Normal Ringer Research Articles

Normal Saline Versus Ringer’s Lactate for Intravenous Fluid Therapy in Children with Diabetic Ketoacidosis: A Randomized Controlled Trial

Normal Saline Versus Ringer’s Lactate for Intravenous Fluid Therapy in Children with Diabetic Ketoacidosis: A Randomized Controlled Trial

Normal saline versus Ringer’s solution and critical-illness mortality in acute pancreatitis: a nationwide inpatient database study

BackgroundFluid resuscitation is fundamental in acute pancreatitis (AP) treatment. However, the optimal choice between normal saline (NS) and Ringer's solution (RS), and its impact on mortality in critically ill patients, remains controversial. This retrospective cohort study, utilizing a national Japanese inpatient database, investigates this question.MethodsUsing the Japanese Diagnosis Procedure Combination database between July 2010 and March 2021, we identified adult patients hospitalized in intensive care units (ICU) or high-dependency care units (HDU) for AP who survived at least three days and received sufficient fluid resuscitation (≥ [10 ml/kg/hr*1 h + 1 ml/kg/hr*71 h] ml) within three days of admission including emergency room infusions. Patients were classified into groups based on the predominant fluid type received: the NS group (> 80% normal saline) and the RS group (> 80% Ringer's solution). Propensity score matching was employed to reduce potential confounding factors and facilitate a balanced comparison of in-hospital mortality between the two groups.ResultsOur analysis included 8710 patients with AP. Of these, 657 (7.5%) received predominantly NS, and 8053 (92.5%) received predominantly RS. Propensity score matching yielded 578 well-balanced pairs for comparison.The NS group demonstrated significantly higher in-hospital mortality than the RS group (12.8% [474/578] vs. 8.5% [49/578]; risk difference, 4.3%; 95% confidence interval, 0.3% to 8.3%).ConclusionsIn patients admitted to ICU or HDU with AP receiving adequate fluid resuscitation, RS can be a preferred infusion treatment compared to NS.

Goal-Directed Fluid Therapy Using Normal Saline versus Ringer's Lactate in Pediatric Neurosurgical Patients: A Randomized Controlled Trial

Abstract Background Ringer's lactate (RL) and 0.9% sodium chloride (NS) are used intraoperatively in pediatric surgical patients. The fluid of choice in pediatric neurosurgical patients is still under research. Hence, we compared NS and RL intraoperatively with a primary objective of measuring the absolute difference in serum chloride concentrations (ΔCl-) after surgery from baseline. Secondary objectives included changes in other electrolytes, osmolarity, pH, creatinine, brain relaxation score (BRS), and neurological outcome at discharge using a modified Rankin scale (mRS). Methods This prospective randomized trial was conducted in American Society of Anesthesiologists status I to II children, aged 6 months to 14 years, after Institutional Ethical Committee approval and written informed consent. Forty patients were randomized in group-S (received 0.9% Saline) and group-R (received RL). The fluid administration was guided by Pleth Variability Index (target <13%). Arterial blood samples were taken at the start of surgery, during tumor resection, and at the end of surgery. Results Twenty-one patients in NS and 19 patients in RL were enrolled. ΔCl- was 12 (9–16) mmol/L in NS group and 4 (2–15) mmol/L in RL group, p = 0.03. NS group developed more metabolic acidosis (6 [28.6%] vs. 0 [0.0%], p = 0.021). There was no difference in the other electrolytes, serum osmolarity, BRS, perioperative creatinine, and mRS between groups, p = 0.36, p = 0.096, p = 0.658, and p = 0.168, respectively. Conclusion Intraoperative use of NS causes derangement in chloride balance, leading to metabolic acidosis compared to RL in children undergoing neurosurgical procedures. However, there was no difference in the other parameters, including serum osmolarity, BRS, and mRS.

Effects of Injectable Solutions on the Quality of Monocyte-Derived Dendritic Cells for Immunotherapy.

