Large-volume Fluid Resuscitation Research Articles

Management and treatment of perioperative hypersensitivity.

Perioperative hypersensitivity reactions are rare but potentially catastrophic events. This review acts to summarize recent recommendations for both immediate and poststabilization management of suspected reactions, alongside practical advice for anaesthetists who may be faced with these events. Prompt treatment is essential but may be hampered by delay in recognition. This can occur because there are multiple differential diagnoses for the observed clinical signs as well as variations in clinical presentation. Resuscitation is dependent on the use of adrenaline and fluids. Adrenaline should be administered in small, titrated intravenous boluses. Low-dose infusions should be commenced early if the response to boluses is poor. Large volume fluid resuscitation may be required to maintain adequate circulating volume. Chest compressions are recommended when there is evidence of inadequate perfusion, rather than waiting until cardiac arrest is confirmed. Antihistamines and corticosteroids are no longer recommended in the immediate management phase. Once the patient has been stabilized, it is important to obtain serial tryptase concentrations to aid the subsequent clinic investigation. The decision to proceed or abandon surgery will be based on an individual risk-benefit analysis. All cases of suspected perioperative hypersensitivity, including fatal cases, must be referred for formal investigation. There have been recent updates to management guidelines in perioperative hypersensitivity. Treatment algorithms, treatment packs and referral packs can all help the anaesthetist manage these complex cases, aid the subsequent investigation and ensure patient safety in the future.

63: RESTRICTIVE FLUIDS IN SEPSIS: A SYSTEMATIC REVIEW AND META-ANALYSIS

Introduction: While large-volume fluid resuscitation as a part of early-goal directed therapy (EGDT) for sepsis has been widely adopted and endorsed by the SCCM Surviving Sepsis Guidelines, the risks of volume overload in the critically ill challenge this approach. The objective of this study is to assess the effects of a restrictive fluid resuscitation approach in sepsis given divergent results from randomized studies. Methods: A systematic review using a random effects meta-analysis with trial sequential analysis (TSA) of randomized controlled trials published from 2001 were evaluated. Studies were included if they evaluated adult patients with sepsis or septic shock involving a comparator group with an effective restrictive resuscitation approach. Two blinded reviewers independently assessed studies for inclusion and risk of bias and extracted data using Cochrane Collaborative methodology. The primary outcome was the incidence of mortality at the latest reported study period. Secondary outcomes included rates of acute kidney injury (AKI), ventilator days, intensive care unit (ICU) and hospital length of stay (LOS), duration of vasopressor therapy, and limb ischemia. Results: A total of 2,375 patients were included among the 8 trials analyzed. The risk of bias was high in 6 studies and low in 2 studies. All studies implemented fluid restriction after an initial 30 mL/kg volume. Use of a restrictive resuscitation approach did not significantly reduce mortality in all studies compared to usual care (37% vs 40% with usual care; risk ratio [RR] 0.94, 95% confidence interval [CI] 0.85–1.04, P=0.25, I2 = 24%) and was confirmed by TSA findings. There were no significant differences in rates of AKI (5 studies), LOS in ICU (4 studies) or hospital (2 studies), duration of vasopressor therapy (6 studies), or incidence of limb ischemia (3 studies). However, a restrictive resuscitation strategy significantly reduced ventilator days evaluated in 7 studies (mean difference -1.25 days, 95% CI -0.59 to -1.93 days, P=0.0003, I2 = 90%). Conclusions: This meta-analysis demonstrated that a restrictive fluid resuscitation strategy in sepsis resulted in no difference in mortality but may reduce ventilator days. Larger randomized trials are required to determine the optimal management of fluids in patients with sepsis.

Fluids or vasopressors for the initial resuscitation of septic shock.

Intravenous fluid resuscitation is recommended first-line treatment for sepsis-associated hypotension and/or hypoperfusion. The rationale is to restore circulating volume and optimize cardiac output in the setting of shock. Nonetheless, there is limited high-level evidence to support this practice. Over the past decade emerging evidence of harm associated with large volume fluid resuscitation among patients with septic shock has led to calls for a more conservative approach. Specifically, clinical trials undertaken in Africa have found harm associated with initial fluid resuscitation in the setting of infection and hypoperfusion. While translating these findings to practice in other settings is problematic, there has been a re-appraisal of current practice with some recommending earlier use of vasopressors rather than repeated fluid boluses as an alternative to restore perfusion in septic shock. There is consequently uncertainty and variation in practice. The question of fluids or vasopressors for initial resuscitation in septic shock is the subject of international multicentre clinical trials.

