Parenteral Fluid Research Articles

Parenteral versus enteral fluid therapy for children hospitalised with bronchiolitis

Parenteral versus enteral fluid therapy for children hospitalised with bronchiolitis

Establishing the Therapeutic Index of Fluid Resuscitation in the Septic Patient: A Narrative Review and Meta-Analysis.

This comprehensive review comparatively evaluates the safety and benefits of parenteral fluids used in resuscitation with a focus on sepsis. It also provides a random-effects meta-analysis of studies comparing restrictive resuscitation and usual care in sepsis with the primary outcome of mortality. In the septic patient, fluid therapy remains a complex interplay between fluid compartments in the body, the integrity of the endothelial barrier, and the inflammatory tone of the patient. Recent data have emerged describing the pharmacokinetics of fluid resuscitation that can be affected by the factors just listed, as well as mean arterial pressure, rate of infusion, volume of fluid infusate, nature of the fluid, and drug interactions. Fluid overload in sepsis has been associated with vasodilation, kidney injury, and increased mortality. Restrictive resuscitation after the initial septic insult is an emerging practice. Our search strategy of Medline databases revealed six randomized studies with 706 patients that examined restrictive resuscitation in sepsis. Results of this meta-analysis demonstrated no differences in mortality with restrictive resuscitation compared with usual care (30.6% vs 37.8%; risk ratio 0.83, 95% confidence interval 0.66-1.05, respectively) but was limited by the small number of studies and larger quantities of pre-randomization fluids. Another approach to address fluid overload is active (diuresis) de-resuscitation strategies that may shorten the need for mechanical ventilation and intensive care unit length of stay. Data suggest that colloids may confer mortality benefit over saline in the most severely ill septic patients. Compared with isotonic saline, balanced resuscitation fluids are associated with a lower incidence of acute kidney injury and mortality. The benefits of balanced resuscitation fluids are most evident when higher volumes of fluids are used for sepsis. Clinicians should consider these pharmacotherapeutic factors when selecting a fluid, its quantity, and rate of infusion.

A case of recurrent, spontaneous rhabdomyolysis: A manifestation of McArdle disease

Background: McArdle Disease is a glycogen storage disease caused by an inherited deficiency in myophosphorylase, an enzyme that initiates the breakdown of muscle glycogen for glycolysis. Due to clinical variability and low prevalence, this disease is often delayed in diagnosis. Patients may present in early adulthood, suffering from exercise intolerance, muscle fatigue, myalgias, and potential end-organ damage from rhabdomyolysis and myoglobinuria. Diagnosis is confirmed with muscle biopsy showing an absence of myophosphorylase activity and can be confirmed with PYGM genetic sequencing. Treatment is preventative through dietary control with the use of complex carbohydrates and the ingestion of simple carbohydrates prior to aerobic activity.Case presentation: A 19-year-old Caucasian male presented with a four-day history of rhabdomyolysis and acute kidney injury triggered by diving into cold water and swimming. The patient had developed muscle spasms and dyspnea, followed by a period of emesis, dysuria, and numbness in the lower extremities. Laboratory tests revealed creatinine kinase levels greater than 100,000 U/L and creatinine of 1.6 mg/dl. The patient had experienced a similar episode three months prior that occurred after sprinting, requiring hospitalization secondary to rhabdomyolysis. After eliminating reversible causes for rhabdomyolysis, there was high clinical suspicion for McArdle Disease, confirmed by muscle biopsy with absent phosphorylase activity. The patient was managed with parenteral fluids to treat the rhabdomyolysis and counseled on preventative dietary and exercise strategies.Conclusions: The late onset of presentation of McArdle Disease should prompt consideration of metabolic myopathies in a systemic evaluation for cases of recurrent rhabdomyolysis.

