Normal Saline Fluid Research Articles

Apelin-13 administration allows for norepinephrine sparing in a rat model of cecal ligation and puncture-induced septic shock

BackgroundInfusion of exogenous catecholamines (i.e., norepinephrine [NE] and dobutamine) is a recommended treatment for septic shock with myocardial dysfunction. However, sustained catecholamine infusion is linked to cardiac toxicity and impaired responsiveness. Several pre-clinical and clinical studies have investigated the use of alternative vasopressors in the treatment of septic shock, with limited benefits and generally no effect on mortality. Apelin-13 (APL-13) is an endogenous positive inotrope and vasoactive peptide and has been demonstrated cardioprotective with vasomodulator and sparing life effects in animal models of septic shock. A primary objective of this study was to evaluate the NE-sparing effect of APL-13 infusion in an experimental sepsis-induced hypotension.MethodsFor this goal, sepsis was induced by cecal ligation and puncture (CLP) in male rats and the arterial blood pressure (BP) monitored continuously via a carotid catheter. Monitoring, fluid resuscitation and experimental treatments were performed on conscious animals. Based on pilot assays, normal saline fluid resuscitation (2.5 mL/Kg/h) was initiated 3 h post-CLP and maintained up to the endpoint. Thus, titrated doses of NE, with or without fixed-doses of APL-13 or the apelin receptor antagonist F13A co-infusion were started when 20% decrease of systolic BP (SBP) from baseline was achieved, to restore SBP values ≥ 115 ± 1.5 mmHg (baseline average ± SEM).ResultsA reduction in mean NE dose was observed with APL-13 but not F13A co-infusion at pre-determined treatment time of 4.5 ± 0.5 h (17.37 ± 1.74 µg/Kg/h [APL-13] vs. 25.64 ± 2.61 µg/Kg/h [Control NE] vs. 28.60 ± 4.79 µg/Kg/min [F13A], P = 0.0491). A 60% decrease in NE infusion rate over time was observed with APL-13 co-infusion, (p = 0.008 vs NE alone), while F13A co-infusion increased the NE infusion rate over time by 218% (p = 0.003 vs NE + APL-13). Associated improvements in cardiac function are likely mediated by (i) enhanced left ventricular end-diastolic volume (0.18 ± 0.02 mL [Control NE] vs. 0.30 ± 0.03 mL [APL-13], P = 0.0051), stroke volume (0.11 ± 0.01 mL [Control NE] vs. 0.21 ± 0.01 mL [APL-13], P < 0.001) and cardiac output (67.57 ± 8.63 mL/min [Control NE] vs. 112.20 ± 8.53 mL/min [APL-13], P = 0.0036), and (ii) a reduced effective arterial elastance (920.6 ± 81.4 mmHg/mL/min [Control NE] vs. 497.633.44 mmHg/mL/min. [APL-13], P = 0.0002). APL-13 administration was also associated with a decrease in lactate levels compared to animals only receiving NE (7.08 ± 0.40 [Control NE] vs. 4.78 ± 0.60 [APL-13], P < 0.01).ConclusionAPL-13 exhibits NE-sparing benefits in the treatment of sepsis-induced shock, potentially reducing deleterious effects of prolonged exogenous catecholamine administration.

Perspectives on the surgical intervention of venous injuries: In-depth analysis

Background. The surgical treatment of venous injuries is examined in this work, with particular attention to the brachial vein and its prevalence, methods, and results. Purposes. It assesses surgical techniques, issues that arise after surgery, and the significance of developments in venous repair. In these complicated instances, the research aids in better decision-making and patient care. Methods. A study at the Advanced Vascular Institute and Al-Hashed military hospitals between 2017 and 2018 involved 150 patients with acute venous injuries, predominantly males aged 3-65 years. The study observed a change in the causes of venous injury, with a rise in cases of blunt trauma, particularly in metropolitan areas, but penetrating trauma remains the most common cause. Diagnosis is mainly reached clinically by looking for signs and symptoms, and surgical plans can be made without the Doppler study, which is now available in all casualty wards. Results. To treat hypovolemia and shock, two bilateral wide-bore cannulas with rapid cross-matched blood (rapid method) and ringers or normal saline fluid. The most common injury was to the brachial vein, which was repaired primarily by ligation and, after that, by various techniques, including venography. Follow-ups were difficult for those from other governments, especially our soldier's surgery done at Al-Hashed hospitals, where we advised them to consult vascular surgeons near their residences. Ten individuals had their venous ligation and fasciotomy complications—often accompanied by concomitant artery trauma—required an amputation. Conclusions. The use of fasciotomies varied and did not significantly correlate with the kind of operation. Doppler study checked the patency of the repaired veins, and the follow-up revealed no signs of thrombotic problems. Four patients, all in critical hemodynamic conditions with significant arterial and venous injuries, died during surgery from irreversible shock, accounting for the study's 2.7% fatality rate.