Rhabdomyolysis

Rhabdomyolysis is a condition that results from the breakdown of skeletal muscle. The etiologies can be broken down into three main categories of causes: traumatic, atraumatic exertional, and atraumatic nonexertional. Patients with rhabdomyolysis often present with myalgia and are found to have myoglobinuria with elevations in serum creatine kinase levels. The mainstay in therapy is focused on restoration of intravascular volume with large-volume fluid resuscitation using isotonic fluids. Adequate hydration is necessary to prevent the potential complications of rhabdomyolysis, including the development of acute kidney injury. Practitioners should maintain a high level of suspicion of compartment syndrome in patients with rhabdomyolysis. If extremity compartment syndrome is diagnosed, prompt decompressive fasciotomies should be performed to preserve muscle and nerve viability. The early use of renal replacement therapy in patients with rhabdomyolysis has been described in the literature and may represent another modality of therapy to prevent the adverse sequelae of rhabdomyolysis. This review contains 8 tables and 42 references Keywords: acute kidney injury, compartment syndrome, creatine kinase, disseminated intravascular coagulation, rhabdomyolysis

Different Depths May Not Determine the Fluid Resuscitation Volume in Early-stage Management of Severe Burns: A Model-comparison Retrospective Analysis of Fluid Volume Determining Factors.

Large-volume fluid resuscitation remains irreplaceable in the early-stage management of severe burns. We aimed to explore the relationship between fluid volume and other indicators. Data of severe burn patients with successful resuscitation in the early stage was collected. Correlation and linear regression analyses were performed. Multiple linear regression models, related goodness-of-fit assessment (adjusted R-square and Akaike Information Criterion), scatter plots, and paired t-test for two models, and a likelihood ratio test were performed. 96 patients were included. The median of total burn area (TBA) was 70%TBSA, with full thickness burn area (FTBA)/TBA of 0.4, a resuscitation volume of 1.93 mL/kg/%TBSA. Among volume-correlated indicators, two linear regression models were established (Model 1: TBA × weight and tracheotomy; and Model 2: FTBA × weight, partial thickness burn area (PTBA) × weight, and tracheotomy). For these models, close values of Akaike Information Criterion, adjusted R-squares, outliers of the prediction range, and the result of paired t-test, all suggest similarity between two models estimations, while the likelihood ratio test for coefficients of FTBA × weight and PTBA × weight showed a statistical difference. Inhalational injury and decompression surgery only correlated with volume, while Tracheotomy, TBA × weight, FTBA × weight, and PTBA × weight correlated with and were accepted in linear models of volume. Although FTBA and PTBA differed statistically, there may be no need to distinguish them when estimating the resuscitation volume requirements in this patient set. Further study about different depths fluid should be conducted.

THE USE OF 5% IV ALBUMIN IN PATIENTS WITH SHOCK: DOES IT DECREASE VASOPRESSOR REQUIREMENT?