Therapeutic vaccines based on monocyte-derived dendritic cells have been shown to be promising strategies and may act as complementary treatments for viral infections, cancers, and, more recently, autoimmune diseases. Alpha-type-1-polarized dendritic cells (aDC1s) have been shown to induce type-1 immunity with a high capacity to produce interleukin-12p70 (IL-12p70). In the clinical use of cell-based therapeutics, injectable solutions can affect the morphology, immunophenotypic profile, and viability of cells before delivery and their survival after injection. In this sense, preparing a cell suspension that maintains the quality of aDC1s is essential to ensure effective immunotherapy. In the present study, monocytes were differentiated into aDC1s in the presence of IL-4 and GM-CSF. On day 5, the cells were matured by the addition of a cytokine cocktail consisting of IFN-α, IFN-γ, IL-1β, TNF-α, and Poly I:C. After 48 hr, mature aDC1s were harvested and suspended in two different solutions: normal saline and Ringer's lactate. The maintenance of cells in suspension was evaluated after 4, 6, and 8 hr of storage. Cell viability, immunophenotyping, and apoptosis analyses were performed by flow cytometry. Cellular morphology was observed by electron microscopy, and the production of IL-12p70 by aDC1s was evaluated by ELISA. Compared with normal saline, Ringer's lactate solution was more effective at maintaining DC viability for up to 8 hr of incubation at 4 or 22°C.

A Hospital-Wide Open-Label Cluster Crossover Pragmatic Comparative Effectiveness Randomized Trial Comparing Normal Saline to Ringer's Lactate: Protocol and Statistical Analysis Plan of The FLUID Trial.

Normal saline (NS) and Ringer's lactate (RL) are the most common crystalloids given to hospitalized patients. Despite concern about possible harm associated with NS (eg, hyperchloremic metabolic acidosis, impaired kidney function, and death), few large multicenter randomized trials focused on critically ill patients have compared these fluids. Uncertainty exists about the effects of these fluids on clinically important outcomes across all hospitalized patients. The FLUID trial is a pragmatic, multicenter, 2×2 cluster crossover comparative effectiveness randomized trial that aims to evaluate the effectiveness of a hospital-wide policy that stocks either NS or RL as the main crystalloid fluid in 16 hospitals across Ontario, Canada. All hospitalized adult and pediatric patients (anticipated sample size 144,000 patients) with an incident admission to the hospital over the course of each study period will be included. Either NS or RL will be preferentially stocked throughout the hospital for 12 weeks before crossing to the alternate fluid for the subsequent 12 weeks. The primary outcome is a composite of death and hospital readmission within 90 days of hospitalization. Secondary outcomes include death, hospital readmission, dialysis, reoperation, postoperative reintubation, length of hospital stay, emergency department visits, and discharge to a facility other than home. All outcomes will be obtained from health administrative data, eliminating the need for individual case reports. The primary analysis will use cluster-level summaries to estimate cluster-average treatment effects. The statistical analysis plan has been prepared "a priori" in advance of receipt of the trial data set from ICES and any analyses. We describe the protocol and statistical analysis plan for the evaluation of primary and secondary outcomes for the FLUID trial. ClinicalTrials.gov NCT04512950; https://classic.clinicaltrials.gov/ct2/show/NCT04512950. DERR1-10.2196/51783.

Bicarbonate-Based Solution for the Management of Established Acute Kidney Injury: A Pilot Open-Label Observation Study.

Background Administration of intravenous (IV) solutions constitutes a key component of acute kidney injury (AKI) management. However, the optimal IV fluid solution in the setting of AKI remains uncertain. In this study, we assessed whether the use of bicarbonate-containing solution in patients with established AKI is associated with early renal recovery as compared to bicarbonate-free solutions. Methods We performed an open-label observational pilot study in 59 patients with established AKI. IV fluid solutions that were used include bicarbonate-based solution with low chloride content (80 mEq/L of 8% sodium bicarbonate in a solution that contains 77 mEq/L of sodium, 77 mEq/L of chloride and 25 g/L of glucose) or solutions without bicarbonate with high chloride content (0.9% normal saline, 0.45% half-saline, normal ringer, or 4% succinylated gelatine). We evaluated the association of IV fluids type with renal recovery. Results The median age of study participants was 66 years (inter-quartile range (IQR) 37-85), and 59% (n=35) were men. The prevalence of diabetes and chronic kidney disease (CKD) stages 1-3 were 34% (n=20) and 39% (n=23), respectively. Patients who received bicarbonate-based IV solutions had a greater reduction of serum creatinine (sCr) per day (delta sCr) as compared with patients who received bicarbonate-free solutions (-0.29±0.47 vs. 0.07±0.42; p=0.007). The renal recovery was faster in patients who received bicarbonate-based solutions as compared to the bicarbonate-free group (days from peak sCr to baseline sCr: 5.6±2.1 vs. 7.6±2.8; p < 0.001, respectively). Conclusions We observed faster renal recovery in patients with established AKI who received the bicarbonate-based solution with low chloride content. Our study findings require confirmation in larger cohorts.

