mL Of Intravenous Fluid Research Articles

Comparing the Push–Pull Technique to Pressure Bag for Administration of Blood Products: A Prospective Nonblinded Observation Simulation-based Study (CoPP toP Study)

Abstract Introduction: Shock is defined as inadequate delivery of oxygen to meet the tissue’s demands. There are four main types of shock: cardiogenic, obstructive, distributive, and hypovolemic. Hypovolemic shock causes include hemorrhage, dehydration, and burns. Blood loss results in inadequate oxygen delivery to the cells resulting in tissue death if not reversed. Rapid infusers allow for the rapid administration of blood and crystalloid products to patients in shock; however, many community emergency departments do not have these devices. The aim of our study is to determine the fastest way to administer blood when the viscosity of the fluid is taken into consideration in a simulated setting. Methods: Volunteers were assigned to one of two arms: either the push–pull technique or pressure bag technique. The push–pull technique involved using a 50 cc syringe connected to a 3-way stop-cock to withdraw and infuse the fluid. The pressure bag technique involved pumping a pressure bag up to the maximum to infuse the fluids. The speed of infusing 250 mL of intravenous fluids was recorded. The time for the subjects to collect the materials throughout the emergency department was also recorded. Results: A total of three trials were conducted. On average, the push–pull technique took 228 s and the pressure bag technique took 340 s. The push–pull technique took an average of 112 s less than the pressure bag technique. Subjects took 62 s to find the materials for the pressure bag technique. It took 133 s to find the material for the push–pull technique. Conclusion: This prospective nonblinded observation simulation-based study demonstrated that the push–pull technique was significantly faster than the pressure bag technique.

Restriction of Intravenous Fluid in ICU Patients with Septic Shock

BackgroundIntravenous fluids are recommended for the treatment of patients who are in septic shock, but higher fluid volumes have been associated with harm in patients who are in the intensive care unit (ICU).MethodsIn this international, randomized trial, we assigned patients with septic shock in the ICU who had received at least 1 liter of intravenous fluid to receive restricted intravenous fluid or standard intravenous fluid therapy; patients were included if the onset of shock had been within 12 hours before screening. The primary outcome was death from any cause within 90 days after randomization.ResultsWe enrolled 1554 patients; 770 were assigned to the restrictive-fluid group and 784 to the standard-fluid group. Primary outcome data were available for 1545 patients (99.4%). In the ICU, the restrictive-fluid group received a median of 1798 ml of intravenous fluid (interquartile range, 500 to 4366); the standard-fluid group received a median of 3811 ml (interquartile range, 1861 to 6762). At 90 days, death had occurred in 323 of 764 patients (42.3%) in the restrictive-fluid group, as compared with 329 of 781 patients (42.1%) in the standard-fluid group (adjusted absolute difference, 0.1 percentage points; 95% confidence interval [CI], −4.7 to 4.9; P=0.96). In the ICU, serious adverse events occurred at least once in 221 of 751 patients (29.4%) in the restrictive-fluid group and in 238 of 772 patients (30.8%) in the standard-fluid group (adjusted absolute difference, −1.7 percentage points; 99% CI, −7.7 to 4.3). At 90 days after randomization, the numbers of days alive without life support and days alive and out of the hospital were similar in the two groups.ConclusionsAmong adult patients with septic shock in the ICU, intravenous fluid restriction did not result in fewer deaths at 90 days than standard intravenous fluid therapy. (Funded by the Novo Nordisk Foundation and others; CLASSIC ClinicalTrials.gov number, NCT03668236.)

Modeling of Usual Care: Vasopressor Initiation for Sepsis With Hypotension.

Usual care regarding vasopressor initiation is ill-defined. We aimed to develop a quantitative “dynamic practice” model for usual care in the emergency department (ED) regarding the timing of vasopressor initiation in sepsis. In a retrospective study of 589 septic patients with hypotension in an urban tertiary care center ED, we developed a multi-variable model that distinguishes between patients who did and did not subsequently receive sustained (>24 h) vasopressor therapy. Candidate predictors were vital signs, intravenous fluid (IVF) volumes, laboratory measurements, and elapsed time from triage computed at timepoints leading up to the final decision timepoint of either vasopressor initiation or ED hypotension resolution without vasopressors. A model with six independently significant covariates (respiratory rate, Glasgow Coma Scale score, SBP, SpO2, administered IVF, and elapsed time) achieved a C-statistic of 0.78 in a held-out test set at the final decision timepoint, demonstrating the ability to reliably model usual care for vasopressor initiation for hypotensive septic patients. The included variables measured depth of hypotension, extent of disease severity and organ dysfunction. At an operating point of 90% specificity, the model identified a minority of patients (39%) more than an hour before actual vasopressor initiation, during which time a median of 2,250 (IQR 1,200–3,300) mL of IVF was administered. This single-center analysis shows the feasibility of a quantitative, objective tool for describing usual care. Dynamic practice models may help assess when management was atypical; such tools may also be useful for designing and interpreting clinical trials.