TOPIC: Critical Care TYPE: Original Investigations PURPOSE: Circulatory shock often requires large volume fluid resuscitation as a part of treatment. While crystalloid fluids are more commonly used, many patients in intensive care are unable to receive crystalloid fluids due to conditions such as congestive heart failure and end stage renal disease. Utilizing traditional fluids in such patients often complicates hospital courses. There are many studies regarding the benefits, effects and potential harms of using IV albumin for fluid resuscitation. The 2004 SAFE study suggested some benefit of using IV albumin in sepsis but equivocal to conventional management in morbidity and mortality. The 2014 ALBIOS Study of IV albumin use resulted in 90 day mortality benefit and decreased vasopressor need in severely septic patients. Despite these studies, the use of IV albumin in the critically ill remains controversial with consensus or guidelines being established regarding its use. METHODS: We conducted a retrospective study of 70 critically ill patients admitted to MICU from 7/2019 to 5/2020 to assess the effects of IV albumin. Patients diagnosed with shock who received 5% IV albumin were included. Patients who received 25% IV albumin were excluded. We analyzed cases by type of shock, conditions limiting crystalloid bolus, serum albumin level before IV albumin, MAP pre- and post- albumin infusion, pressor requirement (type/duration), development of ARDS, HD/CRRT requirement, COVID status and mortality. RESULTS: Septic shock patients received IV albumin most, followed by cardiogenic shock. Those unable to receive fluid boluses were due to primarily cardiac etiology, followed by renal & hepatic. Increased MAP was observed after IV albumin infusion in many cases. Serum albumin 2.8 on ICU admission responded better to IV albumin and had lower vasopressor requirements.IV albumin was not related with renal dysfunction and those receiving IV Albumin did not need HD/CRRT. 69.6% did not develop ARDS, 5.8% developed ARDS, 24.6% tested positive for COVID and they were excluded from the ARDS incidence rate. Survival rate was 65.7%, mortality rate 24.3% and 10% went to hospice CONCLUSIONS: The use of 5% IV albumin for volume resuscitation in patients with different forms of shock in ICU showed favorable results, especially in those with serum albumin >2.7-2.8. Our retrospective study showed low incidence of adverse events such as cardiogenic pulmonary edema, ARDS or a need for HD/CRRT, lower vasopressor requirement, in both duration and agents used. Further research should be done in this regard to solidify these findings and to establish clear guidelines/protocols regarding the use of albumin as a resuscitative fluid in the ICU setting. CLINICAL IMPLICATIONS: When treating patients with shock and specially patients with hypoalbuminemia, 5% IV albumin can potentially be used as a means to decrease vasopressor requirements and duration without increasing the risk of pulmonary edema, ARDS and renal dysfunction. Further research should be done in this regard to solidify these findings and to establish clear guidelines/protocols regarding the use of albumin as a resuscitative fluid in the ICU setting. DISCLOSURES: No relevant relationships by Andrew Ajemian, source=Web Response No relevant relationships by Muhammad Umer Altaf, source=Web Response No relevant relationships by Christopher Bowman, source=Web Response No relevant relationships by Gabriel Diaz, source=Web Response No relevant relationships by Jessica Obeahon, source=Web Response No relevant relationships by Travis Yamanaka, source=Web Response

Most emergency department patients meeting sepsis criteria are not diagnosed with sepsis at discharge.

Effective sepsis resuscitation depends on useful criteria for prompt identification of eligible patients. These criteria should reliably predict a discharge diagnosis of sepsis, ensuring that interventions are triggered for those who need it while avoiding potentially harmful interventions in those who do not. We sought to determine the proportion of patients meeting sepsis criteria in the emergency department (ED) that was ultimately diagnosed with sepsis and to quantify the subset of nonseptic patients with risk factors for harm from fluid resuscitation. This retrospective cohort study of adult ED patients at a tertiary academic medical center included vital signs and laboratory results from the first 6 hours, plus administration of intravenous antibiotics, to determine if patients met 2016 Sepsis-3 consensus criteria. If these patients also had hypotension and lactic acidosis, we categorized them as Sepsis-3 plus shock. We used discharge ICD-9 codes to determine if patients were ultimately diagnosed with sepsis. Over 8 years, 3,121 ED patients met 2016 Sepsis-3 criteria in the first 6 hours. Of these, only 25% and 48% met explicit and implicit criteria for a discharge diagnosis of sepsis. Of 1,032 patients with Sepsis-3 plus shock, 48% and 62% met explicit and implicit criteria. Overall, 60% to 75% of ED patients meeting Sepsis-3 criteria with or without shock did not receive a sepsis discharge diagnosis. At least one plausible risk factor for harm from large-volume fluid resuscitation was identified among 19% to 36% of patients meeting sepsis criteria in the ED but not ultimately diagnosed with sepsis at discharge. Most patients meeting sepsis criteria in the ED were not diagnosed with sepsis at discharge. Urgent treatment bundles triggered by consensus criteria in the early phase of ED care may be administered to several patients without sepsis, potentially exposing some to interventions of uncertain benefit and possible harm.

Fluid resuscitation in sepsis: the great 30 mL per kg hoax.