THE PROCESS OF WOUND HEALING IN POST SECTIO CAESAREA PATIENTS USING NORMAL SALINE (0.9%) AND POVIDONE-IODINE (10%) IRRIGATIONS: A COMPARATIVE STUDY

Surgical Site Infection (SSI) is a complication after surgery, and one of the causes is the use of intra-operative irrigation fluids. The most common irrigation fluid was 0.9% Normal Saline and 10% Povidone-Iodine in several hospitals in Indonesia. However, the difference in composition has not been observed for its effect on wound healing. This study aimed to determine the difference in using 0.9% Normal Saline and 10% Povidone-Iodine for irrigation in the wound healing process for post-cesarean patients. The research design used is a descriptive comparative study with ex post facto approaches. Due to the COVID-19 pandemic, researchers changed the data collection method from direct observations to analyzing secondary data post-cesarean surgery data in 2019. The study was conducted in a referral hospital in West Java Province, Indonesia. The sampling used non-probability sampling with a purposive sampling technique. The sample was 440 patient medical records. These records consisted of 0.9% Normal Saline irrigation fluid, 140 respondents, and 10% Povidone-Iodine irrigation fluid, 300 respondents. The chi-square analysis showed significant differences in the two types of intra-operative wound irrigation (0.9% Normal Saline and 10% Povidone-Iodine) with a wound healing process (P-value = 0.021). The distribution frequency showed that the infection of 0.9% Normal Saline fluid was 5% of the 133 respondents, and 10% Povidone-Iodine was 12% out of 300 respondents. The study results showed that 0.9% Normal Saline and 10% Povidone-iodine could be used for intra-operative wound irrigation with different characteristics and compositions that impact the postoperative wound healing process. There is a need for further research to do a direct observation to test the effectiveness of two types of irrigation fluids from intra-operative to postoperative and assess other influencing factors.

Ochrobactrum anthropi: An Unusual Emerging Pathogen

Ochrobactrum anthropi is an organism which is commonly distributed in the environment and water sources including normal saline, antiseptic solutions, and dialysis fluid. However, it is an opportunistic pathogen, especially in critically ill or immunocompromised patients. The presence of central venous catheter line is a risk factor. Here, we report two cases of bacteremia caused by O. anthropi in patients undergoing chemotherapy.

PRagMatic Pediatric Trial of Balanced vs nOrmaL Saline FlUid in Sepsis: study protocol for the PRoMPT BOLUS randomized interventional trial

Background/aimsDespite evidence that preferential use of balanced/buffered fluids may improve outcomes compared with chloride-rich 0.9% saline, saline remains the most commonly used fluid for children with septic shock. We aim to determine if resuscitation with balanced/buffered fluids as part of usual care will improve outcomes, in part through reduced kidney injury and without an increase in adverse effects, compared to 0.9% saline for children with septic shock.MethodsThe Pragmatic Pediatric Trial of Balanced versus Normal Saline Fluid in Sepsis (PRoMPT BOLUS) study is an international, open-label pragmatic interventional trial being conducted at > 40 sites in the USA, Canada, and Australia/New Zealand starting on August 25, 2020, and continuing for 5 years. Children > 6 months to < 18 years treated for suspected septic shock with abnormal perfusion in an emergency department will be randomized to receive either balanced/buffered crystalloids (intervention) or 0.9% saline (control) for initial resuscitation and maintenance fluids for up to 48 h. Eligible patients are enrolled and randomized using serially numbered, opaque envelopes concurrent with clinical care. Given the life-threatening nature of septic shock and narrow therapeutic window to start fluid resuscitation, patients may be enrolled under “exception from informed consent” in the USA or “deferred consent” in Canada and Australia/New Zealand. Other than fluid type, all decisions about timing, volume, and rate of fluid administration remain at the discretion of the treating clinicians. For pragmatic reasons, clinicians will not be blinded to study fluid type. Anticipated enrollment is 8800 patients. The primary outcome will be major adverse kidney events within 30 days (MAKE30), a composite of death, renal replacement therapy, and persistent kidney dysfunction. Additional effectiveness, safety, and biologic outcomes will also be analyzed.DiscussionPRoMPT BOLUS will provide high-quality evidence for the comparative effectiveness of buffered/balanced crystalloids versus 0.9% saline for the initial fluid management of children with suspected septic shock in emergency settings.Trial registrationPRoMPT BOLUS was first registered at ClinicalTrials.gov (NCT04102371) on September 25, 2019. Enrollment started on August 25, 2020.