A brief history of crystalloids: the origin of the controversy.

Fluid resuscitation with crystalloids has been used in humans for more than 100 years. In patients with trauma, sepsis or shock of any etiology, they can help modify the clinical course of the illness. However, these solutions are medications which are not side-effect free. Recently, they have been questioned in terms of quantity (fluid overload) and their composition. The most frequently used crystalloids, both in high and low-income countries, are 0.9% normal saline (NS) and Ringer's lactate. The first descriptions of the use of sodium and water solutions in humans date from the cholera epidemic which spread throughout Europe in 1831. The composition of the fluids used by medical pioneers at that time differs greatly from the 0.9% NS used routinely today. The term "physiological solution" referred to fluids which did not cause red blood cell hemolysis in amphibians in in vitro studies years later. 0.9% NS has an acid pH, a more than 40% higher chloride concentration than plasma and a strong ion difference of zero, leading many researchers to consider it an unbalanced solution. In many observational studies and clinical trials, this 0.9% NS composition has been associated with multiple microcirculation and immune response complications, acute kidney injury, and worse clinical outcomes. Ringer's lactate has less sodium than plasma, as well as other electrolytes which can cause problems in patients with traumatic brain injury. This review provides a brief summary of the most important historical aspects of the origin of the most frequently used intravenous crystalloids today.

Crystalloid Solutions in Hospital: A Review of Existing Literature.

Intravenous fluids (IVF) like normal saline (NS) and Ringer's lactate (RL) are often crucial in the management of hospitalized patients. Mishandling these fluids can lead to complications in about 20% of patients receiving them. In this review, we present the current evidence through the identification of observational studies and randomized trials that observed the optimal use of IVF. We found that NS may cause hyperchloremic metabolic acidosis in surgical patients, but there is no clear difference in mortality and long-term outcomes between NS and balanced crystalloids. Critically ill patients, particularly those in sepsis, benefit from balanced crystalloids, as high chloride content fluids like NS increase the risk of complications and mortality. In pancreatitis, NS has been shown to increase the risk of ICU admission when compared to RL; however, there is no significant difference in long-term outcomes and mortality between the fluids. RL is preferred for burns due to its isotonicity and lack of protein, preventing edema formation in an already dehydrated state. Plasma-lyte may resolve diabetic ketoacidosis faster, while prolonged NS use can lead to metabolic acidosis, acute kidney injury, and cerebral edema. In conclusion, NS, RL, and plasma-lyte are the most commonly used isotonic IVF in the hospital population. Incorrect choice of fluids in a different clinical scenario can lead to worse outcomes.

Update on the strategy for intravenous fluid treatment in acute pancreatitis.

Fluid therapy/resuscitation is mandatory in acute pancreatitis due to the pathophysiology of fluid loss as a consequence of the inflammatory process. For many years, without clear evidence, early and aggressive fluid resuscitation with crystalloid solutions (normal saline solution or Ringer lactate solution) was recommended. Recently, many randomized control trials and meta-analyses on fluid therapy have revealed that high fluid rate infusion is associated with increased mortality and severe adverse events compared to those resulting from moderate fluid rates, and this has triggered a paradigm shift in fluid management strategies. Meanwhile, there is evidence to show that Ringer lactate solution is superior to normal saline solutions in this context. The purpose of this review is to provide an update on the strategies for intravenous fluid treatment in acute pancreatitis, including the type, optimal amount, rate of infusion, and monitoring guides. Recommendations from recent guidelines are critically evaluated for this review in order to reach the authors' recommendations based on the available evidence.

