Parenteral Fluid Research Articles

Peri‐operative iv fluids in diabetic patients – don’t forget the salt

Peri‐operative iv fluids in diabetic patients – don’t forget the salt

Pleural effusion due to intra‐abdominal extravasation of parenteral nutrition

An 8-week-old preterm boy experienced respiratory deterioration due to unilateral pleural effusion. Intra-abdominal extravasation of parenteral fluid with leakage into the pleural cavity was suspected based on biochemical analysis of the effluent. Perforation of the central venous catheter in the peritoneal cavity was subsequently confirmed by contrast roentgenography. As in peritoneal dialysis and hepatic hydrothorax, pleuroperitoneal communication needs to be considered in patients exhibiting pleural effusion with a central venous line below the diaphragm.

Development and Evaluation of Lorazepam Microemulsions for Parenteral Delivery

The objective of this investigation was to develop lorazepam (LZM) microemulsions as an alternative to the conventional cosolvent based formulation. Solubility of LZM in various oils and Tween 80 was determined. The ternary diagram was plotted to identify area of microemulsion existence and a suitable composition was identified to achieve desired LZM concentration. The LZM microemulsions were evaluated for compatibility with parenteral fluids, globule size, in vitro hemolysis and stability of LZM. Capmul MCM demonstrated highest solubilizing potential for LZM and was used as an oily phase. LZM microemulsions were compatible with parenteral dilution fluids and exhibited mean globule size less than 200 nm. The in vitro hemolysis studies indicated that microemulsions were well tolerated by erythrocytes. The LZM microemulsions containing amino acids exhibited good physical and chemical stability when subjected to refrigeration for 6 months.

Intravenous Therapy: Hazards, Complications and Their Prevention

In this review article, the local and systemic complications of intravenous therapy are highlighted and their preventive measures are discussed. Intravenous therapy exposes the patient to numerous hazards and many of them are avoidable, if the health care provider understands the risks involved and acts appropriately and timely to prevent their occurrence. Local complications such as thrombophlebitis and infiltration occur more commonly than systemic complications such as septicaemia, air embolism and circulatory overload. The nurse plays a key role in achieving safe and effective fluid therapy. In this regard, the attending nurse must visit the patient frequently, checking the flow rate, the amount of solution remaining and the site of infusion for signs of infiltration. Breaks in aseptic techniques, faulty handling of parenteral fluid containers, failure to discard out-dated intravenous solutions and tubings contribute to occurrence of intravenous-associated sepsis. Improper technique and lack of pharmaceutical knowledge when adding drugs into intravenous fluids contribute to incompatibilities which substantially increase the particulate matter in infusions as well as increase the risk of contamination. Keywords: Intravenous therapy, infusions, hazards, complications.Nigerian Hospital Practice Vol. 2 (2) 2008: pp. 27-32

Hyponatremia at autopsy: an analysis of etiologic mechanisms and their possible significance

While electrolyte measurements after death may be confounded by a number of variables, vitreous humor sodium tends to remain stable for some time, enabling correlation between ante- and postmortem levels. Review of natural and unnatural causes of reduced vitreous humor sodium levels at autopsy was undertaken to demonstrate the range of diseases that may result in this finding. Natural diseases affecting the vasopressin-renin-angiotensin axis may cause reduction in sodium levels with associated hypovolemia, euvolemia, and hypervolemia. Low sodium measurements may also occur with redistribution of water, and artefactually when there are underlying lipid and protein disorders. Unnatural causes of hyponatremia at autopsy include water intoxication from psychogenic polydipsia, environmental polydipsia, ingestion of dilute infant formulas, beer potomania, endurance exercise, fresh water immersion (including water births) and iatrogenic causes including drug and parenteral fluid administration, and surgical irrigation. A knowledge of the range of conditions that may result in lowered postmortem sodium levels will help to exclude or confirm certain diseases at autopsy. In addition, significant vitreous hyponatremia may be a useful finding to help clarify mechanisms of unnatural deaths.

Urine sodium composition in ambulatory healthy children: hypotonic or isotonic?

