Patients Received Fluid Resuscitation Research Articles

How a positive fluid balance develops in acute kidney injury: A binational, observational study

PurposeA positive fluid balance (FB) is associated with harm in intensive care unit (ICU) patients with acute kidney injury (AKI). We aimed to understand how a positive balance develops in such patients. MethodsMultinational, retrospective cohort study of critically ill patients with AKI not requiring renal replacement therapy. ResultsAKI occurred at a median of two days after admission in 7894 (17.3%) patients. Cumulative FB became progressively positive, peaking on day three despite only 848 (10.7%) patients receiving fluid resuscitation in the ICU. In those three days, persistent crystalloid use (median:60.0 mL/h; IQR 28.9–89.2), nutritional intake (median:18.2 mL/h; IQR 0.0–45.9) and limited urine output (UO) (median:70.8 mL/h; IQR 49.0–96.7) contributed to a positive FB. Although UO increased each day, it failed to match input, with only 797 (10.1%) patients receiving diuretics in ICU. After adjustment, a positive FB four days after AKI diagnosis was associated with an increased risk of hospital mortality (OR 1.12;95% confidence intervals 1.05–1.19;p-value <0.001). ConclusionAmong ICU patients with AKI, cumulative FB increased after diagnosis and was associated with an increased risk of mortality. Continued crystalloid administration, increased nutritional intake, limited UO, and minimal use of diuretics all contributed to positive FB. Key pointsQuestionHow does a positive fluid balance develop in critically ill patients with acute kidney injury?FindingsCumulative FB increased after AKI diagnosis and was secondary to persistent crystalloid fluid administration, increasing nutritional fluid intake, and insufficient urine output. Despite the absence of resuscitation fluid and an increasing cumulative FB, there was persistently low diuretics use, ongoing crystalloid use, and a progressive escalation of nutritional fluid therapy.MeaningCurrent management results in fluid accumulation after diagnosis of AKI, as a result of ongoing crystalloid administration, increasing nutritional fluid, limited urine output and minimal diuretic use.

1039 Preventing Avoidable Harm with Safe IV Fluid Therapy – a Closed Loop Audit

Abstract Aim The National Institute for Health and Care Excellence (NICE) states that one in five people on intravenous (IV) fluids suffer from complications or morbidity due to their inappropriate administration. We aimed to compare our Trust’s current IV fluid prescription practices to standards set out in the NICE CG174 guidelines. Method We retrospectively reviewed 50 case notes for patients admitted to the Acute Medical Unit. We evaluated if hydration status was assessed comprehensively, and if resuscitation and maintenance fluids were prescribed appropriately, according to the NICE CG174 guidelines. The findings were presented at a local meeting and interventions were implemented by putting up posters and conducting regular teaching sessions on safe IV fluid prescription. To close the audit loop, data from a further 50 patients was collected post-intervention. Results The first audit cycle showed poor overall compliance with the guidelines; however a significant improvement was noted post-intervention. Pre-intervention, only 10% of patients had regular hydration assessments, 32% of patients received fluid resuscitation appropriately, and while 52% of our sample received maintenance fluid when indicated, 0% received the correct composition. Post-intervention, these figures rose to 28%, 66%, 84% and 15% respectively. Conclusions Inappropriate fluid administration is a risk to patient safety. This audit highlighted several areas for improvement regarding IV fluid prescription, and although a significant change was noted, further work is needed to increase compliance. We hope to incorporate the topic of IV fluids into the hospital’s regular teaching programmes to sustainably improve IV fluid prescription practices across the Trust.

Epidemiology and clinical characteristics of pediatric sepsis in PICUs of China: A national cross-sectional study.

Epidemiology and clinical characteristics of pediatric sepsis in PICUs of China: A national cross-sectional study.

Longitudinal profile of routine biomarkers for mortality prediction using unsupervised clustering algorithm in severely burned patients: a retrospective cohort study with prospectively collected data.