P108 TEDUGLUTIDE USE IN CROHN’S DISEASE: A CASE SERIES

Abstract Background Teduglutide is a glucagon-like peptide-2 (GLP-2) analogue with trophic effects on the intestinal mucosa to increase the absorptive surface area and enhance nutrient and fluid absorption of the small bowel (SB).1 It has been shown to reduce parenteral nutrition (PN) and intravenous fluid (IVF) requirements and is an important adjunct in the medical management of short bowel syndrome (SBS).1–2 Crohn’s disease (CD) is an important etiology of SBS but use of teduglutide in this population can be challenging. Aim The aim of this case series was to describe the use of teduglutide in CD patients. Methods A retrospective case series of all CD patients with SBS who used teduglutide at the Inflammatory Bowel Disease Center at Cedars-Sinai Medical Center. Age, duration of SBS, length of remaining SB and colonic continuity status were recorded. BMI, average daily PN kilocalories (kcal), and IVF requirements were recorded at the time of teduglutide initiation. The duration of teduglutide use was calculated. Teduglutide dose, dose adjustment history, reason for dose adjustment, and therapy complications were noted. Results 9 patients were included (5 male/4 female). Median age was 57 years (IQR 32). Median length of remaining small bowel was 60cm (IQR 27.5) and median duration of SBS was 8 years (IQR 9.83). Median BMI at teduglutide initiation was 18.66 (IQR 4.29) with a median duration of PN of 4.5 years (IQR 9.42) and median PN kcal/day of 971.43 (IQR 518). The median duration of teduglutide was 1.1 years (IQR 3.4). 4 patients (44%) had a teduglutide dose change. 2 patients had dose interval extended from daily to every other day to reduce injection burden. 1 patient developed obstructive symptoms on daily dosing, which resolved when the dose interval was extended to every other day. 1 patient had to stop therapy due to a small bowel obstruction requiring hospitalization. 8 patients (88%) were able to wean or stop PN/IVF with addition of teduglutide. 1 patient had to restart PN despite teduglutide therapy. Table 1. Discussion Teduglutide is effective in Crohn’s disease patients and facilitates weaning of PN and IVF requirements. Most patients tolerate the recommended dose with daily injections, but the dose interval can be extended to every other day to reduce obstructive symptoms or reduce the injection burden without affecting ability to wean PN/IVF. References

N30 Experience of living with intestinal failure: a systematic review of qualitative studies

Abstract Background Intestinal failure (IF) affects about 2000 people with Crohn’s disease (CD) in the UK. It is a result of the most severe phenotype of CD where an individual can no longer obtain sufficient nutrients from their gut to sustain life without supplementation in the form of parenteral nutrition (PN) or fluids intravenously and most have a stoma. Many cannot tolerate any food and very little drink by mouth. Such individuals usually need a permanent central venous catheter and must have an infusion of PN overnight, all or most nights in the week, often for 10–12 h at the time. Complications such as infection or thrombosis of the central line are a constant risk. This treatment must often continue for life. This systematic review aimed to explore the experience of people living with IF and the impact of the condition on their daily lives. Methods The following databases were searched in July 2019: MEDLINE, PubMed, PsychINFO, Web of Science and Global Health Scopus. Search terms included ‘intestinal failure’, ‘short bowel syndrome’, ‘quality of life’ (QoL) and terms relating to psychosocial functioning. English language articles were retrieved and screened by one reviewer at title and abstract, ratified by a second reviewer. The resulting articles selected at abstract were screened at full text by 3 reviewers. Results Eight papers, based on 7 studies, were included with a total of 97 participants: 36 male, 61 female. The age range of adults was 28–83. One study was conducted in children, with age range of 7–17. In 5 studies, all participants were on HPN. In 2 studies, 4/6 and 7/10 participants were on HPN respectively. There was one overarching theme: ‘Complications and challenges of living with IF’, with three specific themes that reflect the patients’ experience: (1) ‘Eating for survival’ encompasses the perpetual need to eat in order to make up for the large quantities of nutrients lost due to malabsorption (2) ‘Life with HPN: nutritional safety net at a price’ describes relief from the pressure to eat for survival but with drawbacks such as restrictions on social activities and risk of catheter line infections. (3) ‘Benefits and pitfalls of having a stoma’ relates to benefits of having a stoma, such as reduced frequency of toilet visits, and the accompanying inconvenience of leaks, high output and negative body image. Conclusion Living with IF has many challenges. Patients struggle with retaining enough nutrients and the physical and technical difficulties with having HPN and/or a stoma. The psychosocial well-being in these patients is affected by these challenges, as a result. Overall, QoL is poor and currently very little is being done to improve this.