Transfusion-Associated Circulatory Overload (Taco) Presentations In Pediatric Patients

Abstract Introduction/Objective Limited literature exists regarding Transfusion Associated Circulatory Overload(TACO) in children. Its clinical expressions compared to those in adults remains to be fully explored. We report two TACO cases in children <18 months of age describing their clinical presentations compared to those in older patients. Methods/Case Report Case series Results (if a Case Study enter NA) Case 1: 1.13 kg 18 day old male neonate (27 weeks premature) with anemia requiring hemotherapy(HT). He received 35 ml aliquot of Red Blood Cells(RBCs) which he tolerated well on postoperative day(POD) 1 after bowel surgery. On POD 2, he was transfused RBCs(18 mls). Within 15 minutes of HT initiation, marked elevations in blood pressure(BP) were noted. Workup for a suspected transfusion reaction(STR) was initiated. Blood Bank studies revealed vital sign value(VSV) changes similarly seen in adults with TACO(Transfusion: 52; 2311, 2012). NT-proBNP levels post HT were markedly elevated (8,000 and 64,000 pg/ml).Case 2: 17 month old(11 kg) female with a three weeks prior history of COVID-19 admitted with fever/dehydration and subsequently diagnosed with multisystem inflammatory syndrome in children (MIS-C). Intravenous immunoglobulin(IVIG) infusion ordered and within 20 minutes of starting IVIG, she developed grunting. STR workup showed post HT BP/temperature elevations/chest X-ray with increased interstitial markings. Of note she had also received 1070 ml of intravenous fluids within 48 hours prior to HT. Elevated NT-proBNP levels pre/post HT were measured(17,121 pg/ml and 19, 824 pg/ml respectively). Symptoms improved with diuretics. Conclusion Children experiencing TACO can clinically manifest similarly as in adults with respect to BP elevations and pulmonary changes. Grunting may be an underappreciated manifestation of TACO in pts < 18 months of age. IVIG infusions used in the treatment of patients with MIS-C may present problematic fluid challenges. Recognition of and mitigation strategies for TACO risk factors in such patients may enhance HT safety in this vulnerable patient population.

Effect of Intraoperative Fluid Administration on Post-operative Urinary Retention in Patients Undergoing Outpatient Anorectal Surgery

Post-operative urinary retention, POUR, is a common and potentially avoidable occurrence following surgery under anesthesia. We assessed whether the volume of intraoperative fluid administered is a causative factor of POUR in the setting of outpatient anorectal surgery. Anorectal operations at Hahnemann Hospital from January 2007 to February 2019 were reviewed. A total of 573 patients treated by two surgeons were studied. Data recorded consisted of the procedure date, discharge date, return date if applicable, age, sex, anesthetic type, and amount of perioperative intravenous fluid (IVF). Patients with a prior history of POUR were excluded. The chi-square test for homogeneity was used to assess the individual effects of age, sex, type of anesthetic, and amount of perioperative IVF on the rate of POUR. A p value of 0.05 was considered significant. Seventeen of the 573 patients in the study (3%) had urinary retention, 14 of the 442 males and 3 of the 131 females. POUR was seen in 5 of the 255 patients that had less than 500 mL of intravenous fluids, whereas 12 of 318 had 500 or more mL of fluids. We found that type of anesthesia and length of surgery were significant. No significance was found in amount of IVF used. Using more or less than 500 mL of intraoperative fluid did not have a significant impact on the rates of POUR in outpatient anorectal surgeries. Anesthesia type and surgery duration appear to decrease the occurrence of POUR in these patients.

The Effect of Hypotensive Anesthesia on Hemoglobin Levels during Total Knee Arthroplasty.