POST TRAUMATIC CAROTID CAVERNOUS FISTULA PRESENTING AS PARATHYROID CRISIS

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: This is a case of two rare entities causing non-specific symptoms. Carotid-cavernous sinus fistula (CCF) arises from miscommunication of carotid arterial flow and the cavernous sinus. Post traumatic CCF presents bilaterally are uncommon, only 1-2% of patients. While already a rare diagnosis, our patient presented in an acute parathyroid crisis defined by symptomatology caused by markedly elevated calcium and parathyroid hormone, which may have masked our diagnosis of CCF. CASE PRESENTATION: A 57-year-old Colombian female presented with dizziness, anorexia, nausea, and vomiting. She also endorsed intermittent diplopia in the left eye. Physical exam revealed left sided ptosis. She reports a remote history of head trauma a month prior. Serum calcium on presentation was 13.6 mg/dL, ionized calcium of 6.8 mg/dL, and parathyroid hormone (PTH) was 219.8 pg/mL. Subsequently, a Technetium 99m sestamibi scan showed increased radioisotope along the right lower pole of the thyroid gland confirming primary hyperparathyroidism. She was resuscitated with normal saline fluid and started on Cinacalcet for hypercalcemia. Attempts to lower serum calcium can be achieved using bisphosphonates and may be effective within the first 24 hours. In our patient, Cinacalcet did not achieve sufficient calcium lowering thus, Zoledronic acid was used due to its potency with small doses. Nausea, vomiting, and positional dizziness resolved. Despite resolution of symptoms, she continued with ptosis; thus prompting further work up. Magnetic resonance angiography and venography revealed extensive time of flight enhancement throughout the bilateral cavernous sinuses. A cervical and cerebral angiography revealed bilateral carotid cavernous fistulas with ophthalmic vein arterialization. The next day, she underwent left cavernous sinus embolization with coiling. Parathyroidectomy was delayed due to recurrence of ptosis and need for a second embolization for persistent diplopia that resulted in resolution of symptoms. DISCUSSION: Each of these diagnoses are rare and both require timely evaluation and treatment. The patient's symptoms are classically seen in a parathyroid crisis, with nausea, vomiting, and anorexia being the most common symptoms in up to 48% of parathyroid crises. Like the aforementioned, CCF symptomatology also includes non-specific symptoms; however, may pose more of a challenge during diagnosis as symptoms wax and wane depending on the hemodynamic flow within the fistula. CONCLUSIONS: This case highlights the necessity of a thorough physical exam and further as a reminder that a clinician must be vigilant in ruling out alternative pathologies supported by the objective findings no matter how rare or unlikely. REFERENCE #1: Churojana A, Chawalaparit O, Chiewwit P, Suthipongchai S. Spontaneous occlusion of a bilateral post traumatic carotid cavernous fistula. Interv Neuroradiol. 2001;7(3):245-252. doi:10.1177/159101990100700311 REFERENCE #2: Singh DN, Gupta SK, Kumari N, et al. Primary hyperparathyroidism presenting as hypercalcemic crisis: Twenty-year experience. Indian J Endocrinol Metab. 2015;19(1):100-105. doi:10.4103/2230-8210.131763 REFERENCE #3: Lowell AJ, Bushman NM, Wang X, et al. Assessing the risk of hypercalcemic crisis in patients with primary hyperparathyroidism. J Surg Res. 2017;217:252-257. doi:10.1016/j.jss.2017.06.041 DISCLOSURES: No relevant relationships by Roman Bernstein, source=Web Response No relevant relationships by Ariol Labrada, source=Web Response No relevant relationships by Tram Nguyen, source=Web Response No relevant relationships by Elena Tellez, source=Web Response No relevant relationships by Yaswanraj Yuvaraj, source=Web Response

The role of Vitamin E in hip implant-related corrosion and toxicity: Initial outcome