A controversy exists in the literature as to the most appropriate sodium concentration for maintenance parenteral fluids. The purpose of this study was to evaluate urinary sodium composition in otherwise healthy children in order to help determine if 0.9% sodium chloride (NaCl) would be an appropriate parenteral fluid. The composition of urinary sodium was evaluated over 24 h in 100 otherwise healthy children aged 3-18 years referred to a pediatric nephrology outpatient clinic for hematuria or proteinuria. The average urine sodium concentration was 158+/-59 mEq/l, similar to that of 0.9% NaCl (154 mEq/l). Urine sodium excretion was 2.9+/-1.3 mEq/kg per 24 hours, and urine flow rate was 0.9+/-0.4 ml/kg per hour. It was concluded that healthy children generate free water via the excretion ofa hypertonic urine. It is unlikely that 0.9% NaCl would result in hypernatremia when administered in parenteral fluids.

Retrospective study assessing efficacy of treatment of large colonic impactions

Cases with a history of colic due to a large colonic impaction were recruited retrospectively to assess the treatment efficacy and complications of oral and parenteral fluid therapy regimes for correction of primary large colon impactions. Oral isotonic fluids had been administered at varying intervals following initial treatment with magnesium sulphate and water. There was no significant difference in complication rates between groups. Considering complication rates with impaction clearance, hourly administration of oral fluids appears to be the most appropriate treatment regime of those investigated.

Anticipation of distress after discontinuation of mechanical ventilation in the ICU at the end of life

BackgroundA considerable number of patients admitted to the intensive care unit (ICU) die following withdrawal of mechanical ventilation. After discontinuation of ventilation without proper preparation, excessive respiratory secretion is common, resulting in a ‘death rattle’. Post-extubation stridor can give rise to the relatives’ perception that the patient is choking and suffering. Existing protocols lack adequate anticipatory preparation to respond to all distressing symptoms.MethodsWe analyzed existing treatment strategies in distressing symptoms after discontinuation of mechanical ventilation.ConclusionThe actual period of discontinuation of mechanical ventilation can be very short, but thoughtful anticipation of distressing symptoms takes time. There is an ethical responsibility to anticipate and treat (iatrogenic) symptoms such as pain, dyspnea-associated respiratory distress, anxiety, delirium, post-extubation stridor, and excessive broncho-pulmonary secretions. This makes withdrawal of mechanical ventilation in ICU patients a thoughtful process, taking palliative actions instead of fast terminal actions. We developed a flowchart covering all possible distressing symptoms that can occur after withdrawal of mechanical ventilation and extubation. We recommend a two-phase process. Six hours before extubation, enteral feeding should be stopped and parenteral fluids reduced, overhydrated patients should be dehydrated with furosemide, administration of sedatives (for distress) and opioids (for pain and/or dyspnea) should be continued or started and methylprednisolone should be given in anticipation of stridor after extubation. Thirty minutes before extubation, Butylscopolamine should be given and methylprednisolone repeated. After this the patient should be extubated to secure a dying process as natural as possible with the lowest burden due to distress.

Can the Routine Administration of Hypotonic Parenteral Fluids Be Justified?

Can the Routine Administration of Hypotonic Parenteral Fluids Be Justified?

Hospital Resources for Pandemic Influenza

To the Editor: In their November 2007 article, Pandemic Influenza and Hospital Resources, Nap et al. evaluated hospital resources for pandemic influenza in the northern part of the Netherlands (1). Their results can be compared with those that I have described for the combined suburban communities of Roswell and Alpharetta, Georgia, USA (2). The Netherlands evaluation assumed that antiviral drugs will be available and will reduce hospitalizations by 50% and deaths by 30%. In view of the uncertainty of effective antiviral drugs and timeliness of vaccines, I did not estimate their effects. Nevertheless, several issues warrant comparison. The plan for the Netherlands has no provisions for urgent care, i.e., parenteral fluids or antimicrobial drugs that are administered to ambulatory patients who are not hospitalized. Nap et al. may not perceive a need for enough beds to handle surge capacity. Allowing for 30% of beds to be used for patients with conditions other than influenza, they report a maximum availability of 232 beds per 100,000 population for pandemic influenza patients, and they estimate use of 72 beds per 100,000 in the pandemic model. In contrast, a maximum of 47 beds per 100,000 are available in Roswell/Alpharetta. Availability of beds in intensive care units, however, is identical for both regions, at 8 beds per 100,000 population. The Netherlands plan calls for intensified treatment evaluation in 48 hours to withdraw care from patients who have little chance for recovery. Because most patients can be expected to have pneumonia and 2-organ failure (on average), a 50% mortality rate can be expected. In US hospitals, withdrawing care is difficult, even if mortality rates are expected to be 75% or 90% during acute illness with organ failure. The pandemic influenza resource evaluation from the northern part of the Netherlands provides a useful contrast with at least 1 US hospital. The dramatic difference in bed availability highlights the potential challenges involved in local planning. The surge capacity limits in Roswell/Alpharetta led us to consider an alternative infusion center to provide care during an influenza pandemic.