Introduction: Hypotensive epidural anesthesia (HEA) is used in total joint arthroplasty as a safe and effective blood-saving modality. In order to maintain the blood pressure and heart rate patients, receive 1000 to 1500 mL of lactated Ringer’s solution during surgery. While HEA reduces the intraoperative blood loss, the effect of intravenous fluid loading on hemoglobin levels is not fully understood. The current study investigates the effect of HEA on perioperative hemoglobin levels. Materials and Methods: The study included 35 patients operated on by a single surgeon undergoing primary total knee arthroplasty under HEA. Intraoperatively, at least 300 mL of intravenous fluid were given every 15 min over the first 60 min after HEA. Blood samples were drawn before entering the operating room, after HEA, as well as after inflation of the tourniquet, every 15 min thereafter, as well as in the recovery room and on postoperative days one and two. In addition, fluid in- and outtake was recorded. Results: Patients received a mean 1275 mL during the 60 min of tourniquet time. The mean arterial pressure (MAP) 5 min after HEA dropped to 60 mmHg and reached a constant level of around 58 mmHg 15 min after HEA. The average hemoglobin level dropped from 13.9 g/dL prior to HEA, to 12.5 g/dL immediately after HEA (p < 0.001). Intraoperatively the hemoglobin level dropped further and reached 11.8 g/dL at 60 min in the absence of blood loss. Conclusions: Hypotensive epidural anesthesia and the resulting fluid substitution resulted in an average hemoglobin drop of 2.1 g/dL within the first 60 min. This needs to be taken into account when evaluating the need for blood transfusions after primary joint replacement surgery under HEA.

Inpatient Kidney Function Recovery among Septic Shock Patients Who Initiated Kidney Replacement Therapy in the Hospital

Background: Sepsis and septic shock are life-threatening causes of acute kidney injury (AKI) frequently seen and managed in intensive care units (ICUs). Sepsis-associated AKI (SA-AKI) independently contributes to the mortality of sepsis. Understanding the potential factors involved in kidney function recovery may further aid in the prevention and management of SA-AKI. This study aimed to describe the clinical characteristics of septic shock patients who required kidney replacement therapy and factors associated with kidney function recovery. Methods: We conducted a retrospective cohort study of adult septic shock patients who received in-hospital kidney replacement therapy at medical intensive care unit (MICU) at the Mayo Clinic, Rochester, from January 1, 2006, to May 31, 2018. Kidney function recovery was defined as liberation from kidney replacement therapy before hospital discharge. Associations between clinical features and kidney recovery were analyzed using multivariable Fine and Gray regression accounting for death as a competing event. Results: Our retrospective cohort consisted of 229 patients with a median (interquartile range [IQR]) age of 64 (52–74) years: 55% were men, 89% were Caucasians, 39% had diabetes mellitus (DM), 16% had heart failure, APACHE (Acute Physiology and Chronic Health Evaluation) III score was 105 (84–123), and SOFA (Sequential [Sepsis-related] Organ Failure Assessment) score was 12 (9–14). The patients received 1,567 (524–4,108) mL of intravenous fluids in the first 3 h, 92% required vasopressor support, and 83% required mechanical ventilation. The median MICU and hospital stays were 7 (4–13) and 19 (10–31) days, respectively. Median (IQR) kidney replacement therapy duration was 7 (3.5–17.1) days. Among 158 ICU survivors, 73 (46%) patients were weaned from RRT in ICU and 85 (54%) were transitioned to intermittent RRT. A higher volume of fluid resuscitation in the first 3 h (hazard ratio [HR] = 1.07 per 1 L, CI: 1.01–1.14, p = 0.04) and a history of DM (HR = 1.70, CI: 1.14–2.54, p = 0.009) were associated with kidney function recovery. Conclusion: Among septic shock patients who initiated kidney replacement therapy in the MICU, 41% recovered kidney function before discharge. A higher initial fluid resuscitation volume was associated with recovery, and interestingly, patients with DM had a higher chance of recovery.

Effects of Prophylactic Oxytocin on Bleeding Outcomes in Women Undergoing Dilation and Evacuation: A Randomized Controlled Trial.