In orthopedic healthcare, Total Hip Replacement (THR) is a common and effective solution to hip-related bone and joint diseases/fracture; however, corrosion of the hip implant and the release of degradation metal ions/particles can lead to early implant failure and pose potential toxicity risk for the surrounding tissues. The main objective of this work was to investigate the potential role of Vitamin E to minimize corrosion-related concerns from CoCrMo hip implants. The study focused on two questions (i) Can Vitamin E inhibit CoCrMo corrosion? and (ii) Does Vitamin E moderate the toxicity associated with the CoCrMo implant particles?In the study (i) the electrochemical experiments (ASTM G61) with different concentrations of Vitamin E (1, 2, 3 mg/ml against the control) were performed using normal saline and simulated synovial fluid (Bovine calf serum-BCS, 30 g/L protein, pH 7.4) as electrolytes. The polished CoCrMo disc (Ra 50 nm) was the working electrode. The findings suggested that both Vitamin E-Saline (45 ± 0.9%) and Vitamin E-BCS (91 ± 3%) solutions protected against implant corrosion at a Vitamin E concentration of 3 mg/ml, but Vitamin E-BCS showed protection at all Vitamin E (1-3 mg/ml) concentration levels. These results suggested that the Vitamin E and the protein present in the BCS imparted additive effects towards the electrochemical inhibition.In the study (ii) the role of Vitamin E in cytotoxicity inhibition was studied using a mouse neuroblastoma cell line (N2a) for CoCrMo particles and Cr ions separately. The CoCrMo particles were generated from a custom-built hip simulator. The alamarBlue assay results suggested that Vitamin E provides significant protection (85% and 75% proliferation) to N2a cells against CoCrMo particles and Cr ions, respectively at 1 μg/ml concentration, as compared to the control group. However, the results obtained from ROS expression and DNA fiber staining suggest that Vitamin E is only effective against CoCrMo degradation particles and not against Cr ions.In summary, the findings show that Vitamin E can minimize the corrosion processes and play a role in minimizing the potential toxicity associated with implants.

Use of Peripherally Inserted Central Catheter (PICC) for the Infusion of Peripheral Blood Stem Cell Products Is Safe and Effective

Introduction: Cryopreserved peripheral blood stem cell (PBSC) products are thawed at bedside and infused by gravity through a large bore central venous line (CVL). Peripherally inserted central venous catheters (PICC) are routinely used for infusion of blood products and medications but are rarely used to administer hematopoietic progenitor cells (HPC). The rationale for this practice is not well established but the general assumption is that the smaller gauge sizes of the PICC and resultant decreased infusion rates would damage the HPCs. The use of PICC to infuse HPCs can have many benefits, such as patient comfort, cost effectiveness, and reducing potential line-related complications from the insertion of a large bore, and often additional, CVL. These line-related complications include infections, pneumothorax, haematomas, etc. The aim of this prospective observational study is to present the experience of using PICC in lymphoma patients receiving autologous PBSC transplantation in terms of the safety and efficacy. Methodology: From September 2019 to June 2020, a prospective observational study involving 16 patients with lymphoma undergoing autologous PBSC transplantation was conducted in National University Cancer Institute, Singapore (NCIS). The patients were divided into 2 groups - the first group included 9 lymphoma patients who received their autologous PBSC transplant via PICC, while the second/control group included 7 lymphoma patients who received the treatment via a large bore CVL. The types of PICC and CVL inserted for the patients were standardized - 19G dual lumen PICC and 7Fr triple lumen non-tunnelled CVL respectively. All the CVLs were inserted in the right internal jugular vein, while the PICC were inserted in either the brachial or basilic veins. All patients in both groups underwent BEAM conditioning transplantation regime prior to autologous PBSC transplantation. The duration of the catheter-in-situ, catheter-associated complications, PBSC infusion rate, CD34 cell dose, total nucleated cell dose infused, and the time for absolute neutrophil and platelet count engraftment were analysed for the study. Results: The baseline characteristics and results for both groups are shown in Table 1. It is important to highlight that for the first group using PICC, none of them had any adverse event from PBSC transplantation. 44.4% of the patients had only minor issues during the PBSC infusion, mainly due to slower infusion rate and sediments were seen in the tubing of the PICC. These issues were quickly overcome by manual flushing of the PICC with normal saline fluid boluses. Only 1 out of 9 had a mild skin irritation at the insertion site of the PICC. For the second/control group using CVL, 43% of them had both PICC and CVL in-situ at one point of their treatment. These patients underwent an additional procedure for CVL insertion and the CVL was removed within 2 weeks of insertion. Only 1 out of 7 patients had minor issue of severe nausea during the PBSC infusion. There was no adverse event during the PBSC infusion or catheter associated complication. Conclusion: Our study showed that the use of PICC is safe and effective for patients receiving autologous PBSC transplantation, compared to the conventional large bore central venous catheters. Despite having longer PBSC infusion rate for PICC, the time taken for neutrophil and platelet recovery between both groups were comparable and there were no serious complications. Table Disclosures Chng: Celgene: Honoraria, Research Funding; Janssen: Honoraria, Research Funding; Amgen: Honoraria, Research Funding; Abbvie: Honoraria; Novartis: Honoraria.