Burn injury has high clinical heterogeneity and worse prognosis in severely burned patients. Clustering algorithms using unsupervised methods to identify groups with similar trajectories in heterogeneous disease patients can provide insight into mechanisms of disease pathogenesis. This study analyzed routinely collected biomarkers to evaluate mortality prediction, find clinical meanings for these or their subtypes, and evaluate patterns. This retrospective cohort study included patients aged >18 years, between July 2012 and June 2021. All eligible patients received fluid resuscitation and survived for at least 7 days. Characteristics of clinical interest to the physician at 4 clinically important time points were evaluated. Eligible patients were divided into 4 subgroups according to these time points: from 1st week to 4th week. Total of 1,249 patients admitted within 2 days after burns and receiving fluid resuscitation were included. Mean Harrell's C-index of pH was the highest (0.816), followed by platelets (0.807), creatinine (0.796), red cell distribution width (RDW, 0.778), and lactate (0.759). Longitudinal profiles among biomarkers were different. The main predictors were pH, platelets, creatinine, RDW, and lactate. Creatinine and RDW showed consistent patterns. The other markers varied according to patient condition. Thus, these markers could provide clues into underlying mechanisms and predict mortality.

Use of Albumin as a Resuscitative Fluid in the Intensive Care Unit.

Use of Albumin as a Resuscitative Fluid in the Intensive Care Unit.

A Novel Risk Prediction Model for Severe Acute Kidney Injury in Intensive Care Unit Patients Receiving Fluid Resuscitation.

BackgroundTo develop a risk prediction model for the occurrence of severe acute kidney injury (AKI) in intensive care unit (ICU) patients receiving fluid resuscitation.MethodsWe conducted a secondary analysis of the Crystalloid vs. Hydroxyethyl Starch Trial (CHEST) trial, a blinded randomized controlled trial that enrolled ICU patients who received intravenous fluid resuscitation. The primary outcome was the first event in a composite outcome of doubling of serum creatinine and/or treatment with renal replacement treatment (RRT) within 28 days of randomization. The final model developed using multivariable logistic regression with backwards elimination was validated internally and then translated into a predictive equation.ResultsSix thousand seven hundred twenty-seven ICU participants were studied, among whom 745 developed the study outcome. The final model having six variables, including admission diagnosis of sepsis, illness severity score, mechanical ventilation, tachycardia, baseline estimated glomerular filtration rate and emergency admission. The model had good discrimination (c-statistic = 0.72, 95% confidence interval 0.697–0.736) and calibration (Hosmer-Lemeshow test, χ2 = 14.4, p = 0.07) for the composite outcome, with a c-statistic after internal bootstrapping validation of 0.72, which revealed a low degree of over-fitting. The positive predictive value and negative predictive value were 58.8 and 89.1%, respectively. The decision curve analysis indicates a net benefit in prediction of severe AKI using the model across a range of threshold probabilities between 5 and 35%.ConclusionsOur model, using readily available clinical variables to identify ICU patients at high risk of severe AKI achieved good predictive performance in a clinically relevant population.

The predisposing factors of AKI for prophylactic strategies in burn care.

BackgroundAcute kidney injury (AKI) is one of the most severe complications of burn injury. AKI with severe burn injury causes high mortality. This study aims to investigate the incidence of and predisposing factors for AKI in burn patients.MethodsThis is a single-center, retrospective, descriptive criterion standard study conducted from June 27, 2015, to March 8, 2016. We used Kidney Disease Improving Global Outcomes criteria to define and select patients with AKI. The study was conducted by recruiting in hospital patients who suffered from the flammable cornstarch-based powder explosion and were treated under primary care procedures. A total of 49 patients who suffered from flammable dust explosion-related burn injury were enrolled and admitted on June 27, 2015. The patients with more than 20% total body surface area of burn were transferred to the intensive care unit. Patients received fluid resuscitation in the first 24 hours based on the Parkland formula. The primary measurements were the incidence of and predisposing factors for AKI in these patients. Demographic characteristics, laboratory data, and inpatient outcomes were also evaluated. The incidence of AKI in this cohort was 61.2% (n = 30). The mortality rate was 2.0% (n = 1) during a 59-day follow-up period. The multivariate analysis revealed inhalation injury (adjusted OR = 22.0; 95% CI [1.4–358.2]) and meeting ≥3 American Burn Association (ABA) sepsis criteria (adjusted OR = 13.7; 95% CI [1.7–110.5]) as independent risk factors for early advanced AKI.ConclusionsThe incidence rate of AKI was higher in this cohort than in previous studies, possibly due to the flammable dust explosion-related burn injury. However, the mortality was lower than that expected. In clinical practice, indicators of inflammation, including ABA sepsis criteria may help in predicting the risk of AKI in patients with burn injury.

