Large Volumes Of Intravenous Fluids Research Articles

Outcomes In Patients Admitted With Diabetic Ketoacidosis And Heart Failure With Reduced Ejection Fraction

Outcomes In Patients Admitted With Diabetic Ketoacidosis And Heart Failure With Reduced Ejection Fraction

Multicentre randomised controlled trial: protocol for Plasma-Lyte Usage and Assessment of Kidney Transplant Outcomes in Children (PLUTO)

IntroductionAcute electrolyte and acid–base imbalance is experienced by many children following kidney transplantation. When severe, this can lead to complications including seizures, cerebral oedema and death. Relatively large volumes of...

Peri-operative fluid management during neurosurgical procedures

The management of fluids and electrolytes in neurosurgical patients aims to reduce the risk of cerebral oedema, reduce ICP and at the same time maintain haemodynamic stability and cerebral perfusion. Neurosurgical patients commonly receive diuretics (mannitol and furosemide), developing complications such as bleeding and diabetes insipidus. These patients may require large volumes of intravenous fluids and even blood transfusions for volume resuscitation, treatment of cerebral vasospasm, correction of preoperative dehydration or maintenance of haemodynamic stability. Goal-oriented therapy is recommended in neurological patients, with the aim of maintaining circulating volume and tolerating the changes induced by anaesthesia (vasodilation and myocardial depression).

Idiopathic systemic capillary leak syndrome (Clarkson’s disease) presenting with recurrent hypovolemic shock

A 49-year old male with a past medical history of myocardial infarction and compartment syndromes requiring fasciotomies presented on five occasions with hypovolemic shock. We describe his admissions and presumptive diagnoses which required large volumes of intravenous fluids, admission to intensive care for vasopressors and renal replacement therapy. The presentations were always precipitated by a prodrome of fatigue and pre-syncopal episodes. On his last admission, a diagnosis of Idiopathic systemic capillary leak syndrome (ISCLS), also known as Clarkson’s Disease, was reached. He is currently receiving high dose intravenous immunoglobulins on a monthly basis.

Fluid Response Evaluation in Sepsis Hypotension and Shock

Patients in septic shock routinely receive large volumes of intravenous fluids as part of their initial resuscitation. However, hypervolemia secondary to aggressive fluid administration is associated with increased morbidity and mortality including renal failure, respiratory failure, or death. Dynamic approaches to hemodynamic monitoring for fluid responsiveness (FR) including measurement of stroke volume (SV) following increased fluid volume through IV fluids during passive leg raise (PLR) may have a role in guiding resuscitative efforts, although the benefits in an emergency department or ICU setting are unclear.

Plasma electrolyte imbalance in pediatric kidney transplant recipients.

In current practice, pediatric kidney transplant recipients receive large volumes of intravenous fluid intraoperatively to establish allograft perfusion, and further fluid to replace urinary and insensible losses postoperatively. Acute electrolyte imbalance can result, with potential for neurological sequelae. We aimed to determine the incidence and severity of postoperative plasma electrolyte imbalance in pediatric kidney transplant recipients managed with the current standard intravenous crystalloid regimen. A retrospective analysis of plasma electrolytes in the first 72hours post-kidney transplant in 76 children transplanted between January 1, 2015, and January 31, 2018, managed with a standard intravenous fluid strategy used in most UK pediatric transplant centers. Of 76 pediatric transplant recipients of median age 9.9 (range 2.2-17.9) years predominantly managed with 0.45% sodium chloride 5% glucose, 45 (59%) developed acute hyponatremia, 23 (30%) hyperkalemia, and 43 (57%) non-anion-gap acidosis in the postoperative period. Hyperglycemia occurred in 74 (97%) patients. Hyperkalemia was more prevalent in deceased than live donor recipients (P=0.003) and was significantly associated with non-anion-gap acidosis (P<0.001). Recipient weight was not associated with overt electrolyte imbalance. Postoperative plasma electrolyte imbalance is common in pediatric kidney transplant recipients. Current clinical care strategies mitigate the associated risks of neurological sequelae to some degree. Further studies to optimize intravenous fluid therapy and minimize electrolyte disturbance in this group of patients are needed.

The Impact of Early Identification and a Critical Care-Based Sepsis Response Team on Sepsis Outcomes.

The Impact of Early Identification and a Critical Care-Based Sepsis Response Team on Sepsis Outcomes.

Perioperative fluid management: From physiology to improving clinical outcomes.