A retrospective analysis of normal saline and lactated ringers as resuscitation fluid in sepsis.

The Surviving Sepsis Campaign suggested preferential resuscitation with balanced crystalloids, such as Lactated Ringer's (LR), although the level of recommendation was weak, and the quality of evidence was low. Past studies reported an association of unbalanced solutions, such as normal saline (NS), with increased AKI risks, metabolic acidosis, and prolonged ICU stay, although some of the findings are conflicting. We have compared the outcomes with the preferential use of normal saline vs. ringer's lactate in a cohort of sepsis patients. We performed a retrospective cohort analysis of patients visiting the ED of 19 different Mayo Clinic sites between August 2018 to November 2020 with sepsis and receiving at least 30 mL/kg fluid in the first 6 h. Patients were divided into two cohorts based on the type of resuscitation fluid (LR vs. NS) and propensity-matching was done based on clinical characteristics as well as fluid amount (with 5 ml/kg). Single variable logistic regression (categorical outcomes) and Cox proportional hazards regression models were used to compare the primary and secondary outcomes between the 2 groups. Out of 2022 patients meeting our inclusion criteria; 1,428 (70.6%) received NS, and 594 (29.4%) received LR as the predominant fluid (>30 mL/kg). Patients receiving predominantly NS were more likely to be male and older in age. The LR cohort had a higher BMI, lactate level and incidence of septic shock. Propensity-matched analysis did not show a difference in 30-day and in-hospital mortality rate, mechanical ventilation, oxygen therapy, or CRRT requirement. We did observe longer hospital LOS in the LR group (median 5 vs. 4 days, p = 0.047 and higher requirement for ICU post-admission (OR: 0.70; 95% CI: 0.51-0.96; p = 0.026) in the NS group. However, these did not remain statistically significant after adjustment for multiple testing. In our matched cohort, we did not show any statistically significant difference in mortality rates, hospital LOS, ICU admission after diagnosis, mechanical ventilation, oxygen therapy and RRT between sepsis patients receiving lactated ringers and normal saline as predominant resuscitation fluid. Further large-scale prospective studies are needed to solidify the current guidelines on the use of balanced crystalloids.

An evaluation of postmarketing reports of hyperglycaemia associated with dolutegravir for treatment of HIV in Eswatini

BackgroundDolutegravir (DTG) is an Integrase Strand Transfer Inhibitor (INSTI) indicated in combination with other antiretroviral agents for the treatment of HIV infection. It is available in a number of pharmaceutical preparations including the fixed-dose combination (TLD) containing tenofovir (300 mg) + lamivudine (300 mg) + dolutegravir (50 mg). In 2018, Eswatini adopted TLD as the preferred first-line HIV treatment regimen for adults and adolescents as per WHO recommendations. From March 2019 to March 2020, the National Pharmacovigilance Center (NPC) in Eswatini received 8 reports of hyperglycaemia associated with the use of DTG. This study was conducted to investigate if Eswatini NPC database included cases suggestive of causality between dolutegravir and hyperglycaemia.MethodA qualitative synthesis of information from the Eswatini national pharmacovigilance database from March 2019 to March 2020 was conducted to investigate a casual association between hyperglycaemia and dolutegravir.ResultsAll reports with dolutegravir containing regimen and suspected Adverse Event of hyperglycaemia in the period of March 2019 to March 2020 were included in the study. Seven of the reports were serious (resulted in hospitalization and one case concerned optic neuritis, leading to blindness). Two patients had a medical history of diabetes while the rest of the patients had never experienced hyperglycaemia before starting dolutegravir. For all the reports, the time to onset of hyperglycaemia ranges from 2–5 months after the initiation of DTG. None of the patients discontinued the use of DTG. All the patients were treated with oral hypoglycaemic medication. In severe cases, patients were treated with intravenous normal saline and ringer lactate as well as rapid-acting insulins. All patients are currently stable on oral hypoglycaemic drugs.ConclusionCases that support causality between dolutegravir containing regimen and hyperglycaemia were found. These cases were mainly serious. Based on these findings it is recommended that healthcare professionals (HCPs) actively screen all patients for risk factors of hyperglycaemia before DTG initiation. In addition, it is important that HCPs are aware of the possible association between DTG and hyperglycaemia.