Large volume fluid resuscitation is currently viewed as the cornerstone of the treatment of septic shock. The surviving sepsis campaign (SSC) guidelines provide a strong recommendation to rapidly administer a minimum of 30 mL/kg crystalloid solution intravenously in all patients with septic shock and those with elevated blood lactate levels. However, there is no credible evidence to support this recommendation. In fact, recent findings from experimental, observational and randomized clinical trials demonstrate improved outcomes with a more restrictive approach to fluid resuscitation. Accumulating evidence suggests that aggressive fluid resuscitation is harmful. Paradoxically, excess fluid administration may worsen shock. In this review, we critically evaluate the scientific evidence for a weight-based fluid resuscitation approach. Furthermore, the potential mechanisms and consequences of harm associated with fluid resuscitation are discussed. Finally, we recommend an individualized, conservative and physiologic guided approach to fluid resuscitation.

Abdominal compartment syndrome: Often overlooked conditions in medical intensive care units.

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome are well recognized entities among surgical patients. Nevertheless, a number of prospective and retrospective observational studies have shown that IAH is prevalent in about half of the critically ill patients in the medical intensive care units (ICU) and has been widely recognized as an independent risk factor for mortality. It is alarming to note that many members of the critical care team in medical ICU are not aware of the consequences of untreated IAH and the delay in making the diagnosis leads to increased morbidity and mortality. Frequently it is underdiagnosed and undertreated in this patient population. Elevated intra-abdominal pressure decreases the blood flow to the kidneys and other abdominal viscera and also results in reduced cardiac output and difficulties in ventilating the patient because of increased intrathoracic pressure. When intraabdominal hypertension is not promptly recognized and treated, it leads to abdominal compartment syndrome, multiorgan dysfunction syndrome and death. Large volume fluid resuscitation is very common in medical ICU patients presenting with sepsis, shock and other inflammatory conditions like pancreatitis and it is one of the major risk factors for the development of intra-abdominal hypertension. This article presents an overview of the epidemiology, definitions, risk factors, pathophysiology and management of IAH and abdominal compartment syndrome in critically ill medical ICU patients.

Cardiac Dysfunction in Severely Burned Patients: Current Understanding of Etiology, Pathophysiology, and Treatment.

Patients who experience severe burn injuries face a massive inflammatory response resulting in hemodynamic and cardiovascular complications. Even after immediate and appropriate resuscitation, removal of burn eschar and covering of open areas, burn patients remain at high risk for serious morbidity and mortality. As a result of the massive fluid shifts following the initial injury, along with large volume fluid resuscitation, the cardiovascular system is critically affected. Further, increased inflammation, catecholamine surge, and hypermetabolic syndrome impact cardiac dysfunction, which worsens outcomes of burn patients. This review aimed to summarize the current knowledge about the effect of burns on the cardiovascular system.A comprehensive search of the PubMed and Embase databases and manual review of articles involving effects of burns on the cardiovascular system was conducted.Many burn units use multimodal monitors (e.g., transpulmonary thermodilution) to assess hemodynamics and optimize cardiovascular function. Echocardiography is often used for additional evaluations of hemodynamically unstable patients to assess systolic and diastolic function. Due to its noninvasive character, echocardiography can be repeated easily, which allows us to follow patients longitudinally.The use of anabolic and anticatabolic agents has been shown to be beneficial for short- and long-term outcomes of burn survivors. Administration of propranolol (non-selective β-receptor antagonist) or oxandrolone (synthetic testosterone) for up to 12 months post-burn counteracts hypermetabolism during hospital stay and improves cardiac function.A comprehensive understanding of how burns lead to cardiac dysfunction and new therapeutic options could contribute to better outcomes in this patient population.

Hyperchloremia in Intensive Care Unit Mortality: An Underestimated Fact.