Perioperative fluid management is a key component in the care of the surgical patient. It is an area that has seen significant changes and developments, however there remains a wide disparity in practice between clinicians. Historically, patients received large volumes of intravenous fluids perioperatively. The concept of goal directed therapy was then introduced, with the early studies showing significant improvements in morbidity and mortality. The current focus is on fluid therapy guided by an individual patient's physiology. A fluid challenge is commonly performed as part of an assessment of a patient's fluid responsiveness. There remains wide variation in how clinicians perform a fluid challenge and this review explores the evidence for how to administer an effective challenge that is both reliable and reproducible. The methods for monitoring cardiac output have evolved from the pulmonary artery catheter to a range of less invasive techniques. The different options that are available for perioperative use are considered. Fluid status can also be assessed by examining the microcirculation and the importance of recognising the possibility of a lack of coherence between the macro and microcirculation is discussed. Fluid therapy needs to be targeted to specific end points and individualised. Not all patients who respond to a fluid challenge will necessarily require additional fluid administration and care should be aimed at identifying those who do. This review aims to explain the underlying physiology and describe the evidence base and the changes that have been seen in the approach to perioperative fluid therapy.

Frequency of Fluid Overload and Usefulness of Bioimpedance in Patients Requiring Intensive Care for Sepsis Syndromes

Guideline-directed therapy for sepsis calls for early fluid resuscitation. Often patients receive large volumes of intravenous fluids. Bioimpedance vector analysis (BIVA) is a noninvasive technique useful for measuring total body water. In this prospective observational study, we enrolled 18 patients admitted to the intensive care unit for the treatment of sepsis syndromes. Laboratory data, clinical parameters, and BIVA were recorded daily. All but one patient experienced volume overload during the course of treatment. Two patients had >20 L of excess volume. Volume overload is clinically represented by tissue edema. Edema is not a benign condition, as it impairs tissue oxygenation, obstructs capillary blood flow, disrupts metabolite clearance, and alters cell-to-cell interactions. Specifically, volume overload has been shown to impair pulmonary, cardiac, and renal function. A positive fluid balance is a predictor of hospital mortality. As septic patients recover, volume excess should be aggressively treated with the use of targeted diuretics and renal replacement therapies if necessary.

Using Enteral Sterile Water Feeds for Hypernatremia in Extremely Low Birth-Weight Infants

Extremely low birth-weight infants are prone to fluid and electrolyte imbalance due to multiple etiologies. Hypernatremia can occur in this gestational age group during the first week of life. One therapy that many NICUs initiate to treat hypernatremia is enteral sterile water feeds (SWFs). The use of free water is an adjunct therapy in place of large volumes of intravenous fluids. This article presents a review of renal physiology and 3 case studies of infants, less than 27 weeks' gestational age and less than 1000-g birth weight, treated with SWFs for hypernatremia. Commonalities and differences in treatment are addressed. There is limited evidence-based research using enteral SWFs for the treatment of hypernatremia.

Successful Management of Respiratory Failure Can Improve Renal Function

A subset of patients with acute exacerbation of chronic pulmonary disease present with concomitant acute renal failure (ARF). Acute hypercapnia remains an underappreciated and often overlooked cause of ARF in these patients with acute hypercapnic respiratory failure (AHRF). A nephrology consultation is requested for oliguric ARF in a woman with obesity-hypoventilation syndrome who has been admitted for AHRF and was treated with non-invasive ventilation. Despite stable hemodynamic status, the patient receives a large volume of intravenous fluids in an attempt to improve the renal function and urine output, and develops pulmonary edema and worsening respiratory status.The decision is made to hemodialyze the patient for pulmonary edema and resistant hyperkalemia. However, prior to initiation of hemodialysis, the patient is intubated and started on mechanical ventilation because of progressively worsening respiratory status. This is followed by rapid improvement in hypercapnia and acidosis, and then by a significant increase in urine output. The patient’s renal function and hyperkalemia improves over the next few hours, obviating the need for renal replacement therapy.The potential causes of ARF in patients with AHRF are numerous, and include hemodynamic instability and hypotension, intravascular volume depletion (due to increased insensible loss), concomitant use of medications that affect renal hemodynamics (eg, angiotensin-converting enzyme-I and diuretics), presence of comorbidities with potential impact on renal function (eg, chronic kidney disease, diabetes, heart failure), and interventions performed at the time of admission (eg, intravenous contrast studies and nephrotoxic medications).Management of AHRF frequently parallels the conservative treatment of ARF in these patients, which very often includes administration of large volumes of intravenous fluids with the assumption that the patient is intravascularly volume-depleted. This approach is certainly indicated in patients with hemodynamic instability as well as in those with evidence of intravascular volume depletion and organ hypoperfusion. However, unnecessary and injudicious administration of a large volume of intravenous fluids can result in severe volume overload and worsening respiratory status in other patients.In this regard, it is important to emphasize the role of acute hypercapnia as a potential cause of ARF in patients presenting with AHRF. Although chronically hypercapnic subjects (eg, those with stable chronic obstructive pulmonary disease) have a baseline renovascular resistance similar to normocapnic patients, acute increase in serum CO2 levels is shown to be associated with renal vasoconstriction.1,2 This impact on renal vascular tone is believed to be both direct and indirect (ie, via the sympathetic nervous system).3,4 Vasoconstriction leads to a decrease in renal blood flow and intra-glomerular pressure, with subsequent reduction in glomerular filtration rate. Therefore, it is not unexpected to observe ARF, with pre-renal characteristics without intracascular volume depletion, in patients presenting with AHRF. This physiological concept is further supported by clinical observations such as the one mentioned earlier, in which renal function is improved after successful management of hypercapnia with no additional kidney-oriented intervention.It therefore seems prudent to focus on management of AHRF in patients who present simultaneously with AHRF and ARF. Unnecessary administration of large volumes of intravenous fluids should be avoided in patients without evidence of intravascular volume depletion, and renal replacement therapy can be deferred, if possible, because resolution of AHRF and hypercapnia is typically followed by improvement in renal function.