Case Report on Acute Pancreatitis

Introduction: Upper-abdominal pain is frequently caused by acute pancreatitis. A diagnosis based purely on symptoms and signs is difficult because its clinical features are similar to those of a range of other acute diseases. Acute pancreatitis is diagnosed using two of the 3 criteria given below: Stomach pain, increased serum lipase and/or amylase levels, and abnormal abdominal image processing are all signs of pancreatitis. When it comes to diagnosing acute pancreatitis, lipase has been demonstrated to have good specificity and sensitivity. Pain in the stomach that appears to originate from the pancreas When it comes to diagnosing acute pancreatitis, abnormal abdominal imaging and/or serum lipase and/or amylase values larger than three times the upper period of normal Lipase have been proven to have good sensitivity and accuracy.&#x0D; MAIN Symptoms And / OR Important Clinical Findings: For 5 days, I had abdominal pain, difficulty swallowing, decreased appetite, generalized weakness, fever, and loose movements.&#x0D; Diagnostic Evaluation: He is a male patient who is 22 years old. And all diagnostic testing has been completed. Contrast-enhanced computed tomography of the abdomen, ultrasonography, complete blood count: 12.8 gm/dl.&#x0D; Therapeutic Intervention: Patient was treated injection meropenem 500 milligram thrice a day, injection Levoflox 500 milligram one time a day, injection pan 40 milligram one time a day, injection Emeset 4 milligram thrice a day, injection Tramadol 100 milligram thrice a day, injection Thiamine 100 milligram thrice a day, injection mucomix 600 milligram twice a day, injection Doxy 100 milligram twice a day, Injection Hydrocort 100 milligram thrice a day, Syrup, Kesol 2TSP thrice a day.&#x0D; Outcome: The patient’s overall condition gotten better.&#x0D; Nursing Perspectives: Changing the fluid dextrose normal saline and ringer lactate were set up in the first place. On an hourly basis, keep track of your vital signs and blood pressure. Maintaining the patient’s intake and output chart, as well as providing adequate rest and sleep. Administered drugs as directed by the doctor.&#x0D; Conclusion: During the past five days, patients complained of abdominal pain, nausea and vomiting after each meal, difficulty swallowing, decreased appetite, generalised weakness, fever, and loose movements at Acharya Vinoba Bhave Rural Hospital. These symptoms were eased with proper treatment, and the patient is currently in good health.

Comparison of Adult Diabetic Ketoacidosis Treatment Protocols From Canadian Emergency Departments

BackgroundDiabetic ketoacidosis (DKA) is a common acute life-threatening complication of poorly controlled diabetes mellitus contributing to considerable mortality and morbidity. Use of standardized treatment protocols improves patient outcomes in the emergency department (ED) for many conditions, but variability in adult DKA treatment protocols has not been assessed across EDs. In this study, we compared DKA treatment protocols from adult EDs across Canada to highlight inconsistencies in recommended DKA management. MethodsED staff in Canada were solicited for their treatment protocols used to guide acute ED DKA management. Information regarding initial fluid resuscitation and maintenance fluid, potassium replacement, insulin therapy and bicarbonate administration was abstracted from each protocol, collated in a table and compared. ResultsThirty-six unique protocols were obtained representing 85 institutions (40 urban and 45 rural, with a 65.1% response rate) across Canada, with no protocol use for 4 urban centres. Similarities in protocols included the intravenous insulin infusion rate and instructions for switching to subcutaneous insulin. Variability was noted in the rate, amount and type of fluid bolus given (0.5 to 2 L of normal saline or Ringer’s lactate over 15 minutes to 2 hours), the criteria determining the amount, potassium supplementation at normo/hypokalemic ranges, when to add dextrose to maintenance fluid, insulin bolus inclusion and bicarbonate administration. ConclusionsThis is the first comparison of adult DKA treatment protocols in Canada. Although several common approaches were identified, variability was found in initial fluid boluses, initial insulin bolus and role of bicarbonate, necessitating further study to ensure local DKA protocols reflect current evidence-based best practices for optimal patient clinical outcomes.