Impact of Protocol Based Fluid Resuscitation in Heart Failure Patients Admitted with Sepsis

Introduction Sepsis (severe sepsis and septic shock) with co-existing cardiovascular dysfunction is associated with increased mortality. With concomitant heart failure (HF), clinicians tend to limit fluid resuscitation in sepsis patients due to concerns of pulmonary edema and respiratory failure. We attempted to determine the effect of protocolized fluid resuscitation as per Surviving Sepsis Campaign Guidelines in sepsis patients with HF on clinical outcomes. Methods This was a single center, retrospective study of patients aged ≥18 years, admitted to a critical care unit with sepsis, having a co-diagnosis of systolic HF (EF Results 63 patients received fluids based on clinical judgement (2013), and 54 patients received protocolized fluids (2017). Both groups had similar patient demographics and co-morbidities. In-hospital mortality was higher in 2013, compared to 2017 [49 vs 41%, OR 0.7 (95% CI 0.3,1.5) p=0.36]. Lactic acid ≥4mmol/L was significantly associated with increased mortality [66 vs 36%, OR 3.5 (95% CI 1.6,8.1) p=0.002]. We found no difference in length of stay between the two groups. Patients with coronary artery disease, diabetes mellitus, hypertension, chronic obstructive pulmonary disease and cancer had higher absolute mortality. Conclusion This study demonstrates that there was no difference in-hospital mortality or critical care length of stay between patients receiving protocolized fluid resuscitation and patients receiving fluid resuscitation based on clinical judgement. Further prospective studies in a larger sample of patients are required to support these findings.

Quality Gaps in the Management of Patients With Acute Pancreatitis

Acute pancreatitis is the most common gastrointestinal cause for hospitalization and is associated with high morbidity and mortality. Multiple clinical guidelines outline best practices for the management of these patients. However, recent studies suggest that adherence to such guidelines is poor. In this study, we aim to audit current practice to identify potential targets for quality improvement initiatives. A retrospective chart review of all patients admitted directly to St Michael’s Hospital (a tertiary-care hospital) from the emergency department with a diagnosis of acute pancreatitis between January 1, 2016 and December 31, 2016 was performed. Complex patients transferred from another hospital to the intensive care unit or gastrointestinal ward were excluded. Potential quality indicators were extracted from recent American Gastroenterological Association, American College of Gastroenterology, and Canadian guidelines on the management of acute pancreatitis. Individual charts were reviewed and the following data were extracted: laboratory values, imaging results, dates of admission and discharge, interventions/procedures performed, antibiotic use, and nutrition. A total of 110 patients were included in the study. Mean age was 52 years (range, 16–92 years) and 58 (53%) patients were male. The most common cause of acute pancreatitis was gallstone (29%), followed by idiopathic (28%) and alcohol (20%). The mean Charlson comorbidity index was 2.2 (±2.7). Mean length of stay was 6.8 days (range, 1–84 days). Eight patients required intensive care unit admission. Ultrasound was performed within 48 hours of admission in 64 (58%) patients, and 43 (39%) patients had a computed tomography scan during their admission. The most common reason for computed tomography was diagnostic evaluation (35%), followed by investigation for underlying etiology (21%). Nineteen percent of patients did not obtain any imaging during their admission. Twenty-three (21%) patients did not receive any nutrition within their first 24 hours of admission. Antibiotic prophylaxis was started in 11 (10%) patients. Mean fluid resuscitation rate in the first 24 hours was 111 (±66) mL/h. Only 7 (6%) patients received fluid resuscitation, at a rate of >250 mL/h in the first 24 hours. No patients had appropriate laboratory values drawn to calculate Acute Physiologic Assessment and Chronic Health Evaluation score or other severity index scores. Only 12 (11%) patients had C-reactive protein measured. For patients with biliary pancreatitis, 24 (81%) underwent endoscopic retrograde cholangiopancreatography during their admission, and only 53% of those underwent cholecystectomy within the same admission. The management of patients presenting with acute pancreatitis remains quite variable, even at a large tertiary care center with expertise in pancreaticobiliary endoscopy. The most common areas of deficiency relate to imaging for potential etiologies, risk stratification, under-resuscitation with intravenous fluids, and delay to cholecystectomy, which we intend to target through a multifaceted quality improvement initiative.