ObjectiveThe goal of the study was to determine the percentage of hyperchloremia in patients who died in medical intensive care unit (ICU) and thus emphasizing the need of avoiding chloride-rich solutions due to their deleterious effects.Study designWe conducted a retrospective study of data from 206 patients who expired in medical ICU in one year from January 2017 to December 2017 in the department of critical care medicine at Shifa International Hospital, Islamabad.Material and methodsThe study included 206 patients: 93 (43.1%) men and 123 (56.9%) women, over the age of 18 years who expired in medical ICU in one year from January 2017 to December 2017. Patients included for the study were all those who expired with any diagnosis but those who remained admitted in ICU for at least 72 hours and received intravenous fluids. The serum chloride levels of the patients at the time of admission and at 72 hours of stay in ICU were collected. The patients who were having serum chloride levels of 107 milliequivalent per deciliter (meq/dl) or more were labeled as having hyperchloremia. The data were analyzed using IBM SPSS Statistics for Windows, Version 23.0 (IBM Crop., Armonk, NY, USA). The mean and standard deviations were calculated for continuous variables while frequency and percentages were calculated for qualitative variables.ResultsAmong 206 patients who expired in our ICU, 109 (50.5%) patients had hyperchloremia at 72 hours of admission in ICU while 107 (49.5%) patients did not had hyperchloremia. Hyperchloremia was more frequent in patients with sepsis or septic shock.ConclusionHigher percentage (50.5%) of hyperchloremia at 72 hours of admission among patients (who expired in our medical ICU) indicates excessive use of chloride-rich intravenous fluids. This finding may have significant impact on mortality along with other contributing factors that lead to death of the patients. Keeping in view the findings of the study, chloride-rich solutions should be used carefully to counter the effects of hyperchloremia in patients requiring large volume fluid resuscitation in ICU. Fluids with lower content of chloride such as lactated ringer may be equally good in large volume fluid resuscitation with advantage of avoiding hyperchloremia.

Large Volume Fluid Resuscitation for Severe Acute Pancreatitis is Associated With Reduced Mortality: A Multicenter Retrospective Study.

Although fluid resuscitation is critical in acute pancreatitis, the optimal fluid volume is unknown. The aim of this study is to evaluate the association between the volume of fluid administered and clinical outcomes in patients with severe acute pancreatitis (SAP). We conducted a multicenter retrospective study at 44 institutions in Japan. Inclusion criteria were age 18 years or older, and diagnosed with SAP from 2009 to 2013. Patients were stratified into 2 groups: administered fluid volume <6000 and ≥6000 mL in the first 24 hours. We evaluated the association between the 2 groups and clinical outcomes using multivariable logistic regression analysis. The primary outcome was in-hospital mortality. Secondary outcomes included the incidence of pancreatic infection and the need for surgical intervention. We analyzed 1097 patients, and the mean fluid volume administered was 5618±3018 mL (mean±SD), with 708 and 389 patients stratified into the fluid <6000 mL and fluid ≥6000 mL groups, respectively. Overall in-hospital mortality was 12.3%. The fluid ≥6000 mL group had significantly higher mortality than the fluid <6000 mL group (univariable analysis, 15.9% vs. 10.3%; P<0.05). In multivariable logistic regression analysis, administration of ≥6000 mL of fluid within the first 24 hours was significantly associated with reduced mortality (odds ratio, 0.58; P<0.05). No significant association was found between the administered fluid volume and pancreatic infection, or between the volume administered and the need for surgical intervention. In patients with SAP, administration of a large fluid volume within the first 24 hours is associated with decreased mortality.

Permissive fluid volume in adult patients undergoing extracorporeal membrane oxygenation treatment

BackgroundExtracorporeal membrane oxygenation (ECMO) is a cardiorespiratory support technique for patients with circulatory or pulmonary failure. Frequently, large-volume fluid resuscitation is needed to ensure sufficient extracorporeal blood flow in patients initiating ECMO. However, excessive overhydration is known to increase mortality in critically ill patients. Therefore, in order to define a tolerant volume range in patients undergoing ECMO treatment, the association between cumulative fluid balance (CFB) and outcome was evaluated in patients undergoing ECMO.MethodsThis retrospective multicenter cohort study was conducted with 723 patients who underwent ECMO in three tertiary care hospitals between 2005 and 2016. CFB was calculated as total fluid input minus total fluid output during the first 3 days from ECMO initiation. The patients were divided into groups that initiated ECMO owing to cardiovascular disease (CVD)-related or non-cardiovascular disease (non-CVD)-related causes. The primary endpoint was mortality within 90 days after ECMO commencement.ResultsTotals of 406 and 317 patients were included in the CVD and non-CVD groups, respectively. In the CVD group, the mean age was 58.4 ± 17.7 years, and 68.2% were male. The mean age was 55.7 ± 15.7 years, and 65.3% were male in the non-CVD group. The median CFB values were 64.7 and 53.5 ml/kg in the CVD and non-CVD groups, respectively. Multivariable analysis using Cox proportional hazards models revealed a significantly increased risk of 90-day mortality in patients with higher CFB values in both the CVD and non-CVD groups. However, the risks were elevated only in the two CFB quartile groups with the largest CFB amounts. Cubic spline models showed that mortality risk began to increase significantly when CFB was 82.3 ml/kg in the CVD group. In patients with respiratory diseases, the mortality risk increase was significant for those with CFB levels above 189.6 ml/kg.ConclusionsMortality risk did not increase until a certain level of fluid overload was reached in patients undergoing ECMO. Adequate fluid resuscitation is critical to improving outcomes in these patients.