Response of Esophageal Epithelium to Acute and Chronic Stress in Rabbits.

We studied electrophysiological changes in rabbit esophageal epithelium following acute (AS) and chronic stress (CS). Esophageal tissue was placed in Ussing chamber and the potential difference U between the luminal and abluminal sides, the short-circuit current Isc, as well as the tissue resistance R were measured. The initial values of these parameters for each sample were determined after the samples were stabilized in Ringer solution. Then, the tissues were exposed for 1 h to normal Ringer solution or Ringer solution with pH 4.0 and pH 1.7 with or without pepsin (0.25 mg/ml). Fluorescein was added to the luminal side of the sample to measure its permeability. In the AS group, U at Ringer solution (pH 1.7)+pepsin was significantly decreased in comparison with the baseline and control values (by 46 and 22%, respectively, p<0.05). R decreased by 74% in comparison with baseline, which little differed from the decrease in control samples exposed to Ringer solution (pH 1.7)+pepsin (by 62%). CS did not change U relative to baseline values, while changes in R were similar to those in the AS group. In the AS group, the permeability of the esophageal tissue perfused with Ringer solution (pH 1.7)+pepsin was significantly higher than in both the control and CS groups. AS, but not CS, made the esophageal epithelium more sensitive to the effects of noxious agents, disrupted barrier properties, and increased permeability. The effects of stress on gastroesophageal reflux disease symptoms can be related to severe exposure to acid and/or pepsin; however, the mechanisms other than epithelial defense should be evaluated.

Withdrawal

Zero-balance ultrafiltration (Z-BUF) is considered a significant method during cardiopulmonary bypass (CPB), and has always received support regarding its key role in monitoring electrolyte abnormalities including potassium and sodium derangements and managing them which occur commonly during CPB. With Z-BUF procedure's impact on controlling electrolyte abnormalities, we conducted a study in order to find out the most efficient solution regarding managing potassium and sodium levels to be selected as replacement fluid in Z-BUF out of the three commonly used normal saline, ringer's and ringer's lactate. a randomized clinical trial study was conducted and 90 patients were divided into three groups. Each group was given a certain solution out of the three normal saline (Z-BUF-NS), ringer's (Z-BUF-R), and ringer's lactate (Z-BUF-RL) with allocation concealment strategy then potassium and sodium levels were measured at 5 points of the whole procedure: prior to CPB and after anesthesia induction, cardioplegic solution's delivery, pre-Z-BUF, post-Z-BUFF, and at the end of CPB. Comparing pre-Z-BUF and post-CPB patients' serum potassium demonstrated a change from 4.7 0.9 mEq/L to 5.2 0.7 mEq/L in Z-BUF-RL, 4.4 0.6 mEq/L to 4.7 0.5mEq/L in Z-BUF-R, and 5.1 0.5 mEq/L to 5.1 0.5 mEq/L in Z-BUF-NS. No significant difference was observed between groups regarding managing K+ abnormalities. Changes in Na+ from pre-Z-BUF to post-CPB were as following: from 134 mEq/L to 133 mEq/L in Z-BUF-RL, 137 mEq/L to 137 mEq/L in Z-BUF-R, and 135.2 4 mEq/L to 136.5 4 mEq/L in Z-BUF-NS. Ringer's lactate managed sodium abnormalities more efficiently. Ringer's lactate is more efficient than Ringer's and normal saline regarding managing sodium and potassium abnormalities.

Effects of Different Storage Media, Temperature, and Time on Osteoblast Preservation in Autogenous Bone Grafts: A Histomorphometrical Analysis.