To estimate whether routine use of intravenous oxytocin decreases the frequency of interventions to control excess blood loss during dilation and evacuation (D&E). In this multisite, randomized, double-blind, placebo-controlled trial, women undergoing D&E at 18-24 weeks of gestation received 30 units of oxytocin in 500 mL of intravenous fluid or 500 mL of intravenous fluid alone initiated on speculum placement. The primary outcome was the frequency of interventions to control excess bleeding. A sample size of 75 patients per group was needed to detect a 15% decrease in intervention from 20% to 5% with 80% power and two-sided alpha 0.05. Secondary outcomes included measured blood loss, complications, procedure duration, postoperative pain, and patient satisfaction. From November 2014 to February 2018, we screened 337 women and randomized 160 to receive prophylactic oxytocin (n=82) or placebo (n=78). Demographic characteristics were similar between groups. The frequency of interventions for bleeding, our primary outcome, was 7.3% in the oxytocin group vs 16.7% in the placebo group, difference of 9.4% (95% CI -21.0% to 1.9%). Interventions primarily included uterine massage and uterotonic administration. Among our secondary outcomes, median measured blood loss was lower in the oxytocin group at 152 (interquartile range 98-235) mL vs 317 (interquartile range 168-464) mL (95% CI 71.6-181.5). Frequency of hemorrhage, defined as blood loss of 500 mL or more and 1,000 mL or more, was lower in the oxytocin group at 3.7% vs 21.8%, difference of 18% (95% CI -29 to -6.9%) and 1.2% vs 10.3%, difference of 9.0% (95% CI -17 to -0.7%), respectively. Procedures were shorter in the oxytocin group at a median of 11.0 (interquartile range 8.0-14.0) vs 13.5 (interquartile range 10.0-19.0) minutes in the placebo group (95% CI 1.0-4.0). We found no differences in the frequency of nonhemorrhage complications, pain scores, or satisfaction scores between groups. Prophylactic use of oxytocin during D&E at 18-24 weeks of gestation did not decrease the frequency of interventions to control bleeding. However, oxytocin did decrease blood loss and frequency of hemorrhage. ClinicalTrials.gov, www.clinicaltrials.gov, NCT02083809.

Rhabdomyolysis and Acute Respiratory Distress Syndrome Secondary to Multiple Wasp Stings

Background: Wasp stings usually cause local reactions such as itching, urticaria, angioedema and anaphylaxis. Life-threatening complications following multiple wasp stings are relatively rare and unexpected. However, rhabdomyolysis and acute respiratory distress syndrome following wasp stings are possible. Case presentation: A middle-aged male worker was stung by a swarm of wasps all over his body while attacking a wasp’s nest. He had pain, a swollen face and multiple blisters on his entire body. He initially received the standard treatment of intravenous antihistamine, anesthetic and steroid medications. On admission day, his urine output progressively decreased in volume and turned from clear to bloody in appearance, with the color tending to become progressively darker. A serum creatinine of 0.87 mg/dL and a creatinine phosphokinase of 1403 IU/L at admission confirmed rhabdomyolysis. The following day, his serum creatinine and creatinine phosphokinase rose, with the development of tachypnea with desaturation; a chest radiograph showed bilateral diffuse lung infiltration. He was subsequently diagnosed with acute respiratory distress syndrome (ARDS). A medical record review revealed that he had received only 1150 ml of intravenous fluid in 8 hours. Consequently, his ARDS may have been caused by an anaphylactic reaction to the wasp toxin rather than by a cardiogenic cause or volume overload. He was intubated and transferred from the general ward to the intensive care unit for close clinical monitoring. Mechanical ventilation and intravenous fluid support were given to achieve a minimum urine output of 1 ml/kg/hr. His clinical and biochemical pictures started to improve and normalize from the fourth day after ICU admission. Conclusions:Wasp stings may cause both rhabdomyolysis and acute respiratory distress syndrome. Early detection and immediate supportive treatment is the mainstay to reduce morbidity and mortality in such cases.

The impact of perioperative fluid therapy on short-term outcomes and 5-year survival among patients undergoing colorectal cancer surgery – A prospective cohort study within an ERAS protocol

BackgroundRestricted perioperative fluid therapy is one of several interventions in the enhanced recovery after surgery (ERAS) protocol, designed to reduce morbidity and hospital stay after surgery. The impact of this single intervention on short and long term outcome after colorectal surgery is unknown. Patients and methodsThis cohort study includes all consecutive patients operated with abdominal resection of colorectal cancer 2002–2007 at Ersta Hospital, Stockholm, Sweden. All patients were treated within an ERAS protocol and registered in the ERAS-database. Compliance to interventions in the ERAS protocol was analysed. The impact of a restrictive perioperative fluid therapy (≤3000 ml on the day of surgery) protocol on short-term outcomes as well as 5-year survival was assessed with multivariable analysis adjusted for confounding factors. ResultsNine hundred and eleven patients were included. Patients receiving ≤3000 ml of intravenous fluids on the day of surgery had a lower risk of complications OR 0.44 (95% C I 0.28–0.71), symptoms delaying discharge OR 0.47(95% C I 0.32–0.70) and shorter length of stay compared with patients receiving >3000 ml. In cox regression analysis, the risk of cancer specific death was reduced with 55% HR 0.45(95% C I 0.25–0.81) for patients receiving ≤ 3000 ml compared with patients receiving >3000 ml. ConclusionA restrictive compared with a non-restrictive perioperative fluid therapy on the day of surgery may be associated with lower short-term complication rates, faster recovery, shorter length of stay and improved 5-year survival.