Sepsis now a priority: a quality improvement initiative for early sepsis recognition and care

To develop a triage-based screening algorithm and treatment order-sets aimed at improving the quality of care of all patients with sepsis presenting to our emergency department (ED). Retrospective cohort study conducted during a pre-intervention period from 1 April 2010 to 31 March 2011 and a post-intervention period from 1 September 2014 to 30 April 2015. A large teaching hospital located in Toronto, Ontario, Canada with a 35-bed ED. All patients meeting pre-specified sepsis criteria during the ED encounter. Process of care measures included time to assessment by emergency physician, lactate measurement, blood culture collection, fluid and antibiotic administration. Intensive care unit (ICU) outcomes including admissions, length of stay (LOS) and deaths were reviewed. There were 346 patients pre-intervention, and 270 patients post-intervention. We significantly improved all process measures including mean time to antibiotics by 60 min (P = 0.003) and proportion of patients receiving fluid resuscitation (64.7% vs. 94.4%, P < 0.001). There was no significant difference in the number of patients admitted to ICU (P = 0.14). The median ICU LOS was shorter in the post-intervention group [2.0 days (interquartile range (IQR) 1.0-4.5 days) vs. 5.0 days (IQR 1.5-10.8 days), P = 0.04], and there was no difference in in-hospital mortality between groups (P = 0.27). We have demonstrated that a triage-based sepsis screening tool results in expedited and consistent delivery of care, with a significant improvement in initial resuscitation measures.

Accuracy of Ultrasonographic Measurements of Inferior Vena Cava to Determine Fluid Responsiveness: A Systematic Review and Meta-Analysis.

Fluid responsiveness is the ability to increase the cardiac output in response to a fluid challenge. Only about 50% of patients receiving fluid resuscitation for acute circulatory failure increase their stroke volume, but the other 50% may worsen their outcome. Therefore, predicting fluid responsiveness is needed. In this purpose, in recent years, the assessment of the inferior vena cava (IVC) through ultrasound (US) has become very popular. The aim of our work was to systematically review all the previously published studies assessing the accuracy of the diameter of IVC or its respiratory variations measured through US in predicting fluid responsiveness. We searched in the MEDLINE (PubMed), Embase, Web of Science databases for all relevant articles from inception to September 2017. Included articles specifically addressed the accuracy of IVC diameter or its respiratory variations assessed by US in predicting the fluid responsiveness in critically ill ventilated or not, adult or pediatric patients. We included 26 studies that investigated the role of the caval index (IVC collapsibility or distensibility) and 5 studies on IVC diameter. We conducted a meta-analysis for caval index with 20 studies: The pooled area under the curve, logarithmic diagnostic odds ratio, sensitivity, and specificity were 0.71 (95% confidence interval [CI]: 0.46-0.83), 2.02 (95% CI: 1.29-2.89), 0.71 (95% CI: 0.62-0.80), and 0.75 (95% CI: 0.64-0.85), respectively. An extreme heterogeneity of included studies was highlighted. Ultrasound evaluation of the diameter of the IVC and its respiratory variations does not seem to be a reliable method to predict fluid responsiveness.

Patterns of intravenous fluid resuscitation use in adult intensive care patients between 2007 and 2014: An international cross-sectional study.