Chloride Content of Fluids Used for Large-Volume Resuscitation Is Associated With Reduced Survival.

We sought to investigate if the chloride content of fluids used in resuscitation was associated with short- and long-term outcomes. We identified patients who received large-volume fluid resuscitation, defined as greater than 60 mL/kg over a 24-hour period. Chloride load was determined for each patient based on the chloride ion concentration of the fluids they received during large-volume fluid resuscitation multiplied by the volume of fluids. We compared the development of hyperchloremic acidosis, acute kidney injury, and survival among those with higher and lower chloride loads. University Medical Center. Patients admitted to ICUs from 2000 to 2008. None. Among 4,710 patients receiving large-volume fluid resuscitation, hyperchloremic acidosis was documented in 523 (11%). Crude rates of hyperchloremic acidosis, acute kidney injury, and hospital mortality all increased significantly as chloride load increased (p < 0.001). However, chloride load was no longer associated with hyperchloremic acidosis or acute kidney injury after controlling for total fluids, age, and baseline severity. Conversely, each 100 mEq increase in chloride load was associated with a 5.5% increase in the hazard of death even after controlling for total fluid volume, age, and severity (p = 0.0015) over 1 year. Chloride load is associated with significant adverse effects on survival out to 1 year even after controlling for total fluid load, age, and baseline severity of illness. However, the relationship between chloride load and development of hyperchloremic acidosis or acute kidney injury is less clear, and further research is needed to elucidate the mechanisms underlying the adverse effects of chloride load on survival.

Rhabdomyolysis

Rhabdomyolysis is a condition that results from the breakdown of skeletal muscle. The etiologies can be broken down into three main categories of causes: traumatic, atraumatic exertional, and atraumatic nonexertional. Patients with rhabdomyolysis often present with myalgia and are found to have myoglobinuria with elevations in serum creatine kinase levels. The mainstay in therapy is focused on restoration of intravascular volume with large-volume fluid resuscitation using isotonic fluids. Adequate hydration is necessary to prevent the potential complications of rhabdomyolysis, including the development of acute kidney injury. Practitioners should maintain a high level of suspicion of compartment syndrome in patients with rhabdomyolysis. If extremity compartment syndrome is diagnosed, prompt decompressive fasciotomies should be performed to preserve muscle and nerve viability. The early use of renal replacement therapy in patients with rhabdomyolysis has been described in the literature and may represent another modality of therapy to prevent the adverse sequelae of rhabdomyolysis. Key words: acute kidney injury, compartment syndrome, creatine kinase, disseminated intravascular coagulation, rhabdomyolysis

Plasma syndecan-1 levels identify a cohort of patients with severe sepsis at high risk for intubation after large-volume intravenous fluid resuscitation

PurposeSepsis damages the endothelial glycocalyx, contributing to fluid extravasation, organ injury, and death. Our goal was to determine if syndecan-1 level is associated with the risk of intubation and modifying effect of intravenous fluids (IVFs) in these patients. MethodsSyndecan-1 was measured at enrollment in patients underdoing protocolized resuscitation for severe sepsis or septic shock. The primary outcome was difference in syndecan-1 based on subsequent intubation status, with in-hospital mortality and acute kidney injury serving as secondary outcomes. Logistic regression was performed to evaluate the effect of IVF volume on each outcome. ResultsSyndecan-1 was measured in 175 patients. Twenty-two percent met the primary outcome, 21% died, and 57% developed kidney injury. Syndecan-1 was nonsignificantly higher in intubated patients and was significantly higher in nonsurvivors and those with kidney injury. High syndecan-1 was defined as >240 ng/mL. The IVFs did not differ significantly between high and low syndecan-1 groups. Fluid volume was not associated with intubation in patients with a low syndecan-1 level but was associated with intubation in those with high syndecan-1 levels. ConclusionsSyndecan-1 is elevated in emergency department sepsis nonsurvivors. Patients with high syndecan-1 may represent a cohort at particular risk for intubation after large-volume fluid administration.