A Novel Device Developed, Tested, and Used for Warming and Maintaining Intravenous Fluids in a Forward Surgical Team during Operation Enduring Freedom

To determine whether an accessory to the Bair Hugger warming unit (BHWU), a piece of equipment intrinsic to the forward surgical team, could be designed and used to warm and to maintain large volumes of intravenous fluids at an optimal infusion temperature in an austere environment. The X-1 is a simple, collapsible, 5-gallon nylon cooler with handles, modified with a port for the BHWU hose and a one-way flutter valve vent. The warming of intravenous fluids to the optimal infusion temperature was accomplished with the BHWU and X-1. The warming time was influenced by the ambient temperature, the starting temperature of the fluids, and the number of bags being warmed. The warmed fluid could be stored and maintained in the X-1. The heat retention of the fluids was influenced by the ambient temperature, the number of bags warmed, and the insulating properties of the X-1. The BHWU can be used with the compact X-1 to warm and to store large volumes of intravenous fluids at the optimal infusion temperature in the field environment and was successfully used by a forward surgical team in Afghanistan, during Operation Enduring Freedom, for the treatment of combat-wounded soldiers.

Effect of weight loss in congestive heart failure from idiopathic dilated cardiomyopathy on electrocardiographic QRS voltage

It was appreciated in the 1950s and 1960s that patients with congestive heart failure (CHF) had lower QRS voltages on their electrocardiograms than they had when compensated.1–4 Also, 30 years ago Ishikawa et al5 documented an increase in ECG voltages in 12 patients after treatment of CHF, whereas a decrease in the QRS amplitudes occurred in 3 patients with poor response to therapy.5 Recently, a phenomenon consisting of a reduction in ECG amplitude commensurate with weight gain in patients with anasarca was reported6; the involved patients had a variety of critical illnesses, mainly sepsis, and required administration of large volumes of intravenous fluids. During the last month of implementation of this study,6 we encountered in the coronary care unit 3 patients with CHF who had the reverse phenomenon, i.e., an increase in the amplitude of electrocardiograms in response to treatment of CHF, and a resultant loss of weight. These were the only patients admitted in the course of 1 month, with CHF and visible “pitting” peripheral edema in the pretibial aspect of their legs and the dorsum of their feet. Daily weights and standard electrocardiograms were obtained. Measurements to the nearest 0.5 mm of the amplitude (highest positive + lowest negative deflections) of the QRS complex of all 12 leads were obtained by 1 of the investigators (JEM) using a magnifying glass and calipers. Calibration was 1 mV = 10 mm. Sums of the QRS amplitudes of all leads (ΣQRS) were calculated for electrocardiograms of each patient from the days corresponding to the initial (peak) and the lowest weights attained in response to therapy for CHF. Both the change in weights and ΣQRS, and the adjusted values to the commencement of therapy as a percent change were used as variables. The intraobserver variability of ΣQRS in 10 random electrocardiograms from a previous study was found to be 0.41 ± 3.34% (mean ± SD).6 Because hematocrit change may affect blood conductivity,7,8 and thus the amplitude of ECG potentials, this parameter was followed closely. Electrolytes were monitored, and supplemental potassium was administered. Frequent portable chest radiographs were obtained in the study patients to evaluate heart size and status of pulmonary congestion, and its change. Echocardiograms were obtained to assess cardiac structure and function. Management of CHF was done routinely.