In vitro and in vivo effects of hemodilution on kaolin-based activated clotting time predicted heparin requirement using a heparin dose-response technique.

The heparin dose-response (HDR) technique is based on activated clotting time (ACT) response to a fixed-dose heparin bolus, which varies substantially among patients. It is unclear, however, whether hemodilution-associated reductions in coagulation and anticoagulation factors affect the HDR slope. For in vitro hemodilution, aliquots of whole blood from healthy volunteers were diluted 9:1 and 8:2 v/v with normal saline. For in vivo hemodilution, a prospective observational study was performed on 46 patients who underwent elective cardiovascular surgery with or without cardiopulmonary bypass. HDR slope, antithrombin (AT) activity, complete blood count, and other coagulation parameters were compared after induction of anesthesia and after hemodilution with 500ml of intravenous fluid. In vitro 10 and 20% hemodilution significantly increased the HDR slope relative to baseline, reducing the heparin requirement. Hemodilution of heparinized samples significantly prolonged ACT, whereas there was no significant change in non-heparinized blood. The percent changes in fibrinogen and AT activity were significantly greater at 20% than those of the other coagulation variables. In vivo, hemodilution significantly increased the HDR slope and reduced heparin requirement. The percent change in fibrinogen due to hemodilution was significantly greater than the change in AT activity. Target ACTs of 300 and 450s were not achieved in 83.3 and 53.8% of patients, respectively. In vitro and in vivo hemodilution significantly increased the HDR slope and reduced the requirement for heparin. In vitro, the HDR slope did not change in parallel but became steeper, depending on the degree of hemodilution.

Acute Compartment Syndrome of the forearm in a patient undergoing coronary artery bypass surgery.

Sir, Compartment Syndrome is a life-threatening condition in which rapidly increasing interstitial pressures in a limb compartment compromise the vascular supply to the limb tissues, causing ischaemic tissue injury. If uncorrected, tissue necrosis may ensue, requiring limb amputation.[12] For the prevention of intraoperative compartment syndrome, the importance of an excellent intravenous access and constant visual monitoring of the catheter site is often stressed.[3] We report a unique case in which a patient undergoing coronary artery bypass surgery (CABG) developed forearm compartment syndrome intraoperatively after infusion of about 2000 ml of intravenous fluids via a peripheral 16 gauge intravenous cannula without showing any signs of resistance to flow. A 62-year-old male, known hypertensive and diabetic on medication, was taken up for CABG after a thorough pre-anaesthetic check-up. In the operation theatre, a peripheral vein (cephalic) on the flexor aspect of the right forearm was cannulated with a 16 gauge cannula in a single attempt without any difficulty and a normal saline infusion started. Flow was good without any signs of extravasation. The patient was then induced with intravenous fentanyl 150 μg, thiopentone 250 mg and vecuronium 8 mg through the same cannula. Radial arterial (left arm) and right jugular central line were inserted and positioning done for CABG with the arms tucked in by the side of the patient. After positioning, the flow to the peripheral vein was checked again and found to be satisfactory. Surgery was then started and proceeded as routine. During the surgery, the patient was infused about 1500 ml of crystalloids and 500 ml of colloid (tetrastarch). There was no resistance to flow in the peripheral vein at any point of time. When drapes were removed after the surgery, the patient's right arm was extremely tense and swollen with cyanosed fingers and absent pulses. A diagnosis of acute forearm compartment syndrome was made and a decision to do emergency fasciotomy of the forearm and upper arm was taken to salvage the limb. The limb was draped, and fasciotomy done along the entire length of the forearm and upper arm. The colour of the limb rapidly changed to red as the compartmental pressures reduced. The right arm was kept elevated to reduce the oedema by gravity. The limb circulation was monitored with a combination of limb colour, plethysmography tracing and capillary refill. The fasciotomy was closed on the 3rd day after a considerable amount of oedema had dissipated and capillary refill and plethysmography trace were normal for about 48 h. The patient was then shifted to the ward and recovered uneventfully. Acute forearm compartment syndrome due to intravenous fluid extravasation is uncommon, but many case reports of forearm compartment syndrome due to mannitol extravasation[34] and autologous blood transfusion[5] have been published. This case report highlights the fact that although obtaining a secure intravascular access, securing it properly and constant visual inspection of the cannula site[36] are of paramount importance; this is not always possible particularly in surgeries where the upper limbs are tucked by the patient's side as a part of surgical positioning. Due to the absence of resistance to flow, the compartment syndrome could be recognised only at the end of surgery when the drapes were removed. This case illustrates the fact that prompt recognition and treatment are vital for limb salvage in compartment syndrome. Time is the key when circulation to any tissue is compromised, and the forearm compartment syndrome is no exception.