The effect of addition of dexamethasone into normal saline irrigation solution on Prevention of Intraperitoneal Adhesion Post Laparotomy in wistar rats (Rattus norvegicus)

IntroductionIntraperitoneal adhesion is a pathological condition of adhesion between the omentum, intestine and abdominal wall. The purpose of this study was to determine the effect of adding dexamethasone into normal saline fluid to prevent intra peritoneal adhesion. Materials and methodsThis study used experimental post-test only control group design. There were four treatment groups using six white rats in each group: group I without administration of normal saline and dexamethasone, group II with administration of normal saline irrigation, group III by adding dexamethasone dose 0.2 mg/BW into 5 cc normal saline, and group IV by adding 0.5 mg/BW into 5 cc normal saline. Laparotomy was performed to all samples followed by excoriation and abrasion in cecum and terminal ileum using gauze. Intra peritoneal adhesion assessment was carried out on the 10th day post laparotomy. Macroscopic and microscopic assessments were performed to evaluate formation of collagen, fibrin and the spread of inflammatory cells of each group. ResultsFrom macroscopic observations, it was found that the average adhesion that occurred was 3.333; 2.333; 0.666; 0.333 by using statistical calculations with one-way ANOVA with P value of 0.000. Post-Hoc analysis showed that the administration of dexamethasone 0.5 mg/BW is proven to minimize the occurrence of adhesion between the 3 groups. Microscopic assessment of the formation of collagen, fibrin and the spread of inflammatory cells by one-way ANOVA produced P 0.000 in all three parameters, but the dose of dexamethasone administration between 0.2 mg/BW and 0.5 kg/BW did not prove significant in either group. ConclusionThere is evidence that the addition of dexamethasone to normal saline as an irrigation liquid during laparotomy can reduce the occurrence of adhesion. However, the dose difference was not proven to be better in this study. Further studies are suggested to use more experimental animals.

Intractable Normal Anion Gap Metabolic Acidosis in a Patient with Diabetic Ketoacidosis

High anion gap metabolic acidosis (HAGMA) is a hallmark of Diabetic Ketoacidosis (DKA). Occasionally, a Normal Anion Gap Metabolic Acidosis (NAGMA) can be seen, especially during the treatment phase. In this case report, a 55-year-old lady with diabetes mellitus who presented with a 2-day history of fever, lethargy and multiple episodes of vomiting and diarrhoea. Initial laboratory investigations revealed: capillary blood glucose as 27 mmol/L, urine ketone as 3+, blood ketone as 3.5 mmol/L, serum bicarbonate as 14 mmol/L, and serum chloride as 95 mmol/L. She was treated with intravenous normal saline fluid resuscitation and constant rate insulin infusion which was fortunately accompanied by stabilization of blood glucose and normalization of blood ketone to 0.2 mmol/L. However, despite normalization of her anion gap (25 to 14), she remained unwell with acidotic breathing due to refractory hyperchloraemic NAGMA with bicarbonate at 11 mol/L and chloride of 112 mmol/L. It was then decided to administer 100 mL of 8.4% Sodium Bicarbonate solution. The next day, she was no longer tachypneic as her bicarbonate and carbon dioxide improved to 21 mmol/L and 32 mmHg respectively. The presence of NAGMA in DKA should prompt clinicians to conduct a thorough search for possible underlying causes, such as gastrointestinal fluid loss, sepsis and chloride load from aggressive fluid resuscitation with normal saline. Sodium bicarbonate should only be considered in intractable cases to correct a NAGMA and not routinely used in the treatment of DKA.

Pragmatic Pediatric Trial of Balanced Versus Normal Saline Fluid in Sepsis

Pragmatic Pediatric Trial of Balanced Versus Normal Saline Fluid in Sepsis

Pragmatic Pediatric Trial of Balanced Versus Normal Saline Fluid in Sepsis: The PRoMPT BOLUS Randomized Controlled Trial Pilot Feasibility Study.