Chronic biochemical cholestasis in patients receiving home parenteral nutrition: prevalence and predisposing factors

Chronic biochemical cholestasis has been shown to be associated with a fivefold increase in histologically advanced liver disease in patients receiving home parenteral nutrition. To investigate prevalence of chronic biochemical cholestasis in home parenteral nutrition patients and examine factors influencing its occurrence. Records of all patients receiving home parenteral nutrition for >6 months treated at a single centre were reviewed and plasma biochemistry recorded. Logistic regression analysis was employed to identify factors associated with prevalence of chronic biochemical cholestasis. Records of 113 patients were reviewed. The point prevalence of chronic biochemical cholestasis was 24%, increasing to 28% if patients receiving parenteral fluid and electrolytes only were excluded. In multivariate analysis, presence of colon in continuity was associated with a significantly lower prevalence of chronic biochemical cholestasis, while total parenteral calorie intake was associated with a higher prevalence of chronic biochemical cholestasis. No association was seen between small intestinal lengths or between parenteral lipid intake and chronic biochemical cholestasis in multivariate analysis. Chronic biochemical cholestasis is common in patients receiving home parenteral nutrition. High parenteral calorie intake and lack of a colon in continuity with small intestine are independently associated with an increased risk of chronic biochemical cholestasis.

Successful Treatment of Capture Myopathy in Three Wild Greater Sandhill Cranes (Grus Canadensis Tabida)

Two adult and 1 juvenile free-flying greater sandhill cranes (Grus canadensis tabida) were diagnosed with capture myopathy after alpha-chloralose baiting and physical capture during a banding and feeding ecologic study. Blood samples were collected for serum biochemical analysis at the time of capture for the 2 adults, and at 24 hours postcapture, at various intervals during treatment, and at the time of release for all 3 birds. Concentrations of creatine kinase, aspartate transaminase, and lactate dehydrogenase were high within 1 hour of capture and peaked approximately 3 days after capture. By days 10-17 after capture, creatine kinase and lactate dehydrogenase concentrations both decreased to within the reference range measured for cranes at capture, but aspartate transaminase concentrations remained 2-5 times higher than the measured reference range. Treatment consisted of corticosteroids, selenium/vitamin E, parenteral fluids, and gavage feedings. Physical therapy consisted of assisting the cranes to stand and walk 2-8 times a day, massaging leg muscles, and moving limbs manually through the range of motion. The adults were released when they were able to stand up independently and were pacing in the pen. The juvenile was released 12 hours after it was able to stand independently but was returned to the pen when it fell and could not rise. It was treated supportively for an additional 3 days and then successfully released. Both adult cranes were observed on their territories with their original mates after release and returned to their territories for the subsequent 8 years, raising chicks most years. After release, the juvenile was observed in a flock of cranes near its natal territory for the next 2 days.