Postoperative Nausea and Vomiting: Risks, Prophylaxis, Non-Drug Alternative Methods

Nausea and vomiting are among the most common complaints in the postoperative period. The type of surgical technique and the site of intervention, as well as the anesthetic drugs and methods directly contribute to the rates of postoperative nausea and vomiting (PONV). One of the most important factors affecting the frequency of postoperative nausea and vomiting is the anesthetic drugs and methods used. Many antiemetic drugs are used to prevent postoperative nausea and vomiting. With the use of these drugs, side effects especially such as delayed recovery from anesthesia, dry mouth, undesirable changes in blood pressure and the occurrence of extrapyramidal symptoms are seen. Several antiemetic drugs are commonly used for the treatment of postoperative nausea and vomiting; including scopolamine, chlorpromazine, diphenhydramine, metoclopramide, promethazine, and ondansetron. Low-dose haloperidol and metoclopramide are effective in opioid-induced nausea and vomiting. Dexamethasone reduces the incidence of postoperative nausea in the first 6 hours after surgery. Oral intake starts in patients with severe vomiting parenteral fluid and electrolyte treatment is required. Sometimes provide may need gastric decompression with nasogastric tube. Parenteral fluid and electrolyte treatment and in severe cases gastric decompression with a nasogastric tube may be necessary. Alternative medicine such as acupuncture and acupressure can help prevent or reduce postoperative nausea and vomiting. The aim of this review is to examine the medical therapies and drug-free methods used for the treatment of PONV in the light of the literatüre

Low prevalence of clinical decision support to calculate caloric and fluid intake for infants in the neonatal intensive care unit

BackgroundClinical decision support (CDS) improves nutrition delivery for infants in the neonatal intensive care unit (NICU), however, the prevalence of CDS to support nutrition is unknown.MethodsOnline surveys, with telephone and email validation of responses, were administered to NICU clinicians in the Children’s Hospital Neonatal Consortium (CHNC). We determined and compared the availability of CDS to calculate calories and fluid received in the prior 24 h, stratified by enteral and parenteral intake, using McNemar’s test.ResultsClinicians at all 34 CHNC hospitals responded with 98 of 108 (91%) surveys completed. NICUs have considerably less CDS to calculate enteral calories received than enteral fluid received (32% vs. 82%, p < 0.001) and less CDS to calculate parenteral calories received than parenteral fluid received (29% vs. 82%, p < 0.001).DiscussionMost CHNC NICUs are unable to reliably and consistently monitor caloric intake delivered to critically ill infants at risk for growth failure.

Management of Dehydration in Patients Suffering Swallowing Difficulties.

Swallowing difficulties, also called dysphagia, can have various causes and may occur at many points in the swallowing process. The treatment and rehabilitation of dysphagia represent a major interdisciplinary and multiprofessional challenge. In dysphagic patients, dehydration is frequent and often accelerated as a result of limited fluid intake. This condition results from loss of water from the intracellular space, disturbing the normal levels of electrolytes and fluid interfering with metabolic processes and body functions. Dehydration is associated with increased morbidity and mortality rates. Dysphagic patients at risk of dehydration thus require close monitoring of their hydration state, and existing imbalances should be addressed quickly. This review gives an overview on dehydration, as well as its pathophysiology, risk factors, and clinical signs/symptoms in general. Available management strategies of dehydration are presented for oral, enteral, and parenteral fluid replacement.