Statement of the Problem: Autogenous bone graft is the gold standard for bone reconstruction. Osteogenic cells must be kept viable in graft for a successful procedure. In extracorporeal preservation of grafts during surgery, three different factors may influence the quality of grafts. These factors include temperature, storage medium, and time interval.Purpose: In this study, we evaluated the effects of different storage media, temperatures, and times on osteoblast count in autogenous bone grafts, preserved extracorporeally.Materials and Method: Samples were obtained from iliac crest region in a goat. The grafts were preserved in 36 groups of different storage time, temperature, and medium. Samples were histomorphometrically analyzed to determine osteoblast count as the criteria of graft quality.Results: In almost all samples, room temperature was the most and incubator was the least favorable storage temperatures. In grafts preserved in room temperature, no difference was noted between normal saline and Ringer’s lactate solution and in almost all of the samples autologous blood and dry environment were more favorable media than Ringer’s lactate solution. The effect of storage time was highly depended on the combination of temperature and solution.Conclusion: The results demonstrated that for preserving as many osteoblasts as possible in bone grafts, the best temperature was room temperature and the least favorable temperature was incubator. In addition, when bone fragments were preserved in room temperature, the best medium for graft storage was blood, which showed better results than normal saline and Ringer’s lactate solution.

Comparison of the Effects of Fluid Therapy With Normal Saline, Ringer, and Ringer’s Lactate During Anesthesia on the Hemodynamic Status and Events During Orthopedic Lower Limb Orthopedics Surgeries

Objectives: Given that no study has so far carefully examined the effects and benefits of crystalloids on the hemodynamic status and events during the surgery for lower limb orthopedic surgeries, the current study aimed to compare fluid therapy with normal saline (NS), Ringer (R), and Ringer’s lactate (RL) during anesthesia on the hemodynamic status and events during lower limb elective orthopedic surgeries. Materials and Methods: This cross-sectional descriptive study was conducted in 2019 with the participation of 270 patients (three groups each including 90 subjects) who were scheduled for an elective lower limb orthopedic surgery in Imam Reza hospital of Tabriz. Patients received one of these serums of NS, R, and RL. Electrolytes were measured before and after the surgery. Finally, data were analyzed using ANOVA and chi-square tests. Results: Based on the results, there was no significant difference between the three groups in terms of hemoglobin, hematocrit, sodium, calcium, potassium, chlorine, albumin, creatinine, urea, bicarbonate, pH, and arterial oxygen levels (P&gt;0.05), and RL serum had the least effect on all factors. Conclusions: In general, the administration of NS, R, and RL in lower limb orthopedic surgeries did not result in significant differences although RL had the least adverse effects and was associated with better results.

Effect of Rehydration With Normal Saline Versus Ringer Lactate on Serum Sodium Level of Children With Acute Diarrhea and Severe Dehydration: A Randomized Controlled Trial

To demonstrate the equivalence of Normal Saline (NS) and Ringer Lactate (RL) for change in serum sodium levels during correction of severe dehydration in children with acute diarrhea based on World Health Organization (WHO) plan C. Equivalence randomized control trial. Pediatric diarrhea unit of a tertiary care hospital from May, 2016 to April, 2017. 72 children of 1-12 years with acute diarrhea and severe dehydration were enrolled. Children with dysentery, severe acute malnutrition, severe anemia, meningitis, and known surgical and systemic diseases were excluded. RL (n=36) or NS (n=36) were used as per WHO plan C. Blood samples were drawn before intravenous fluid correction and 3 h post-intervention. Mean change in serum sodium level from the baseline between the RL and NS groups. 70 children (35 in each group) completed the study. The difference in mean serum sodium levels from baseline in RL and NS groups were 1.4 (4.5) mEq/L and 2.1(4.9) mEq/L, respectively (P=0.58). Both RL and NS are equivalent in terms of change in serum sodium from baseline for intravenous rehydration in children with acute diarrhea and severe dehydration.

Characteristics of resuscitation, and association between use of dynamic tests of fluid responsiveness and outcomes in septic patients: results of a multicenter prospective cohort study in Argentina