BackgroundIn 2007, the Saline versus Albumin Fluid Evaluation—Translation of Research Into Practice Study (SAFE-TRIPS) reported that 0.9% sodium chloride (saline) and hydroxyethyl starch (HES) were the most commonly used resuscitation fluids in intensive care unit (ICU) patients. Evidence has emerged since 2007 that these fluids are associated with adverse patient-centred outcomes. Based on the published evidence since 2007, we sought to determine the current type of fluid resuscitation used in clinical practice and the predictors of fluid choice and determine whether these have changed between 2007 and 2014.MethodsIn 2014, an international, cross-sectional study was conducted (Fluid-TRIPS) to document current patterns of intravenous resuscitation fluid use and determine factors associated with fluid choice. We examined univariate and multivariate associations between patients and prescriber characteristics, geographical region and fluid type. Additionally, we report secular trends of resuscitation fluid use in a cohort of ICUs that participated in both the 2007 and 2014 studies. Regression analysis were conducted to determine changes in the administration of crystalloid or colloid between 2007 and 2014.FindingsIn 2014, a total of 426 ICUs in 27 countries participated. Over the 24 hour study day, 1456/6707 (21.7%) patients received resuscitation fluid during 2716 resuscitation episodes. Crystalloids were administered to 1227/1456 (84.3%) patients during 2208/2716 (81.3%) episodes and colloids to 394/1456 (27.1%) patients during 581/2716 (21.4%) episodes. In multivariate analyses, practice significantly varied between geographical regions. Additionally, patients with a traumatic brain injury were less likely to receive colloid when compared to patients with no trauma (adjusted OR 0.24; 95% CI 0.1 to 0.62; p = 0.003). Patients in the ICU for one or more days where more likely to receive colloid compared to patients in the ICU on their admission date (adjusted OR 1.75; 95% CI 1.27 to 2.41; p = <0.001).For secular trends in fluid resuscitation, 84 ICUs in 17 countries contributed data. In 2007, 527/1663 (31.7%) patients received fluid resuscitation during 1167 episodes compared to 491/1763 (27.9%) patients during 960 episodes in 2014. The use of crystalloids increased from 498/1167 (42.7%) in 2007 to 694/960 (72.3%) in 2014 (odds ratio (OR) 3.75, 95% confidence interval (CI) 2.95 to 4.77; p = <0.001), primarily due to a significant increase in the use of buffered salt solutions. The use of colloids decreased from 724/1167 (62.0%) in 2007 to 297/960 (30.9%) in 2014 (OR 0.29, 95% CI 0.19 to 0.43; p = <0.001), primarily due to a decrease in the use of HES, but an overall increase in the use of albumin.ConclusionsClinical practices of intravenous fluid resuscitation have changed between 2007 and 2014. Geographical location remains a strong predictor of the type of fluid administered for fluid resuscitation. Overall, there is a preferential use of crystalloids, specifically buffered salt solutions, over colloids. There is now an imperative to conduct a trial determining the safety and efficacy of these fluids on patient-centred outcomes.Trial registrationClinicaltrials.gov: Fluid-Translation of research into practice study (Fluid-TRIPS) NCT02002013

Steven Johnson Syndrome and Toxic Epidermal Necrolysis in a burn unit: A 15-year experience

IntroductionThe diffuse epidermal exfoliation seen in Steven Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TEN) is similar to skin loss in second degree burns, and many of these patients are referred for treatment at burn centers. Treatment can differ markedly from center to center, and mortality can range from 25% to 70%, including a considerable morbidity. However, our experience over a 15-year period from 2000 to 2015 with 40 patients found a mortality rate of only 10% (4/40). The purpose of this paper is to discuss our treatment algorithm as a model for other centers treating SJS/TENs patients. MethodsRecords were reviewed for all patients admitted to the LAC+USC burn unit between 2000 and 2015 and 40 patients were identified with biopsy-proven SJS or TENS. These cases were reviewed for age, gender, initial and greatest TBSA, causative drug, pre-existing medical conditions, and morbidity and mortality. All data were entered into the SPSS statistical software package and all statistical analyses were performed using this program. ResultsOur treatment algorithm focused on early referral to a specialty burn unit, immediate discontinuation of the offending drug, fluid resuscitation, nutritional supplementation, and meticulous wound care. Average time to transfer to a burn unit was 3.36 days. Silver-releasing antimicrobial dressings were applied to the affected skin surface and changed every 3 days. Mupirocin coated petroleum gauze was used for facial involvement. Steroids were tapered and discontinued if initiated at an outside facility (58% of patients), and starting after 2001, all patients received a course of IVIG. All patients received fluid resuscitation and the majority received supplemental tube feedings (69%). Average length of total stay was 17.1 days and length of ICU stay 15.9 days. While 44% were transferred to another facility for further rehabilitative care, 37% of patients discharge to home. In patients discharged home with complete resolution of skin lesions, time to healing was an average of 14 days. DiscussionWith our 10% mortality rate in 40 patients, our study represents a relatively large study population while maintaining a relatively low mortality rate. The demographic data from our study largely aligns with the existing literature, and we therefore feel that our low mortality rate is due to our treatment algorithm, rather than to a less severe pathology in our patient population. This claim is supported by a standard mortality ratio of 1.68. This ratio proves a significantly improved mortality than would be expected based on disease severity on admission.