Resuscitation with crystalloid fluid is a cornerstone of pediatric septic shock treatment. However, the optimal type of crystalloid fluid is unknown. We aimed to determine the feasibility of conducting a pragmatic randomized trial to compare balanced (lactated Ringer's [LR]) with 0.9% normal saline (NS) fluid resuscitation in children with suspected septic shock. Open-label pragmatic randomized controlled trial at a single academic children's hospital from January to August 2018. Eligible patients were>6 months to<18 years old who were treated in the emergency department for suspected septic shock, operationalized as blood culture, parenteral antibiotics, and fluid resuscitation for abnormal perfusion. Screening, enrollment, and randomization were carried out by the clinical team as part of routine care. Patients were randomized to receive either LR or NS for up to 48 hours following randomization. Other than fluid type, all treatment decisions were at the clinical team's discretion. Feasibility outcomes included proportion of eligible patients enrolled, acceptability of enrollment via the U.S. federal exception from informed consent (EFIC) regulations, and adherence to randomized study fluid administration. Of 59 eligible patients, 50 (85%) were enrolled and randomized. Twenty-four were randomized to LR and 26 to NS. Only one (2%) of 44 patients enrolled using EFIC withdrew before study completion. Total median (interquartile range [IQR]) crystalloid fluid volume received during the intervention window was 107 (60 to 155) mL/kg and 98 (63 to 128) mL/kg in the LR and NS arms, respectively (p=0.50). Patients randomized to LR received a median (IQR) of only 20% (13 to 32) of all study fluid as NS compared to 99% (64% to 100%) of study fluid as NS in the NS arm (absolute difference= 79%, 95% CI= 48% to 85%). A pragmatic study design proved feasible to study comparative effectiveness of LR versus NS fluid resuscitation for pediatric septic shock.

Saline versus albumin fluid for extracorporeal removal with slow low-efficiency dialysis (SAFER-SLED): study protocol for a pilot trial

BackgroundCritically ill patients frequently develop acute kidney injury that necessitates renal replacement therapy (RRT). At some centers, critically ill patients who are hemodynamically unstable and require RRT are treated with slow low-efficiency dialysis (SLED). Unfortunately, hypotension is a frequent complication that occurs during SLED treatments and may limit the recovery of kidney function. Hypotension may also limit the amount of fluid that can be removed by ultrafiltration with SLED. Fluid overload can be exacerbated as a consequence, and fluid overload is associated with increased mortality.Occasionally, intravenous albumin fluid is given to prevent or treat low blood pressure during SLED. The intent of doing so is to increase the colloid oncotic pressure in the circulation to draw in extravascular fluid, increase the blood pressure, and enable more aggressive fluid removal with ultrafiltration. Nonetheless, there is little evidence to support this practice and theoretical reasons why it may not be especially effective at augmenting fluid removal in critically ill patients. At the same time, albumin fluid is expensive.As such, we present a protocol for a study to assess the feasibility of a randomized controlled trial evaluating the use of albumin fluid versus saline in critically ill patients receiving SLED.MethodsThis study is a single-center, double-blind, and randomized controlled pilot trial with two parallel arms. It involves randomly assigning patients receiving SLED treatment in the ICU to receive either albumin (25%) boluses or normal saline fluid boluses (placebo) to prevent and treat low blood pressure.DiscussionThe results of this pilot trial will help with planning a larger trial comparing the efficacy of the interventions in achieving fluid removal in critically ill patients with AKI on SLED. They will establish whether enough participants would participate in a larger study and accept the study procedures.Trial registrationThis trial is registered on ClinicalTrials.gov Identifier NCT03665311, registered on September 11, 2018.

Effect of Warmed Hysteroscopic Fluid Distention Medium on Postoperative Core Body Temperature: A Randomized Trial [8J

INTRODUCTION: The purpose of this research study was to determine whether warming of the distention fluid during operative hysteroscopy will have an effect on perioperative core body temperature, and secondarily to assess postoperative self-rated pain scores. METHODS: Single-blind, 3-arm stratified randomized trial. Total of 96 patients were randomly allocated to 3 groups. Group 1 received normal saline fluid bags at room temperature 22°C (71.6°F), group 2 received fluid bags pulled from a warming cabinet set at 40°C (104°F), and group 3 received continuously warmed fluid at 40°C (104°F). Randomization was stratified by procedure type (myomectomy and non-myomectomy) to ensure 50% of the cases in each group included resections of submucous leiomyoma. RESULTS: There was no statistically significant difference between the 3 arms of the trial in near-core body temperature (P=.29) or in self-rated pain scores (P=.09). However, when compared to all other procedure types, the myomectomy procedures had statistically significant higher fluid deficits in group 1 (P=.01) and group 2 (P=.02), as well as significantly longer operative times in group 1 (P=.05) and group 2 (P=.03). Group 3 demonstrated no statistically significant difference in average fluid deficit between hysteroscopic myomectomy to all other procedure types (P=.16), despite there not being a statistically significant difference in total procedure time between myomectomy procedures and all other surgical procedure types (P=.42). CONCLUSION: Warming of hysteroscopic distention media did not impact near-core body temperature or post-operative pain scores. Use of continuously warmed hysteroscopic fluid in hysteroscopic myomectomy may decrease operative times as well as volume of fluid deficits.