Hypotensive Anesthesia may Result in False Anemia and Increase Transfusion Requirements in Total Hip Arthroplasty

Background: Deliberate hypotension under spinal or epidural anesthesia is a readily available and effective method to reduce intraoperative blood loss in total hip arthroplasty. However, induced hypotension has been shown to alter the physiologic handling of crystalloid solutions, with blood volume increasing in proportion to the drop in blood pressure. This study aims to investigate the effect of hemodilution secondary to hypotensive anesthesia and volume loading on postoperative hemoglobin levels. Methods: 211 non-anemic adult patients who underwent primary total hip arthroplasty utilizing a minimal invasive posterior approach with hypotensive spinal-epidural anesthesia were evaluated retrospectively. The effect of fluid loading under hypotensive anesthesia was investigated by calculating the blood loss that corresponds to patients’ preoperative and postoperative hemoglobin levels, as well as calculating the hemoglobin levels expected for known volumes of blood loss. Results: There was a large discrepancy between the calculated blood loss (1358 mL) and the actual measured blood loss (212 mL). Patients received an average of 4488 (SD 1209) mL of intravenous fluid within 24 hours of surgery. There was also a large difference between the calculated hemoglobin level based on the measured blood loss (13.6 g/dL) and the actual measured mean hemoglobin (10.8 g/dL). Conclusion: Blood volume expansion and hemodilution with hypotensive epidural anesthesia leads to decreased hemoglobin levels in the early postoperative period and likely impacts on transfusion requirements. Hypotensive anesthesia might have a detrimental effect on transfusion requirements in procedures with relatively low blood loss.

Feasibility of Outpatient Chemotherapy with S-1 and Cisplatin for Gastric Cancer

Objective: To evaluate the feasibility of S-1 and high-dose cisplatin short hydration regimens for outpatients with unresectable metastatic gastric cancer. Methods: Data for individual outpatients treated in our institution were retrospectively pooled to assess the feasibility of an S-1 and highdose cisplatin short hydration regimen (S-1: 80 to 120 mg on Days 1 to 21; cisplatin: 60 mg/m2 on Day 8, every 5 weeks), which included 2250 ml of intravenous fluids and 1000 ml oral hydration. Ten consecutive patients were treated with S-1 and high-dose cisplatin short hydration for unresectable metastatic gastric cancer from July 2011 to May 2012 and were included in the analysis. Results: With a median of 3.5 medication cycles, unscheduled admission occurred in two patients for 5 days each due to paralytic ileus and cerebral infarction. Four patients required dose reduction, in both S-1 and cisplatin in two patients, and in S-1 alone and cisplatin alone in one patient each. Renal function transiently declined after administration of cisplatin, but serum creatinine level and estimated glomerular filtration rate were both improved by the time of the next administration. Conclusion: This study suggests that an S-1 and high-dose cisplatin short hydration strategy for outpatients with unresectable metastatic gastric cancer might be feasible.

Perioperative fluid infusion and its influence on anastomotic leakage after rectal cancer surgery: implications for prevention strategies

This study aimed to identify modifiable risk factors for anastomotic leakage during the postoperative period to recognize areas of clinical practice that could be improved. Medical charts of patients who underwent elective open anterior resection for rectal cancer over a 5-year period were reviewed retrospectively. One hundred and twenty-four patients [64 men, mean age (± SD) 68.0 ± 9.0 years] underwent an anterior resection for rectal cancer during the study period. Twenty-two (17.7%) patients had anastomotic leakage. Patients who were given more than 8000 ml of intravenous fluid during the 72-h perioperative period had a statistically significant increased risk of developing anastomotic leakage [odds ratio (OR) 3.20, 95% confidence interval (CI) 1.10-9.31, P = 0.049] and the risk increased further when patients were given more than 8500 ml of intravenous fluid (OR 3.86, 95% CI 1.29-11.5, P = 0.019). The incidence of anastomotic leakage was not influenced by baseline comorbidity or tumour stage. Perioperative intravenous fluid of more than 8000 ml was associated with increased occurrence of anastomotic leakage. Vigorous monitoring of intravenous fluid use in the perioperative period may minimize this complication.