BackgroundResuscitation of septic patients regarding goals, monitoring aspects and therapy is highly variable. Our aim was to characterize cardiovascular and fluid management of sepsis in Argentina, a low and middle-income country (LMIC). Furthermore, we sought to test whether the utilization of dynamic tests of fluid responsiveness, as a guide for fluid therapy after initial resuscitation in patients with persistent or recurrent hypoperfusion, was associated with decreased mortality.MethodsSecondary analysis of a national, multicenter prospective cohort study (n = 787) fulfilling Sepsis-3 definitions. Epidemiological characteristics, hemodynamic management data, type of fluids and vasopressors administered, physiological variables denoting hypoperfusion, use of tests of fluid responsiveness, and outcomes, were registered. Independent predictors of mortality were identified with logistic regression analysis.ResultsInitially, 584 of 787 patients (74%) had mean arterial pressure (MAP) < 65 mm Hg and/or signs of hypoperfusion and received 30 mL/kg of fluids, mostly normal saline (53%) and Ringer lactate (35%). Vasopressors and/or inotropes were administered in 514 (65%) patients, mainly norepinephrine (100%) and dobutamine (9%); in 22%, vasopressors were administered before ending the fluid load. After this, 413 patients (53%) presented persisting or recurrent hypotension and/or hypoperfusion, which prompted administration of additional fluid, based on: lactate levels (66%), urine output (62%), heart rate (54%), central venous O2 saturation (39%), central venous–arterial PCO2 difference (38%), MAP (31%), dynamic tests of fluid responsiveness (30%), capillary-refill time (28%), mottling (26%), central venous pressure (24%), cardiac index (13%) and/or pulmonary wedge pressure (3%). Independent predictors of mortality were SOFA and Charlson scores, lactate, requirement of mechanical ventilation, and utilization of dynamic tests of fluid responsiveness.ConclusionsIn this prospective observational study assessing the characteristics of resuscitation of septic patients in Argentina, a LMIC, the prevalent use of initial fluid bolus with normal saline and Ringer lactate and the use of norepinephrine as the most frequent vasopressor, reflect current worldwide practices. After initial resuscitation with 30 mL/kg of fluids and vasopressors, 413 patients developed persistent or recurrent hypoperfusion, which required further volume expansion. In this setting, the assessment of fluid responsiveness with dynamic tests to guide fluid resuscitation was independently associated with decreased mortality.

2805 Targeted Interventions Improving Compliance With Guideline-Based Care in Acute Pancreatitis

INTRODUCTION: Acute pancreatitis (AP) is the 3rd leading cause of GI related hospitalizations nationwide. In an effort to improve guideline-based care at our institution, we acquired retrospective data from 247 patients admitted to our institution between April 1, 2015 to September 30, 2017 with AP. We identified multiple areas in which to improve care based on the American College of Gastroenterology (ACG) Guidelines: intravenous fluid (IVF) resuscitation, right upper quadrant ultrasound (RUQ-US) use, and antibiotic stewardship in patients admitted with AP. We aimed to increase the percentage of AP patients who receive adequate IVF resuscitation in the first 24 hours from 6.4% to 50%, increase the RUQ-US rate from 59.5% to 80%, and decrease the rate of inappropriate antibiotic use from 24% to 10%, by April 1, 2019. METHODS: Within the internal medicine department, a quality improvement group was assembled. Barriers to implementing guideline-based care within our target areas were identified. We then implemented interventions aimed at improving performance in our three focus areas. The interventions included: house staff education, development and implementation of an AP admission order set within the electronic medical record (EMR), meeting with the emergency department to encourage early fluid resuscitation, distribution of a management flowsheet to house staff work rooms, and the antimicrobial stewardship program (ASP) including patients with AP who meet criteria for inappropriate use (on antibiotics for &gt;48 hours without evidence of intrapancreatic or extrapancreatic infection) in their EMR based communication. We tracked our progress utilizing a real-time patient monitoring software. RESULTS: On April 1, 2019, a total of 35 patients were captured after the start of our interventions. Appropriate IVF resuscitation [defined as &gt;250cc/hr of normal saline or lactated ringers (6L in the 1st 24 hours)] improved from 6.4% to 20%. RUQ-US obtained on admission improved from 59.5% to 71.4%. Inappropriate antibiotic use decreased from 24% to 11.4%. CONCLUSION: While improvements in appropriate IVF resuscitation, RUQ-US rate, and antibiotic stewardship were noted, we have not yet met our goals. We aim to build on this progress through increased utilization of the AP order set, and the ASP will continue to monitor and intervene for inappropriate antibiotic use in AP patients. We intend to evaluate pre and post intervention 30-day readmission rates and length of stay.