Balance is Associated with Mortality in Patients Treated with Veno-Arterial Extra Corporeal Membrane Oxygenation For Cardiogenic Shock: a Retrospective Cohort Study.

Veno-arterial Extracoporeal Membrane Oxygenation (VA-ECMO) provides circulatory assistance for patients in cardiogenic shock. Large quantities of fluids are often required, especially during the early stages, but can result in a potentially harmful fluid-overload. The objective was to determine the association of early fluid-balance and mortality. Retrospective single-center study in 101 VA-ECMO patients between 2013 and 2016. Daily fluid-balance and weight changes over the 5 first days were observed. Analyses between survivors and non-survivors were conducted using Mann-Whitney tests and logistic regression multivariable and Cox hazard-proportional analyses to determine any association with 28-days mortality. Mortality was 47.5%. The fluid-balance was higher in non-survivors at day-1 (47.3[18.1-71.9] vs. 19.3[1.5-36.2] mL/kg, P < 0.0001) and day-2 (30.6[14.8-71.0] vs. 10.1[-9.8 to 34.7] mL/kg, P = 0.025), as was the cumulative fluid-balance over the first 5 days (107.3[40.5-146.2] vs. 53.0[7.5-74.3] mL/kg, P = 0.04). The administration of unintentional fluids (used for preparation and infusion of drugs) represented an important part of the administrated fluids (15 mL/kg/d-23 mL/kg/d). A significant but moderate correlation was observed between fluid-balance and weight variations over the 5 days (r values ranging from 0.36 to 0.54). Among other parameters, day-1 fluid-balance was independently associated with mortality (OR = 14.34 [1.58-129.79], P = 0.02) and day-1 and day-2 with time to death (HR = 8.26 [1.12-60.98], P = 0.04 and 2.89 [1.26-6.65], P = 0.01). A threshold of 38.8 mL/kg predicted mortality with a sensitivity of 60% and specificity of 83% (area under the curve: 0.749). Early positive fluid-balance is associated with mortality in VA-ECMO patients.

Effect and safety of 4% albumin in the treatment of cardiac surgery patients: study protocol for the randomized, double-blind, clinical ALBICS (ALBumin In Cardiac Surgery) trial

BackgroundIn cardiac surgery with cardiopulmonary bypass (CPB), large amounts of fluids are administered. CPB priming with crystalloid solution causes marked hemodilution and fluid extravasation. Colloid solutions may reduce fluid overload because they have a better volume expansion effect than crystalloids. The European Medicines Agency does not recommend the use of hydroxyethyl starch solutions (HES) due to harmful renal effects. Albumin solution does not impair blood coagulation but the findings on kidney function are conflicting. On the other hand, albumin may reduce endothelial glycocalyx destruction and decrease platelet count during CPB. No large randomized, double-blind, clinical trials have compared albumin solution to crystalloid solution in cardiac surgery.Methods/designIn this single-center, double-blind, randomized controlled trial comprising 1386 adult cardiac surgery patients, 4% albumin solution will be compared to Ringer’s acetate solution in CPB priming and volume replacement up to 3200 mL during surgery and the first 24 h of intensive care unit stay. The primary efficacy outcome is the number of patients with at least one major adverse event (MAE) during 90 postoperative days (all-cause death, acute myocardial injury, acute heart failure or low output syndrome, resternotomy, stroke, major arrhythmia, major bleeding, infection compromising post-procedural rehabilitation, acute kidney injury). Secondary outcomes are total number of MAEs, incidence of major adverse cardiac events (MACE; cardiac death, acute myocardial injury, acute heart failure, arrhythmia), amount of each type of blood product transfused (red blood cells, fresh frozen plasma, platelets), total fluid balance at the end of the intervention period, total measured blood loss, development of acute kidney injury, days alive without mechanical ventilation in 90 days, days alive outside intensive care unit at 90 days, days alive at home at 90 days, and 90-day mortality.DiscussionThe findings of this study will provide new evidence regarding efficacy and safety of albumin solution in adult patients undergoing cardiac surgery with CPB.Trial registrationEudraCT (clinicaltrialsregister.eu) 2015–002556-27 Registered 11 Nov 2016 and ClinicalTrials.gov NCT02560519. Registered 25 Sept 2015.