Functional definition and characterization of acute traumatic coagulopathy

To identify an appropriate diagnostic tool for the early diagnosis of acute traumatic coagulopathy and validate this modality through prediction of transfusion requirements in trauma hemorrhage. Prospective observational cohort study. Level 1 trauma center. Adult trauma patients who met the local criteria for full trauma team activation. Exclusion criteria included emergency department arrival >2 hrs after injury, >2000 mL of intravenous fluid before emergency department arrival, or transfer from another hospital. None. Blood was collected on arrival in the emergency department and analyzed with laboratory prothrombin time, point-of-care prothrombin time, and rotational thromboelastometry. Prothrombin time ratio was calculated and acute traumatic coagulopathy defined as laboratory prothrombin time ratio >1.2. Transfusion requirements were recorded for the first 12 hrs following admission. Three hundred patients were included in the study. Laboratory prothrombin time results were available at a median of 78 (62-103) mins. Point-of-care prothrombin time ratio had reduced agreement with laboratory prothrombin time ratio in patients with acute traumatic coagulopathy, with 29% false-negative results. In acute traumatic coagulopathy, the rotational thromboelastometry clot amplitude at 5 mins was diminished by 42%, and this persisted throughout clot maturation. Rotational thromboelastometry clotting time was not significantly prolonged. Clot amplitude at a 5-min threshold of ≤35 mm had a detection rate of 77% for acute traumatic coagulopathy with a false-positive rate of 13%. Patients with clot amplitude at 5 mins ≤35 mm were more likely to receive red cell (46% vs. 17%, p < .001) and plasma (37% vs. 11%, p < .001) transfusions. The clot amplitude at 5 mins could identify patients who would require massive transfusion (detection rate of 71%, vs. 43% for prothrombin time ratio >1.2, p < .001). In trauma hemorrhage, prothrombin time ratio is not rapidly available from the laboratory and point-of-care devices can be inaccurate. Acute traumatic coagulopathy is functionally characterized by a reduction in clot strength. With a threshold of clot amplitude at 5 mins of ≤35 mm, rotational thromboelastometry can identify acute traumatic coagulopathy at 5 mins and predict the need for massive transfusion.

Acute kidney injury criteria predict outcomes of critically ill patients*

The Acute Kidney Injury Network's proposed definition for acute kidney injury (increment of serum creatinine > or = 0.3 mg/dL or 50% from baseline within 48 hrs or urine output < 0.5 mL/kg/hr for > 6 hrs despite fluid resuscitation when applicable) predicts meaningful clinical outcomes. Retrospective cohort study. A 350-bed community teaching hospital. The study population consisted of 471 patients with no recent history of renal replacement therapy who were admitted to the medical intensive care unit during 1 yr. Medical records of all patients were reviewed using a data abstraction tool. Demographic information, diagnoses, risk factors for acute kidney disease, physiologic and laboratory data, and outcomes were recorded. Of 496 patients, 471 were not receiving renal replacement therapy in the weeks before medical intensive care unit admission; 213 had changes > or = .3 mg/dL in serum creatinine within 48 hrs and/or urine output of < or = .5 mL/kg/hr for > 6 hrs. Detailed fluid challenge information was available for only 123 patients, who met acute kidney injury criteria, and three patients reversed after administration of > or = 500 mL of intravenous fluid and/or blood products. All patients whose creatinine increased > or = 50% also had increments > or = 0.3 mg/dL. The 120 patients with acute kidney injury were older (mean +/- SE: 69.3 +/- 1.7 vs. 62.9 +/- 1.3, p < .01), were more ill (Acute Physiology and Chronic Health Evaluation II score 18.7 +/- .6 vs. 13.3 +/- .4, p < .01), and had multiple comorbidities (two or more organs, 65% vs. 51.3%, p < .01) compared with those without acute kidney injury. The mortality rate of patients who met criteria for acute kidney injury was significantly higher than that of patients who did not have acute kidney injury (45.8 vs. 16.4%, p < .01). In multivariate logistic regression analyses, acute kidney injury was an independent predictor of mortality (adjusted odds ratio 3.7, 95% confidence interval 2.2-6.1). Acute kidney injury was a better predictor of in-hospital mortality than was Acute Physiology and Chronic Health Evaluation II score, advanced age, or presence of nonrenal organ failures. Median hospital stay was twice as long in patients with acute kidney injury (14 vs. 7 days, p < .01), and only patients with acute kidney injury required hemodialysis during hospitalization. The oliguria criterion of acute kidney injury did not affect the odds of in-hospital mortality. The Acute Kidney Injury Network definition of acute kidney injury predicts hospital mortality, need for renal replacement therapy, and prolonged hospital stay in critically ill patients. An increment of serum creatinine > or = 0.3 mg/dL in 48 hrs alone predicts clinical outcomes as well as the full Acute Kidney Injury Network definition.