Case 2: Asymmetrical Frontal Bossing and Refractory Seizures in a Newborn

A male infant is born at 37 6/7 weeks' gestation by repeat cesarean delivery to a 33-year-old gravida 2, para 0 mother who had a previous fetal demise at 37 weeks' gestation (etiology unknown; no autopsy performed). For this current pregnancy the mother had regular prenatal care. Gestational diabetes was treated with dietary interventions. The mother is deaf due to childhood meningitis. She has a history of genital herpes simplex virus (HSV), with no active lesions at the time of delivery while receiving suppressive valacyclovir. The delivery is complicated by a nuchal cord and difficult extraction. The infant requires brief positive pressure ventilation. Apgar scores of 8 and 9 at 1 and 5 minutes, respectively, are given. The infant weighs 3,735 g and is noted to have macrocephaly, with a head circumference of 15.8 in (40 cm). His length is 19.7 in (50 cm) and plots at 52%. He has a large open anterior fontanelle and asymmetrical frontal bossing, with prominence of the right forehead. The remainder of his newborn examination findings are normal. At 2 hours after birth he develops intermittent oxygen desaturations associated with arching of his back followed by right-sided shaking. His blood sugar level is 78 mg/dL (4.3 mmol/L). He is placed on 1-L nasal cannula oxygen and is loaded with 20 mg/kg of phenobarbital for suspected seizures. A blood culture is performed, and he is started on ampicillin, gentamicin, and acyclovir. A normal saline fluid bolus is given, and maintenance fluids are initiated at 80 mL/kg per day. The infant is then transferred to a facility that provides a higher level of care. On arrival at our facility he is noted to be hypotonic and requires nasal cannula oxygen at 2 L. The results of his complete blood cell count and comprehensive metabolic panel are …

A Newborn with Multiple Anomalies

A late preterm neonate is born with an occipital encephalocele and other anomalies. ### Prenatal and Birth Histories ### Presentation The neurosurgery, otolaryngology, and neonatology departments were present at delivery. The encephalocele was large (Fig 1) and was initially placed in a sterile bag. Some spontaneous breaths were noted. Given the infant’s micrognathia, the otolaryngology team provided nasal intubation and placed the infant on positive pressure ventilation (Fig 2). The encephalocele was cleaned, wrapped in wet gauze, and placed in a polyethylene skin wrap by the neurosurgery team. The infant’s Apgar scores were 2, 6, and 8 at 1, 5, and 10 minutes, respectively. Before arrival at the NICU, a peripheral intravenous line was placed. The infant required 2 dextrose boluses to obtain a normal serum glucose value, and 1 normal saline fluid bolus to maintain appropriate blood pressure. She was then brought to the NICU and placed on assisted ventilation. …

Syringe Pump Performance Maintained with IV Filter Use During Low Flow Rate Delivery for Pediatric Patients.

Complex surgical and critically ill pediatric patients rely on syringe infusion pumps for precise delivery of IV medications. Low flow rates and in-line IV filter use may affect drug delivery. To determine the effects of an in-line filter to remove air and/or contaminants on syringe pump performance at low flow rates, we compared the measured rates with the programmed flow rates with and without in-line IV filters. Standardized IV infusion assemblies with and without IV filters (filter and control groups) attached to a 10-mL syringe were primed and then loaded onto a syringe pump and connected to a 16-gauge, 16-cm single-lumen catheter. The catheter was suspended in a normal saline fluid column to simulate the back pressure from central venous circulation. The delivered infusate was measured by gravimetric methods at predetermined time intervals, and flow rate was calculated. Experimental trials for initial programmed rates of 1.0, 0.8, 0.6, and 0.4 mL/h were performed in control and filter groups. For each trial, the flow rate was changed to double the initial flow rate and was then returned to the initial flow rate to analyze pump performance for titration of rates often required during medication administration. These conditions (initial rate, doubling of initial rate, and return to initial rate) were analyzed separately for steady-state flow rate and time to steady state, whereas their average was used for percent deviation analysis. Differences between control and filter groups were assessed using Student t tests with adjustment for multiplicity (using n = 3 replications per group). Mean time from 0 to initial flow (startup delay) was <1 minute in both groups with no statistical difference between groups (P = 1.0). The average time to reach steady-state flow after infusion startup or rate changes was not statistically different between the groups (range, 0.8-5.5 minutes), for any flow rate or part of the trial (initial rate, doubling of initial rate, and return to initial rate), although the study was underpowered to detect small time differences. Overall, the mean steady-state flow rate for each trial was below the programmed flow rate with negative mean percent deviations for each trial. In the 1.0-mL/h initial rate trial, the steady-state flow rate attained was lower in the filter than the control group for the initial rate (P = 0.04) and doubling of initial rate (P = 0.04) with a trend during the return to initial rate (P = 0.06), although this same effect was not observed when doubling the initial rate trials of 0.8 or 0.6 mL/h or any other rate trials compared with the control group. With low flow rates used in complex surgical and pediatric critically ill patients, the addition of IV filters did not confer statistically significant changes in startup delay, flow variability, or time to reach steady-state flow of medications administered by syringe infusion pumps. The overall flow rate was lower than programmed flow rate with or without a filter.