Successful outcome after intravenous gasoline injection

Gasoline, ingested intentionally or accidentally, is toxic. The majority of reported cases of gasoline intoxication involve oral ingestion or inhalation. Data are scarce on complications and outcomes following hydrocarbon poisoning by intravenous injection. Following a suicide attempt by intravenous self-injection of 10 ml of gasoline, a 26-year-old medical student was admitted to the intensive care unit (ICU) with hemoptysis, symptoms of acute respiratory failure, chest pain, and severe abdominal cramps. Gas exchange was severely impaired and a chest x-ray indicated chemical pneumonitis. Initial treatment consisted of mechanical ventilation, supportive hyperventilation, administration of nitrogen oxide (NO), and prednisone. Unfortunately, the patient developed multi-organ dysfunction syndrome (MODS) complicated by life-threatening severe vasoplegia within 24 hours after gasoline injection. High doses of vasopressors along with massive amounts of parenteral fluids were necessary. Despite fluid replacement, renal function worsened and required hemofiltration on 5 sequential days. After 12 days of intensive care management, the patient recovered completely and was discharged to a psychiatric care facility. Intravenous gasoline injection causes major injury to the lungs, the organ bearing the first capillary bed encountered. Treatment of gasoline poisoning is symptomatic because no specific antidote is available. Early and aggressive supportive care may be conducive to a favorable outcome with minimal residual pulmonary sequelae.

Hyperbaric Oxygen Therapy In Calcium Chloride Extravasation Injuries: An Experimental Animal Study

Aim: Parenteral alimentation fluids containing calcium are widely used to treat sick neonates and children. Extravasation of calcium presents with local swelling, erythema, blistering and progresses to skin necrosis and skin loss. Several treatment modalities including hyperbaric oxygen therapy have been used for extravasation injuries. The role of hyperbaric oxygen therapy on extravasation injuries was investigated in this study by an experimental rat model based on facilitating effect of hyperbaric oxygen on wound healing. Methods: After shaving the dorsal side of 16 female Wistar rats, 1 ml of calcium chloride were injected intradermally. The rats were divided into two groups as control and hyperbaric oxygen. The control group received no treatment while the hyperbaric oxygen group received hyperbaric oxygen therapy for 7 days after injection. At the end of seventh day skin biopsy including all necrotic tissue and surrounding healthy tissue were obtained and histopathologic examination was performed for control and hyperbaric oxygen groups. Results: Hyperbaric oxygen group showed a statistically significant preservation of epidermis and dermis with minimal necrosing findings of skin injury. Conclusion: Although further research is required to develop management guidelines, we concluded that in this experimental study, hyperbaric oxygen therapy prevents dermal injury and may decrease the morbidity associated with calcium chloride extravasation injury.

Complete recovery from acute encephalopathy of late‐onset ornithine transcarbamylase deficiency in a 3‐year‐old boy

Ornithine transcarbamylase deficiency is the commonest urea cycle disorder which is transmitted in X-linked inheritance. It is mainly characterized in males by acute encephalopathy and hyperammonaemia with fatal outcomes in both classical neonatal and late-onset types. We report a 3-year-old healthy Hong Kong Chinese boy who presented with acute encephalopathy and coma after three days of gastroenteritis. He had no focal neurological deficit and brain CT imaging was normal. His plasma ammonia (54 micromol/L) and glutamine (747 micromol/L) concentrations were normal. The only biochemical abnormalities detected were marked orotic aciduria (700 micromol/mmol creatinine) and elevated urinary uracil. He regained consciousness spontaneously after three days under intensive care with parenteral fluid therapy. He recovered completely without any neurological deficits. Five months after discharge, urinary uracil concentration remained elevated despite normalized orotic acid concentration. Finally, ornithine transcarbamylase deficiency was diagnosed by DNA analysis. A missense mutation of arginine-to-glutamine substitution on amino acid 277 (p.R277Q) was revealed to be a late-onset mutant. Our case strengthens the argument that in any child with coma or acute encephalopathy of undetermined cause, genetic analysis of the OTC gene and the measurement of urinary uracil concentration remain the most reliable indicators of late-onset OTCD during acute and even quiescent phases. Existing neonatal screening programmes for inheritable metabolic disorders fail to detect late-onset variants. Therefore, a high clinical suspicion is a key to correct and timely diagnosis, especially in those patients with atypical presentations.