Effect of different fluid resuscitation on kidney function in pediatric patients with sepsis

Objective To prospectively study the effects of different fluid resuscitation on kidney function in pediatric patients with sepsis. Methods One hundred and eighteen pediatric patients with sepsis shock who needed fluid resuscitation in Intensive Care Unit, Zhengzhou Children's Hospital from June 2012 to June 2015 were selected, and they were randomly divided into group A, B and C by random number in the table.The patients received fluid resuscitation of hydroxyethyl starch, 50 g/L albumin and 9 g/L saline.After that, neutrophil gelatinase associated lipocalin (NGAL), α-1 microglobulin, urea nitrogen, creatinine, urine volume, the incidence of acute kidney injury (AKI), and the renal replacement therapy rate accepted by the patients were recorded.Then all the data were analyzed with SPSS 19.0 software. Results Serum levels of NGAL and α-1 microglobulin in group A [(103.50±1.23) μg/L, (3.32±0.20) mg/L]were higher than those in group B [(93.54±1.42) μg/L, (2.71±0.18)mg/L]and group C[(79.57±1.54) μg/L, (2.08±0.14) mg/L], which were statistically different(all P 0.05). The urine volume in group A [(0.50±0.12) mL/(kg·h)] was less than that in group B[(0.90±0.23) mL/(kg·h)] and group C[(1.30±0.14) mL/(kg·h)], which was statistically different(all P 0.05). In three groups, there were 13 cases(34.2%) with AKI in group A, 9 cases(23.1%) with AKI in group B, and 8 cases(19.5%) with AKI in group C, the incidence of AKI in group C was less than that in group B and group C, which was statistically different(χ2=12.74, 10.43; all P<0.05). All the groups all had children accepted renal replacement therapy, there were 8 cases(21.1%)in group A, 7 cases(17.9%)in group B, and 6 cases (14.6%)in group C, and the cases who accepted renal replacement therapy rate in group C were less than those in group A and group B, which was statistically different(χ2=11.36, 8.73; all P<0.05). Conclusions The adverse effect of 9 g/L saline on kidney function is less than hydrox-yethyl starch and 50 g/L albumin, and hydroxyethyl starch has more adverse effects on kidney.Thus, 9 g/L saline is a better option for fluid resuscitation in pediatric sepsis patients. Key words: Fluid resuscitation; Sepsis; Kidney function; Child

Ascorbic acid effect on CIN incidence in diabetic patient after coronary angiography.

Background:This study aims to investigate the antioxidant effect of vitamin C in preventing contrast-induced nephropathy (CIN) in diabetic patients after catheterization.Materials and Methods:In a double blinded, randomized controlled trial, 90 diabetic patients who were referred for cardiac catheterization were randomly allocated into two arms of vitamin C (A) and placebo (B). The treatment arm (A) received 2 g of vitamin C orally 2 h before catheterization and the control group (B) received 2 g of oral placebo. Six hours before catheterization, patients received fluid resuscitation with normal saline (CIN was considered as a 25% rise in creatinine (Cr) level or an increase of 0.5 mg/dL in earlier creatinine). CIN was compared between groups. Before andthree days after catheterization. Serum Bun – Cr was measured and GFR were calculated. The results were compared between the two groups. Six hours before catheterization, patients received fluid resuscitation with normal saline CIN was compare between arms.Results:Mean GFR in group (A) before procedure was respectively 69.82±19.26 and after the treatment was 81.51±27.40 (P=0.001). But in group (B) it was 74.18±24.41 and 75.20±29.65 (P=0.747). Contrast-induced nephropathy was observed in 10 patients (12.3%) including 3 patients (7.7%) in group (A) and (16.7%, 7 patients) in group (B) (P=0.315).Conclusion:Ascorbic acid intake in diabetic patients prior to use of contrast agents can be effective in maintaining GFR, but the incidence of contrast-induced nephropathy is not associated with the consumption of ascorbic acid.

Resuscitation fluid use in Australian and New Zealand Intensive Care Units between 2007 and 2013.