Intestinal Rehabilitation in Short Bowel Syndrome and Chronic Intestinal Failure

Patients with severely orally decompensated malsaborption due to surgical rescetion suffer from short bowel syndrome (SBS). The resultant decrease in intestinal surface area after rescetion of parts of the intestines leads to chronic functional intestinal insufficiency or even complete failure (cIF) which requires parenteral fluid and nutrient restoration for establishment of metabolc stability. Since the introduction of glucagon-like peptide (GLP)-2 analogues such as teduglutide functional rehabilitation of the remaining gastrointestinal tract has become a causal treatment option. Teduglutide functionally and effectively enhances intestinal absorption of fluid as well micro- and macronutrients allowing a reduction of parenteral nutrition and/or volume with even complete weaning off in some patients. This results increased metabolic stability, oral autonomy, quality of life and putatively less complications.

50 Years Ago in TheJournal ofPediatrics: A Unified Guide to Parenteral Fluid Therapy. I. Maintenance Requirements and Repair of Dehydration

50 Years Ago in TheJournal ofPediatrics: A Unified Guide to Parenteral Fluid Therapy. I. Maintenance Requirements and Repair of Dehydration

Concurrent retroperitoneal, mediastinal, cervical and subcutaneous emphysema secondary to iatrogenic sigmoid colon perforation

A 76-year-old woman patient without a remarkable medical history underwent colonoscopy because of diarrhoea and black stool for 1 month. Colonoscopy was aborted at 23 cm from the anal verge...

Early surgical management in patients with burns

Burns can be life threatening injuries with asignificant risk of lifelong consequences. Severity of thermal injury is assessed using the combination of six essential factors (mechanism of injury, presence of inhalation trauma, extent of the burn area, depth of the burn, its location, patientsage and co-morbidities) which also represent the determinants of referral to one of the three specialized burn centers in the Czech Republic. Early management consists of ABC Trauma Life Support (adequate oxygenation and ventilation, avenous access, parenteral fluid administration), pain relief, and sterile covering of the burn areas.

OR17-6 Parenteral Cephalosporins and Glucose During the Neonatal Period Are Associated with Pediatric Type 1 Diabetes Development

Background: The incidence of both the survival of premature infants and type 1 diabetes (T1D) is rising worldwide. The pathophysiology of T1D depends on the differentiation of cellular and humoral immune systems recognition of the self, which occurs during the neonatal period and is influenced by environmental exposures. Aim: To assess the association between nutritional, antibiotic and parenteral exposures during the neonatal period and the development of pediatric T1D. Methods: a multicenter, paired case-control study. Preterm subjects who were born between 1990-2013, and developed T1D before the age of 18 years (T1D group), were paired with subjects who didn't develop TID (Control group) at a ratio of 1:3 by: gender, gestational age (GA), month of birth and birth medical center . This preterm population is a model of a neonatal population with strictly meticulous follow up data available in all medical centers in Israel. Data retrieved from charts included maternal history, delivery method, ethnic origin, weight for GA, NICU length of hospitalization, medications, parenteral fluid types, feeding modes and their timing. Univariate and multivariate analysis via Generalized Estimating Equations (GEE) using a binary logistic regression model were performed to evaluate the association between T1D and the assessed exposures. Results: T1D group included 52 subjects, 26 males, median GA 35 (26-36), mean BW 2307.6±534.5. Control group included 133 subjects, 69 males. median GA 35 (27-36), mean BW 2094.5±484.1. In univariate analysis, the odds ratio (OR) for T1D increased with each extra 100 grams in BW (OR 1.13, 95%CI 1.057-1.206, p < 0.001), later day of parenteral glucose initiation (OR 1.61, 95%CI 1.05-2.48, p 0.03), and parenteral cephalosporines initiated beyond the first week of life (OR 3.25, 95%CI 1.504-7.04, p 0.003). Treatment with narrow spectrum beta-lactam antibiotics during the first week of life was associated with lower risk for T1D development (OR 0.23, 95%CI 0.12-0.47, p < 0.001). Multivariate analysis revealed significant association between both treatment with cephalosporins beyond the first week of life and later day of parenteral glucose initiation and the development of pediatric T1D (OR 6.49, 95%CI 1.54-27.44, p 0.011 and OR 1.61, 95%CI 1.05-2.48, p 0.002, respectively). No association with feeding modality (oral/nasogastric), timing and type of feeding (breast or bottle) was found. Conclusions: This is the first report indicating a significant association between parenteral exposure and timing of variable antibiotic treatments and glucose solution administration during the neonatal period with development of T1D. This report indicates the need for a larger study to conclude clinical implications of management and exposure to these substances during the neonatal period and its relevance to the neonatal microbiome.