Drug utilization study in a neonatology unit of a tertiary care hospital in eastern India

To evaluate the drug prescribing trends in a neonatal intensive care unit (NICU) of a tertiary care hospital in eastern India. The study was a prospective study that spanned for a period of 6 months from March 2005 to August 2005. Prescriptions and patient records were reviewed and analyzed using the World Health Organization (WHO) indicators for drug utilization studies. Rationality of drug usage was also evaluated by analyzing the drug prescriptions. A total of 176 neonates were admitted and 21 deaths were noted. The total number of drugs prescribed were 849. The average number of drugs per prescription was 4.8. The intravenous route (92.1%) was the commonest route of drug administration. 79.7% of the drugs were prescribed in generics. 30.2% of the total drugs prescribed were antimicrobials. It was noted that 88.6% of the drugs prescribed were in compliance with the National list of Essential Medicines 2003. The common diseases for which the neonates sought admission in the NICU were suspected septicaemia, birth asphyxia, neonatal jaundice and major congenital malformations. As antibiotics were the most frequently used drugs, their usage was analyzed in all cases. It was found to be rational in 84% of suspected septicaemia cases, as the provisional diagnosis on admission was confirmed with subsequent investigations thereby justifying appropriate antibiotic therapy. The diagnosis and treatment of other cases like neonatal jaundice, birth asphyxia, congenital malformations and electrolyte imbalance were rational and treatment was given as per treatment guidelines. Irrational usage of vitamins, nutritional supplements and parenteral fluids was not noted. The absence of the latest National essential list of medicines at the neonatology unit was noted. Secondly an antibiotic usage policy for the unit depending on the local microbial sensitivity pattern should have been in place.

Prognostic Factors in Cats with Chronic Kidney Disease

Chronic kidney disease (CKD) is a common cause of morbidity and mortality in cats. Some baseline variables are associated with shorter survival times in cats with CKD. Client-owned cats. Cats with CKD with initial plasma creatinine concentration > or =2.0 mg/dL and urine specific gravity (USG) < or = 1.025 were recruited into a prospective clinical trial that compared benazepril with a placebo. We describe baseline variables in 190 cats and their influence on renal survival time in the placebo group (95 cats), which was followed for up to 1,097 days. Renal survival time was defined as the time from initiation of therapy to the need for parenteral fluid therapy, euthanasia, or death related to renal failure. Of the 95 cats treated with a placebo, 58 were censored and 37 reached the renal survival end point (died, n = 0; euthanized, n = 17; parenteral fluids, n = 12; parenteral fluids followed by euthanasia, n = 8). Increased plasma creatinine concentration, increased urine protein-to-creatinine ratio (UPC), and increased blood leukocyte count were significantly (P < .01) associated with a shorter renal survival time and were independent risk factors. Increased concentrations of plasma phosphate or urea, and lower blood hemoglobin concentration or hematocrit were significantly (P < .01) associated with a shorter renal survival time and were dependent risk factors, because they also were significantly (P < .01) correlated with plasma creatinine concentration at baseline. Several variables were significantly associated with a shorter renal survival time in cats with CKD.

A Rare Case of Metastasis-Induced Acute Pancreatitis in a Patient with Small Cell Carcinoma of the Lung