Emergency Treatment of Lithium-Induced Diabetes Insipidus with Nonsteroidal Anti-Inflammatory Drugs

Thiazides and amiloride are the most often suggested treatment for nephrogenic diabetic insipidus. We found this ineffectual in a patient with acute problems and reviewed the literature to see if there were other more efficient approaches. A 47-year-old woman on lithium had polyuria. When inadvertently fasted for 48 h she became confused, had a seizure, and her sodium was 170 mmol/L. Urinary output was 24 L/day. Large volumes of intravenous fluids were given but sodium remained >170 mmol/L. Treatment with DDAVP, thiazides, and amiloride did not decrease urinary output. Indomethacin 150 mg was started and urine volume immediately fell to one-half. However, because of persistent high urine output the patient was then fluid depleted, with further reduction to normal in urine volume, and Na decreased to 140 mmol/L. Creatinine rose from 135 μmol/L to 173 μmol/L, but decreased to 152 μmol/L when indomethacin was decreased to 75 mg q.d.; urinary output remained stable around 2 L/day. The literature described 22 patients with nephrogenic diabetes insipidus (16 congenital, 6 lithium) treated with nonsteroidal anti-inflammatory drugs. Urine flow was reduced to 1/3, within hours. Rarely, mild renal failure ensued, improving in all but one case when nonsteroidal anti-inflammatory drugs were reduced. Indomethacin (and controlled volume reduction if continued high urine output), while observing renal function, appears the emergency treatment of choice for serious complications of nephrogenic diabetes insipidus.

Calcium-Free Hemodialysis for the Management of Hypercalcemia

The drug therapies for hypercalcemia of malignancy have been known to be associated with either limited efficacy or cumulative toxicity in patients with advanced renal failure. To establish the guidelines for the use of dialysis and to determine its optimal prescription for hypercalcemia, calcium-free hemodialysis was performed in 6 hypercalcemic patients with renal failure not responding enough to forced saline diuresis. Calcium-free dialysate contained sodium 135, potassium 2.5, chloride 108, magnesium 0.75, bicarbonate 30 mmol/l. Mean hemodialysis time was 160 +/- 27 min and mean Kt/V urea was 0.75 +/- 0.2. Plasma calcium concentrations fell from a mean value of 2.92 +/- 0.21 mmol/l (range 2.55-3.25) to 2.58 +/- 0.16 mmol/l at 1 h of hemodialysis and to 2.16 +/- 0.33 mmol/l (range 1.63-2.53) following 2-3 h of hemodialysis. The ionized calcium (n = 4) decreased from 1.44 +/- 0.14 mmol/l to 0.99 +/- 0.2 mmol/l. No patient showed any hypocalcemic symptoms and signs during hemodialysis. The rate of decrease in plasma calcium did not appear to produce adverse effects in any of the patients. There was a significant positive correlation between the decrease in plasma calcium concentration and the Kt/V urea (y = 1.4x - 0.29, r = 0.92, p < 0.01). We conclude that calcium-free hemodialysis is indicated when the presence of severe renal failure prevents the administration of large volumes of intravenous fluids to hypercalcemic patients. The amount of dialysis (Kt/V urea) can be used to predict the decrease in plasma calcium concentration during calcium-free hemodialysis.

The relation of atherosclerotic lesions to antemortem and postmortem lipid levels: the Bogalusa Heart Study

Although postmortem lipid levels have been used as surrogates for levels during life, it is uncertain whether atherosclerotic lesions are related similarly to antemortem and postmortem lipid values. In a sample of 23 children and young adults who had been examined for cardiovascular disease risk factors and subsequently died from violent causes, we examined the relation of (a) postmortem lipid levels to values obtained 1 to 14 years earlier, and (b) atherosclerotic lesions to antemortem and postmortem lipid levels. Postmortem levels of triglycerides and very-low-density lipoprotein cholesterol (VLDLC) were higher than levels during life, but postmortem levels of total cholesterol (TC), low-density lipoprotein cholesterol (LDLC) and high-density lipoprotein cholesterol (HDLC) were related to antemortem levels ( r s > 0.40). After excluding eight persons who likely received large volumes of intravenous fluids before death, the within-person variability between antemortem and postmortem levels of LDLC and HDLC was similar to the antemortem variability. Furthermore, the relation of atherosclerotic lesions to antemortem and postmortem lipid levels differed only slightly for TC, LDLC and HDLC. In contrast, lesions in the coronary arteries showed the strongest association with antemortem VLDLC levels, but were not associated with postmortem VLDLC levels. Despite the very small number of subjects, our results suggest that if intravenous fluids are not administered before death, postmortem levels of TC, LDLC and HDLC are fairly representative of levels during life. Postmortem levels of VLDLC or triglycerides, however, should not be used as surrogates for antemortem levels.