Does the addition of dextrose to parenteral fluid therapy during labor decrease time to delivery or risk of cesarean delivery compared with non-dextrose-containing parenteral fluid therapy?

Memorial University Medical Center FMRP, Savannah, GA The authors declare no conflicts of interest.

Design of a liquid nano-sized drug delivery system with enhanced solubility of rivaroxaban for venous thromboembolism management in paediatric patients and emergency cases

The increasing incidence of venous thromboembolism (VTE) in paediatric population has stimulated the development of liquid anticoagulant formulations. Thus our goal is to formulate a liquid formulation of poorly-water soluble anticoagulant, rivaroxaban (RIVA), for paediatric use and to assess the possibility of its intravenous administration in emergencies. Self-nanoemulsifying drug delivery systems (SNEDDSs) were developed and characterized. SNEDDS constituents were estimated from the saturated solubility study followed by plotting the corresponding ternary phase diagrams to determine the best self-emulsified systems. Thermodynamic stability, emulsification, dispersibility, robustness to dilution tests, in vitro dissolution, particle size, and zeta potential were executed to optimize the formulations. The optimized formulation, that composed of Capryol 90:Tween 20:PEG 300 (5:45:50), increased RIVA solubility (285.7-fold than water), it formed nanoemulsion with a particle size of 16.15 nm, PDI of 0.25 and zeta potential of −21.8. It released 100.83 ± 2.78% of RIVA after 5 min. SNEDDS was robust to dilution with oral and parenteral fluids and showed safety to human RBCs. SNEDDS showed enhanced bioavailability after oral and intravenous administration than the oral drug suspension (by 1.25 and 1.26-fold, respectively). Moreover, it exhibited enhanced anticoagulant efficacy in the prevention and treatment of carrageenan-induced thrombosis rat model.

Aluminium release by coated and uncoated fluid-warming devices.

The use of fluid-warming systems is recommended for infusion rates >500ml.h-1 to avoid peri-operative hypothermia. Some fluid-warming devices use disposable aluminium-heated plates for heat transfer, but there is no protective coating to separate the fluid from the heated aluminium surface. It is unknown if this could promote release of aluminium into infusion fluids. We investigated a coated (Fluido compact) and an uncoated (enFlow) fluid-warming device using normal saline or balanced electrolyte solution as infusion fluids, pumped through the heated disposables at flow rates of 2, 4 and 8ml.min-1 for 60min each. Aluminium concentrations in the fluid samples were analysed using graphite furnace atomic absorption spectrometry. With saline the coated and uncoated devices yielded aluminium concentrations below the level of quantification (<128μg.l-1 ). Similarly, balanced electrolyte solution in the coated device yielded aluminium concentrations <128μg.l-1 . However, balanced electrolyte solution in the uncoated device yielded aluminium concentrations of up to 6794 (3465-8002 [1868-7421]) μg.l-1 . Repeating this last study at a flow rate of 2ml.min-1 resulted in quite high aluminium concentrations when the uncoated device was not heated (~1000μg.l-1 ) and higher concentrations after the device was heated. We conclude that using uncoated aluminium plates in fluid-warming systems can lead to a risk of administering potentially harmful concentrations of aluminium when balanced crystalloid solutions are used. The mechanism is unclear, but heat is in part involved. Coating for aluminium within medical devices in direct contact with infusion fluids should be recommended.