Incidence and prognosis of intra-abdominal hypertension and abdominal compartment syndrome in severely burned patients: Pilot study and review of the literature.

Burn patients are at high risk for secondary intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) due to capillary leak and large volume fluid resuscitation. Our objective was to examine the incidence the incidence of IAH and ACS and their relation to outcome in mechanically ventilated (MV) burn patients. This observational study included all MV burn patients admitted between April 2007 and December 2009. Various physiological parameters, intra-abdominal pressure (IAP) measurements and severity scoring indices were recorded on admission and/or each day in ICU. Transpulmonary thermodilution parameters were also obtained in 23 patients. The mean and maximum IAP during admission was calculated. The primary endpoint was ICU (burn unit) mortality. Fifty-six patients were included. The average Simplified Acute Physiology Score (SAPS II) and Sequential Organ Failure Assessment (SOFA) scores were 43.4 (± 15.1) and 6.4 (± 3.4), respectively. The average total body surface area (TBSA) affected by burns was 24.9% (± 24.9), with 33 patients suffering inhalational injuries. Forty-four (78.6%) patients developed IAH and 16 (28.6%) suffered ACS. Patients with ACS had higher TBSAs burned (35.8 ± 30 vs. 20.6 ± 21.4%, P = 0.04) and higher cumulative fluid balances after 48 hours (13.6 ± 16L vs. 7.6 ± 4.1 L, P = 0.03). The TBSA burned correlated well with the mean IAP (R = 0.34, P = 0.01). Mortality was notably high (26.8%) and significantly higher in patients with IAH (34.1%, P = 0.014) and ACS (62.5%, P < 0.0001). Most patients received more fluids than calculated by the Parkland Consensus Formula while, interestingly, non-survivors received less. However, when patients with pure inhalation injury were excluded there were no differences. Non-surgical interventions (n = 24) were successful in removing body fluids and were related to a significant decrease in IAP, central venous pressure (CVP) and an improvement in oxygenation and urine output. Non-resolution of IAH was associated with a significantly worse outcome (P < 0.0001). Based on our preliminary results we conclude that IAH and ACS have a relatively high incidence in MV burn patients compared to other groups of critically ill patients. The percentage of TBSA burned correlates with the mean IAP. The combination of high CLI, positive (daily and cumulative) fluid balance, high IAP, high EVLWI and low APP suggest a poor outcome. Non-surgical interventions appear to improve end-organ function. Non-resolution of IAH is related to a worse outcome.

Vasopressin decreases pulmonary-to-systemic vascular resistance ratio in a porcine model of severe hemorrhagic shock.

Vasopressors are gaining renewed interest as treatment adjuncts in hemorrhagic shock. The ideal vasoconstrictor will increase systemic blood pressure without increasing pulmonary vascular resistance (PVR), which hinders pulmonary perfusion and exacerbates hypoxemia. However, the selectivity of pressors for pulmonary versus systemic vasoconstriction during hemorrhage has not been characterized. The purpose of this study was to test the hypothesis that vasopressin (VP) has distinct effects on pulmonary versus systemic hemodynamics, unlike the catecholamine vasopressors norepinephrine (NE) and phenylephrine (PE). Anesthetized and ventilated pigs were assigned to resuscitation with saline only (n = 7) or saline with VP (n = 6), NE (n = 6), or PE (n = 6). Animals were hemorrhaged to a target volume of 30 mL/kg and a mean arterial pressure of 35 mmHg. One hour after the start of hemorrhage, animals were resuscitated with saline up to one shed blood volume, followed by either additional saline or a vasopressor. Hemodynamics and oxygenation were measured hourly for 4 h after the start of hemorrhage. Vasopressin increased systemic vascular resistance (SVR) while sparing the pulmonary vasculature, leading to a 45% decrease in the PVR/SVR ratio compared with treatment with PE. Conversely, NE induced pulmonary hypertension and led to an increased PVR/SVR ratio associated with decreased oxygen saturation. Phenylephrine and crystalloid had no significant effect on the PVR/SVR ratio. Sparing of pulmonary vasoconstriction occurs only with VP, not with administration of crystalloid or catecholamine pressors. The ability of VP to maintain blood oxygenation indicates that VP may prevent hypoxemia in the management of hemorrhagic shock.