44: Vaginal cyst presenting as pelvic organ prolapse

The purpose of this video is to describe an unusual case of a large vaginal cyst presenting as pelvic organ prolapse and to demonstrate techniques for vaginal reconstruction. A 47-year-old gravida 4 para 2 presented with pelvic fullness, which she thought was prolapse. On pelvic exam, a 4-centimeter cystic mass was located on the posterior vagina and protruded past the hymen. Magnetic resonance imaging showed a 3.5 x 2.8 x 3.8 cm posterior vaginal wall cyst without solid components, septations, nodularity, or other suspicious features. The patient desired corrective surgery, so she underwent vaginal excision of the cyst. When in the operating room, exam under anesthesia confirmed the posterior vaginal wall mass. There was no evidence of pelvic floor prolapse. The vaginal mucosa overlying the cyst was incised. Allis clamps were placed on the mucosal edges bilaterally to provide traction. The cyst wall was sharply dissected off the vaginal mucosa. During the dissection, the cyst cavity was entered and a large amount of fluid was expulsed. The cyst was completely excised from the underlying tissue. The rectovaginal fascia was reinforced and plicated with interrupted 2-0 absorbable sutures. The posterior vaginal mucosa was trimmed and re-approximated with a running locking 2-0 absorbable suture. Hemostasis was ensured along the suture line. Rectovaginal exam confirmed no injury to the rectum. The patient was discharged home in a stable condition. Pathology demonstrated a benign simple cyst and benign vaginal mucosa without dysplasia. She was seen for a postoperative visit, at which time there was a healing but intact suture line along the posterior vaginal mucosa. It is important to include vaginal cysts in the differential diagnosis of pelvic organ prolapse. Vaginal removal and reconstruction can be performed successfully.

Endometriosis as a Reason of Intraabdominal Bleeding in Pregnancy. Clinical Case

The article defines the significance and relevance of the problem of endometriosis during pregnancy. 10% of women in the reproductive period have different localization of endometriosis. 25% of pregnancies with endometriosis are complicated by preterm labor. The article presents a clinical case of intra-abdominal bleeding in a 28-year-old pregnant woman with retrocervical endometriosis at gestation age of 32 weeks and 6 days. The article covers the results of examination and special diagnostic procedures of intra-abdominal bleeding in pregnant women with retrocervical endometriosis. The main diagnostic methods were the study of past medical history, ultrasound examination, and laboratory tests. Due to their infrequency during pregnancy internal bleedings present difficulties in their diagnosis. Ultrasound reliably revealed a large amount of fluid in the abdominal cavity and small pelvis and excluded the presence of intrauterine bleeding. Clinical and laboratory tests indicated the severity of the patient's condition. Symptoms of moderate fetal distress were also identified. Therefore, a decision was made about an emergency delivery by the cesarean section followed by an abdominal revision. During the cesarean section, 500 ml of blood in the form of dark blood clots was found in the abdominal cavity. The condition of the premature newborn was in conformity with his gestational age. The source of bleeding were the of endometriosis on the back wall of the uterus. These focuses most likely caused hemoperitoneum. The revision of the abdominal cavity did not find any other foci of bleeding. The postoperative period was uneventful. The article provides general guidelines for the management of pregnant women with severe forms of endometriosis.

3175 Gynecological Intervention Leading to Multiple Gastrointestinal Events

INTRODUCTION: This study follows a case of a right ovarian cystectomy gone wrong. Ninety studies published between 1972-2014, representing 474,063 gynecologic laparoscopies. Six hundred and four bowel injuries were reported for an incidence of 1 in 769. The rate of bowel injuries was dependent on the type of procedure. The small bowel happens to be the most frequently injured in the gastrointestinal tract, with about 166 of 354 (45%) of the cases. The majority of these injuries were due to veres needle or trocar placement with about 201 of 366 (55%) (Llarena N.C et al 2015). This review is to evaluate the gastrointestinal complications that accompanied a trocar induced injury during a gynecological procedure. CASE DESCRIPTION/METHODS: A 28-year-old female presented to the ED with septic shock. History obtained from relative stated the patient had a right ovarian cystectomy performed a week before ED visit. Post-op, the patient had increasing abdominal pain which worsened until EMS was called. An abdominal ultrasound showed central vowel dilation predominantly in the small bowel in correlation with ileus. CT abdomen showed free air throughout the abdomen large amount of fluid including the edge of the liver with infarcts in the Liver and spleen. Comprehensive Metabolic Panel showed AST- 5974, ALT- 2472, LDH- 1195 Total bilirubin- 1.5, direct bilirubin- 1.91, Amylase- 155. Complete Blood Count with WBC- 20.70. Coagulation with INR- 2.39, Fibrin &gt; 700. The above test after consultation with specialists indicated Ischemic hepatitis “shock liver” with very strong indications due to hepatic infarction as a result of hemodynamic instability (Friedman L.S et al 2018). Other complications included small bowel ileus, peritonitis due to perforation and systemic involvement as a result of shock. DISCUSSION: In conclusion, gastrointestinal complications are rare after a laparoscopic procedure. Irrespective of their frequency can result in mortality. The best approach lies in the surgical technique and experience. Early recognition is the best way to avoid further complications as a delay could result in sepsis and untimely death. In an event of a suspected gastrointestinal injury, general surgical consultation should be sought, and a management strategy implemented. (Karadag M.A et al 2015).