Comparison of acid–base and electrolyte imbalances between normal saline and 1.4% sodium bicarbonate intravenous fluids therapy during cervical and lumbar laminectomy

Abstract Introduction Large amounts of normal saline infused in surgeries can cause hyperchloremic metabolic acidosis. Aim This study was designed to evaluate electrolyte and acid–base imbalances in the common fluid therapy method (normal saline) and the use of 1.4% sodium bicarbonate with normal saline fluid therapy during surgical laminectomy. Material and methods In this double-blind randomized clinical trial patients from 35 to 70 years in age, having American Society of Anesthesiologists physical status class I–II, candidation for cervical and lumbar laminectomy in Baqiyatallah Hospital (Tehran, Iran) in 2015 were enrolled. Patients were randomized into either two groups receiving 1.4% sodium bicarbonate and normal saline intravenous solutions for deficit fluid therapy during the surgery. Hemodynamics, arterial blood gases, and electrolytes levels were measured before and after surgery. Data were compared between the groups by SPSS. Results and discussion Forty patients with a mean age of 49.9 ± 12.7 years were evaluated. There were no significant differences in demographic data, mean surgery duration, blood loss, urine output, and infused fluid volumes between the two groups ( P > 0.05). The mean PCO 2 and HCO 3 values significantly increased in the bicarbonate group, whereas they decreased significantly in the normal saline group. The mean serum lactate increased significantly in the bicarbonate group while the mean serum Cl − increased significantly in the normal saline group ( P Conclusions The results of this study showed the superiority of 1.4% sodium bicarbonate fluid in controlling acid–base and electrolyte imbalances during this kind of surgery, but it should be verified by further studies.

Histogenesis of gastric mucosa in human fetal stomach

Abstract Background and aims: Human fetal stomach starts developing at 4th week of gestational age. The precise knowledge of development of gastric mucosa is important for better understanding, diagnosis and treatment of different clinical conditions like Intestinal metaplasia, pernicious anaemia, heterotopic pancreatic tissue, atrophic gastritis etc. All these conditions are related to anomalous histogenesis of stomach. The aim of the study was to find out development of lining epithelium, gastric pits and glands and their ratio, time of appearance of different gastric mucosal cells in different weeks of gestation. Materials and methods: Sixty three normal fresh aborted fetuses were collected from obstetrics and gynaecology department of Regional Institute of Medical Sciences, Imphal. The fetuses were dissected and stomach was gently taken out, fixed in 10% normal saline and Bouin's fluid followed by processing of the tissue. Staining was done with Haematoxylin and Eosin and Masson's Trichrome. Results: The lining epithelium of stomach was seen to be simple cuboidal at 15 to 16 weeks which changed to columnar at 17th week of age. Gastric pits were seen to be very shallow in fundic part at 15th week and attained adult pattern by 28th week where as in pyloric part pits were deeper than fundic part from 17th week onwards. Parietal cells were frrst appreciated by 19th-20th week, chief cells and mucous neck cell were first seen by 25th-26th and 23rd-24th weeks respectively. Entero­ endocrine cells were seen from 26th week onwards. No funding was suggestive of intestinal metaplasia or heterotopic pancreatic tissue or any other histogenetic anomaly. Conclusion: Very few studies have been conducted so far regarding histogenesis of human fetal stomach in India. The present study is expected to supplement known data and knowledge regarding histogenesis of human fetal stomach and help in diagnosis and treatment of related congenital anomalies.

Severe rhabdomyolysis secondary to adenovirus infection: case report and literature review

A 38-year-old male presented with renal failure in the setting of a flu-like illness. Urinalysis showed myoglobinuria and granular casts. His serum creatine phosphokinase was markedly elevated. He was diagnosed with rhabdomyolysis and was volume resuscitated with normal saline and bicarbonate-containing fluid. Workup included a respiratory viral panel which was positive for adenovirus. Other causes such as trauma, seizure, and intoxicants were excluded. He developed progressive renal failure necessitating hemodialysis. After ~ 4 weeks he recovered renal function and dialysis was discontinued. Viral-induced myopathy should be suspected in patients who present with rhabdomyolysis.