Fluid overload, de-resuscitation, and outcomes in critically ill or injured patients: a systematic review with suggestions for clinical practice.

Sepsis is associated with generalised endothelial injury and capillary leak and has traditionally been treated with large volume fluid resuscitation. Some patients with sepsis will accumulate bodily fluids. The aim of this study was to systematically review the association between a positive fluid balance/fluid overload and outcomes in critically ill adults, and to determine whether interventions aimed at reducing fluid balance may be linked with improved outcomes. We searched MEDLINE, PubMed, EMBASE, Web of Science, The Cochrane Database, clinical trials registries, and bibliographies of included articles. Two authors independently reviewed citations and selected studies examining the association between fluid balance and outcomes or where the intervention was any strategy or protocol that attempted to obtain a negative or neutral cumulative fluid balance after the third day of intensive care compared to usual care. The primary outcomes of interest were the incidence of IAH and mortality. Among all identified citations, one individual patient meta-analysis, 11 randomised controlled clinical trials, seven interventional studies, 24 observational studies, and four case series met the inclusion criteria. Altogether, 19,902 critically ill patients were studied. The cumulative fluid balance after one week of ICU stay was 4.4 L more positive in non-survivors compared to survivors. A restrictive fluid management strategy resulted in a less positive cumulative fluid balance of 5.6 L compared to controls after one week of ICU stay. A restrictive fluid management was associated with a lower mortality compared to patients treated with a more liberal fluid management strategy (24.7% vs 33.2%; OR, 0.42; 95% CI 0.32-0.55; P < 0.0001). Patients with intra-abdominal hypertension (IAH) had a more positive cumulative fluid balance of 3.4 L after one week of ICU stay. Interventions to decrease fluid balance resulted in a decrease in intra-abdominal pressure (IAP): an average total body fluid removal of 4.9 L resulted in a drop in IAP from 19.3 ± 9.1 mm Hg to 11.5 ± 3.9 mm Hg. A positive cumulative fluid balance is associated with IAH and worse outcomes. Interventions to limit the development of a positive cumulative fluid balance are associated with improved outcomes. In patients not transgressing spontaneously from the Ebb to Flow phases of shock, late conservative fluid management and late goal directed fluid removal (de-resuscitation) should be considered.

Traumatic coagulopathy‐Part 2: Resuscitative strategies

To discuss the current resuscitative strategies for trauma-induced hemorrhagic shock and acute traumatic coagulopathy (ATC). Hemorrhagic shock can be acutely fatal if not immediately and appropriately treated. The primary tenets of hemorrhagic shock resuscitation are to arrest hemorrhage and restore the effective circulating volume. Large volumes of isotonic crystalloids have been the resuscitative strategy of choice; however, data from experimental animal models and retrospective human analyses now recognize that large-volume fluid resuscitation in uncontrolled hemorrhage may be deleterious. The optimal resuscitative strategy has yet to be defined. In human trauma, implementing damage control resuscitation with damage control surgery for controlling ongoing hemorrhage, acidosis, and hypothermia; managing ATC; and restoring effective circulating volume is emerging as a more optimal resuscitative strategy. With hyperfibrinolysis playing an integral role in the manifestation of ATC, the use of antifibrinolytics (eg, tranexamic acid and aminocaproic acid) may also serve a beneficial role in the early posttraumatic period. Considering the sparse information regarding these resuscitative techniques in veterinary medicine, veterinarians are left with extrapolating information from human trials and experimental animal models. Viscoelastic tests integrated with predictive scoring systems may prove to be the most reliable methods for early detection of ATC as well as for guiding transfusion requirements. Hemorrhage accounts for up to 40% of human trauma-related deaths and remains the leading cause of preventable death in human trauma. The exact proportion of trauma-related deaths due to exsanguinations in veterinary patients remains uncertain. Survivability depends upon achieving rapid definitive hemostasis, early attenuation of posttraumatic coagulopathy, and timely restoration of effective circulating volume. Early institution of damage control resuscitation in severely injured patients with uncontrolled hemorrhage has the ability to curtail posttraumatic coagulopathy and the exacerbation of metabolic acidosis and hypothermia and improve survival until definitive hemostasis is achieved.