Pediatric Principles for Pediatric Surgeons - Part I Parenteral Maintenance Fluid Therapy

Pediatric Principles for Pediatric Surgeons - Part I Parenteral Maintenance Fluid Therapy

Clinical Application Analysis of Tunneled-PICC

Peripherally inserted central catheters (PICCs) play a critical role in the infusion of parenteral nutrition, chemotherapy and intravenous fluids for the increased safety and efficacy for long-term use. However, during the insertion and management of PICCs, there are still some PICC-related complications need to be reduced as much as possible for both operators and researchers. In this case, the tunneled-PICC provides a new “a nedesl subcutaneous route” technology for PICC application. This article reviews the principle and characteristics of tunneled-PICC. Tunneled PICCs, seems to be a safe option and easy to perform as an alternative to standard placement for its advantages of the better exit location, reduced incidences of thrombosis and infection, reduced the shift rate as well as extended retention time. However, more research on the standard tunneling technique and large-scale clinical applications need to be proposed.

Endometrial tumour as a cause of mechanical bowel obstruction – a case report

Endometriosis is a disease that involves the presence of physiologically active uterine tissue beyond the uterus. It is classified as a non-malignant disease that typically develops within the reproductive system: in the ovaries, fallopian tubes, or uterine ligaments. These changes tend to occur also beyond the reproductive structures, usually within the digestive system, where the most common sites are the peritoneum, postsurgical scars or umbilicus. Moreover, the disease can occur in the intestine, usually in the large bowel, and particularly in the caecum. The literature reports that endometriosis may affect even 10% of women of child-bearing age. The authors present a case of a patient admitted to the surgical ward due to mechanical bowel obstruction. Intraoperatively, an endophytic tumour, completely occluding the ileum, was found. Due to its location, i.e. approximately 15 cm from the Bauhin’s valve, it was resected together with the ascending colon and the right half of the transverse colon. Based on the morphology of the lesion and a positive family history, cancer was thought to be the most probable cause of the patient’s symptoms. The result of the histopathological examination did not confirm this, however. The specimen showed endometriosis. On the day of surgery, the patient was administered antibiotics, total parenteral nutrition and essential fluid supplementation. The wound healed normally, and abdominal pain did not return as diet was being extended. The patient was discharged on the 6th day after the operation with recommended follow-up in a surgical clinic.

Consolidating tender coconuts as a source of safe natural large volume parenteral fluid under regulatory oversight

Purpose: To investigate reported absence of hyperkalema episodes due to high [K+] and the absence of hypersensitivity reactions due to tracer proteins in tender coconut water following IV infusion. To establish tender coconuts as a prospective natural large volume parenteral ‘dosage unit’. Method: Fluid from nuts identified with ‘Rosette Alba’ sign to be of 5-6 months maturity were evaluated. Important tests performed were the shelf life, direct tapping of the fluid, hemolysis and the molecular mass studies of tracer proteins by SDS PAGE gel electrophoresis. Results: Calculations indicate that [K+] dropped by 1/6th -1/9th in blood following IV infusion of fluid. Proteins are in the low molecular mass range of 10,000 Da, hence below potent antigen range. Conclusion: Drastic dilution of [K+] and the presence of hyperkalemia antidotal ingredients in the fluid and the low molecular mass of the proteins found in low concentration of 0.2 % and IV administration bypassing immunogenic subcutaneous route could be the possible reasons for absence of hyperkalemia and hypersensitivity reactions. The study did not show any dosage parameter that adversely restrains IV infusion potential of tender coconut water.