A Comparison of 5% Dextrose in 0.9% Normal Saline versus Non-Dextrose-Containing Crystalloids as the Initial Intravenous Replacement Fluid in Elective Surgery

Intravenous fluid replacement in adult elective surgery is often initiated with dextrose-containing fluids. We sought to determine if this practice resulted in significant hyperglycaemia and if there was a risk of hypoglycaemia if non-dextrose-containing crystalloids were used instead. We conducted a randomized controlled trial in 50 non-diabetic adult patients undergoing elective surgery which did not involve entry into major body cavities, large fluid shifts, or require administration of >500 ml of intravenous fluid in the first two hours of peri-operative care. Patients received 500 ml of either 5% dextrose in 0.9% normal saline, lactated Ringer's solution, or 0.9% normal saline over 45 to 60 minutes. Plasma glucose, electrolytes and osmolarity were measured prior to infusion, and at 15 minutes and one hour after completion of infusion. None of the patients had preoperative hypoglycaemia despite average fasting times of almost 13 hours. Patients receiving lactated Ringer's and normal saline remained normoglycaemic throughout the study period. Patients receiving dextrose saline had significantly elevated plasma glucose 15 minutes after completion of infusion (11.1 (9.9-12.2, 95% CI) mmol/l). Plasma glucose exceeded 10 mmol/l in 72% of patients receiving dextrose saline. There was no significant difference in plasma glucose between the groups at one hour after infusion, but 33% of patients receiving DS had plasma glucose > or = 8 mmol/l. We conclude that initiation of intravenous fluid replacement with dextrose-containing solutions is not required to prevent hypoglycaemia in elective surgery. On the contrary, a relatively small volume of 500 ml causes significant, albeit transient, hyperglycaemia, even in non-diabetic patients.

Increased intravenous fluid intake and the course of labor in nulliparous women

Objective To compare the effect of 2 regimens of intravenous fluid therapy on the course of labor. Methods In a prospective, randomized, double-blind study of 300 nulliparous pregnant women at term conducted at a teaching hospital, 153 women received 125 mL and 147 received 250 mL of intravenous fluid per hour. The groups were matched and analysis was done using the t, χ 2, and Fisher exact tests. P < 0.05 was considered statistically significant. Results In the group that received intravenous fluid at a rate of 250 mL per hour the mean ± S.D. duration of labor was significantly shorter (253 ± 97 vs. 386 ± 110 min; P = 0.0001), the frequency of labor lasting both more than 10 h and more than 15 h was statistically lower (4.8% vs. 13.8%; P = 0.001 and 0% vs. 4.5%; P = 0.02, respectively), and the frequency of oxytocin administration was significantly lower (8.1% vs. 20.4%; P = 0.001). There was a trend toward a lower frequency of cesarean deliveries in the 250-mL group (16% vs. 22.8%; P = 0.1). Conclusion A greater volume per hour of intravenous fluid than is commonly administered to nulliparous women in active labor is associated with significantly shorter duration of labor and lower frequency of both prolonged labor and oxytocin administration.

Vinorelbine and venous irritation: optimal parenteral administration

Vinorelbine is a vesicant associated with extra-vasation hazards and injection site reactions, which can be alleviated by shortening of infusion time and flushing of intravenous fluid. A critical review of the current evidence showed that the optimal administration is to flush >or= 75-124 mL of intravenous fluid after vinorelbine infusion. Intravenous push administration over 1-2 min does not seem to offer significant improvement over rapid intravenous infusion over 6-10 min.