Crush syndrome

ABSTRACTObjective: To describe the clinical features of crush syndrome, the inter‐relationship between rhabdomyolysis, compartment syndrome and crush syndrome, and to make recommendations on the pre‐hospital and emergency department management of the condition.Clinical features: Three case reports are described of patients presenting with crush syndrome following drug induced coma, including one patient in cardiac arrest. Raised compartment pressures were confirmed by manometry, and extensive rhabdomyolysis by myoglobinuria and raised creatine kinase.Intervention and outcome: Vigorous medical management was undertaken including infusion of large volumes of intravenous fluid, and therapy with bicarbonate; mannitol, frusemide and dopamine. Surgical fasciotomy was not performed and a good outcome resulted in each case.Conclusion: Drug induced coma is now the commonest cause of the crush syndrome. Effective medical management may obviate the need for surgical fasciotomy in cases with raised compartment pressures.

Survival of intravenous chemotherapy infusion sites

Factors associated with the failure of intravenous infusions due to phlebitis and extravasation were studied with 218 infusions delivering cytotoxic drugs. The survival rate of these infusions was not significantly different from that of 56 non-cytotoxic infusions in oncology patients. Although survival analysis indicated that cisplatin was associated with longer survival, this was probably an artifact caused by this drug usually being preceded by 24 h prehydration. Multivariate analysis indicated that etoposide was the only drug associated with decreased infusion survival and that bleomycin, cyclophosphamide, doxorubicin, ifosphamide, methotrexate, treosulphan and 5-fluorouracil had no significant effects. Also age of patient, infusion site and flow rate had no effects but survival was shorter in women. Follow-up indicated that failure of an infusion tended to result in loss of the vein. It is suggested that irritancy of the large volumes of intravenous fluids given to hydrate these patients rather than the cytotoxic drugs was the main factor reducing the survival of these infusions.

3% NaCl and 7.5% NaCl/Dextran 70 in the Resuscitation of Severely Injured Patients

Cardiovascular resuscitation of the severely injured patient in the field remains unsatisfactory because large volumes of intravenous fluid are needed to keep up with ongoing blood losses and because only small volumes of fluid can be given. In the first study reported here, small volumes (less than or equal to 12 mL/kg) of 3% NaCl were given to patients who were having surgery for severe injuries. The 3% NaCl restored blood pressure, pH, and urine output with approximately one half of the cumulative fluid requirement of patients who received isotonic fluids (p less than 0.05). In a second study, 7.5% NaCl/dextran 70, 250 mL, was given in a prospective, randomized, and double-blinded trial to injured patients in the field. Blood pressure in the hypertonic/hyperoncotic group increased 49 mmHg during transport (p less than 0.005); blood pressure in patients given lactated Ringer's solution increased 19 mmHg (NS). Survival favored the hypertonic/hyperoncotic group. The 7.5% NaCl/dextran 70 solution appears particularly promising for treatment of injured patients in the field.

Cardiopulmonary effects of volume expansion in man: radiographic manifestations.

Cardiovascular and humoral responses to extremes of sodium intake (10-1500 mEq/day) were studied. Chest radiographs of eight normal men were obtained to measure changes in heart volume and central vascular structures. Echocardiographic measurements of cardiac chamber dimensions were also obtained. Sodium loading resulted in a 16-mm-Hg increase in mean arterial pressure and increases in cardiac output, stroke volume, left ventricular end-diastolic volume, and all radiographically determined cardiac dimensions. There was direct correlation between the radiographic cardiac dimensions and left ventricular end-diastolic volume. There was no echocardiographic evidence of pericardial fluid. After sodium loading, there was enlargement of the superior vena cava, innominate veins, azygos vein, pulmonary vessels, and the aortic knob. Small pleural effusions were commonly seen. Volume expansion may cause radiographic changes that may mimic those associated with congestive heart failure. This may particularly be the case in patients with renal failure, those receiving dialysis treatment, or patients receiving large volumes of intravenous fluids.