Acute pancreatitis caused by metastatic carcinoma to the pancreas is uncommon. We report a rare case of metastasis-induced acute pancreatitis with small cell carcinoma of the lung. A 49 year old female, smoker, with history of small cell carcinoma with limited disease to the right lung, was admitted with constant epigastric abdominal pain radiating to the back for 4 days. The patient denied any fever, chills, or nausea. One month earlier she had completed 1 cycle of chemotherapy with cisplatin and etoposide. She denied any history of heavy alcohol use or hypertriglyceridemia. On admission, the patient was afebrile and in mild distress. Temperature was 98.1°F, blood pressure was 127/76 mm Hg, pulse was 78/minute, and respiration rate was 20/min. Physical examination revealed mild bibasilar crackles. The bowel sounds were normoactive. Mild tenderness to palpation was noted over the mid-epigastric region without rebound tenderness, guarding, or palpable mass. Laboratory evaluation revealed a lipase of 2206 IU/dL [10–45 IU/dL], white blood cell count of 32.3 × 103/μL [4.8–11.0 × 103/μL], and hematocrit of 29.1%[ 37–47%]. Liver tests and creatinine were all in normal range. CT scan of the abdomen revealed a 2.3 × 2.2 cm hypodense mass in the head of the pancreas without associated pancreatic or common bile duct dilatation. In addition, multiple small liver lesions and a moderate right pleural effusion were noted. To clarify the lesion seen on the pancreas, EUS-guided FNA of the mass in the pancreas was performed. The cytology revealed malignant cells consistent with small cell carcinoma of the lung. The patient was managed conservatively with dietary restriction, narcotics for pain control, and parenteral fluids. Although her pain improved, serum lipase was persistently elevated up to 1000 IU/L. Subsequently, she experienced increasing shortness of breath. She elected for comfort care and died a few days later. Metastasis-induced acute pancreatitis is rare and can occur as the initial presenting manifestation of a carcinoma or late in the course of the disease. Mechanisms of acute pancreatitis in our patient is unclear but may include mass effect on the pancreas and/or mechanical pancreatic duct obstruction. Chemotherapy, surgery and endoscopic intrapancreatic stenting may be considered. However, the overall prognosis, as seen in our case, is extremely poor.

Hospital-acquired hyponatremia—why are hypotonic parenteral fluids still being used?

Hospital-acquired hyponatremia can be lethal. There have been multiple reports of death or permanent neurological impairment in both children and adults. The main factor contributing to the development of hospital-acquired hyponatremia is routine use of hypotonic fluids in patients in whom the excretion of free water, which is retained in response to excess arginine vasopressin (AVP), might be impaired. The practice of administering hypotonic parental fluids was established over 50 years ago, before recognition of the fact that there are numerous potential stimuli for AVP production in most hospitalized patients. Virtually all neurological morbidity resulting from hospital-acquired hyponatremia has been associated with administration of hypotonic fluids. Multiple prospective studies have shown that 0.9% NaCl is effective prophylaxis against hyponatremia. There is not a single report in the literature of neurological complications resulting from the use of 0.9% NaCl in non-neurosurgical patients. Patients at greatest risk of developing hyponatremic encephalopathy following hypotonic fluid administration are children, premenopausal females, postoperative patients, and those with brain injury or infection, pulmonary disease or hypoxemia. When hyponatremic encephalopathy develops, immediate administration of 3% NaCl is essential. In this Review, we discuss the question of why administering hypotonic fluids is unphysiologic and potentially dangerous, the settings in which isotonic fluids should be administered to prevent hyponatremia, and the appropriate treatment of hyponatremic encephalopathy.

Parenteral Amino Acid and Metabolic Acidosis in Premature Infants

Aggressive parenteral nutrition (PN) including amino acids is recommended for low-birth-weight infants to prevent energy and protein deficit. Their impact on acid-base homeostasis has not been examined. We investigated the impact of dose and duration of parenteral amino acids, with cysteine, on acid-base parameters in 122 low-birth-weight infants. Premature infants <or=32 weeks, <or=1850 g, and receiving parenteral amino acids at 1.5 g/kg/d for an extended period (>24 hours), or 3 g/kg/d for a short (5 hour), extended (24 hour), or prolonged (3-5 days) duration were included in the study. Data were obtained at age 0-3 days (n = 43) or, when clinically stable, age 3-5 days (n = 49). Data from 30 infants, matched for birth weight and gestational age, receiving PN during the first 5 days after birth were also obtained. Acidosis was defined as pH <7.25. Acidosis was evident in all infants between 2 and 5 days after birth. Infants with large patent ductus arteriosus (PDA) exhibited significantly (p < .05) lower pH early, had higher blood urea nitrogen levels (26 +/- 9 vs 18 + 8 mg/dL; p < .05), and had greater weight loss ( approximately 17% of birth weight) when compared with infants without PDA. Gestational age, weight loss, and patent ductus arteriosus accounted for 65% of variance in acidosis. Low-birth-weight infants develop metabolic acidosis between 2 and 5 days after birth, irrespective of dose and duration of parenteral amino acid administration. Careful management of parenteral fluids and comorbidities may lower the incidence of acidosis and promote protein accretion.