Recent evidence indicates that the choice of intravenous fluids may affect outcomes in critically ill patients. We recorded the administration of resuscitation fluids in patients admitted to Australian and New Zealand adult intensive care units (ICUs) for a 24-h period at 6 time points between 2007 and 2013. Changes in patterns of fluid use over this period were determined using regression analyses. Of the 2825 patients admitted to the 61 ICUs on the 6 study days, 754 (26.7%) patients received fluid resuscitation. Of those receiving fluid resuscitation, the proportion of patients receiving crystalloid significantly increased from 28.9% (41/142) in 2007 to 50.5% (48/95) in 2013 (adjusted odds ratio (OR) 2.93; 95% confidence intervals (CI) 1.35-6.33; p = 0.006); of these, the proportion of patients receiving buffered salt solutions significantly increased from 4.9% (7/142) in 2007 to 31.6% (30/95) in 2013 (OR 7.00; 95% CI 2.14-22.92; p = 0.001). The use of colloids significantly decreased from 59.9% (85/142) in 2007 to 42.1% (40/95) in 2013 (adjusted OR 0.34; 95% CI 0.16-0.74; p = 0.007) due to a significant decrease in the proportion of patients receiving gelatin; 28.9% (41/142) to 2.1% (2/95) (OR 0.10; 95% CI 0.03-0.29; p ≤ 0.001). Fluid resuscitation practice in Australia and New Zealand adult ICUs has changed over the 6-year study period. Crystalloid use increased primarily due to an increase in the use of buffered salt solutions while overall the use of colloid has decreased.

Hydroxyethyl starch for fluid resuscitation in critically ill patients

Intravenous fluid therapy is one of the most frequent interventions provided to patients in the intensive care unit; however, the type of fluid (i.e., crystalloid or colloid) used for resuscitation remains controversial. The most common type of colloid administered to resuscitate critically ill patients is hydroxyethyl starch (HES); however, its safety and efficacy have not been rigorously evaluated in large pragmatic randomized trials, and emerging data have accumulated to question its potential for toxic adverse effects. To evaluate the efficacy and safety of HES for fluid resuscitation in critically ill patients with a focus on survival and kidney function. Multicentre (32 sites in Australia and New Zealand) blinded randomized controlled parallel-group trial. Seven thousand eligible adult patients (age - ≥ 18 yr) admitted to an intensive care unit and judged by their treating clinician to require fluid resuscitation were included in the study. Study treatment allocation used encrypted Web-based randomization stratified by site and an admission diagnosis of trauma. Randomized patients were assigned to receive either 6% HES with a molecular weight of 130 kD and molar substitution ratio of 0.4 (130/0.4; Voluven(®), Fresenius Kabi) in 0.9% sodium chloride or 0.9% sodium chloride (saline) in indistinguishable Free flex 500 mL bags until intensive care unit (ICU) discharge, death, or 90 days after randomization. According to registration guidelines, the study fluid was administered to a maximum dose of 50 mL kg(-1) body weight per day and followed, if necessary, by open-label saline during the remaining 24-hr period. The primary efficacy outcome was death within 90 days after randomization. The key secondary outcomes were incidence of acute kidney injury (AKI), defined by the RIFLE (Risk, Injury, Failure, Loss, Endstage) criteria; treatment with renal replacement therapy(RRT); development of new organ dysfunction, defined by the sequential organ failure assessment score; duration of mechanical ventilation; duration of RRT; cause-specific mortality; and adverse events. Tertiary outcomes were ICU and hospital lengths of stay and ICU and hospital mortality. The primary outcome was evaluated across six a prior idefined subgroups: urine output criteria for AKI; presence of sepsis; presence of trauma, with or without traumatic brain injury; acute physiology and chronic health evaluation (APACHE) score C ≥ 25; and receipt of HES prior to randomization. The HES and saline groups had similar characteristics at baseline. The average age was 63 yr, 60.4% of patients were male, and 42.7% were admitted to the ICU after surgery (54.7% after elective surgery). The median [interquartile range] APACHE II score was 17[12.0-23.0] with a score C ≥ 25 in 18.2%. Sepsis and trauma were primary diagnoses in 28.8% and 7.9% of patients, respectively. Mechanical ventilation was received by 64.5% of patients, vasopressor therapy by 45.8%, and HES fluid prior to randomization by 15.1%. Enrolment occurred approximately 11 hr after ICU admission. During the first four days after randomization, the mean (standard deviation) study fluid received by the HES group was less when compared with the saline group [526 (425) mL day(-1) vs 616 (488) mL day(-1), respectively; P < 0.001]. Mortality at 90 days was 18.0% in patients receiving HES (597/3,315) and 17.0% in those receiving saline (566/3,336) (relative risk [RR] for HES, 1.06; 95% confidence interval (CI), 0.96 to 1.18; P = 0.26). There was no significant difference in 90-day mortality across the six a priori defined subgroups. Renal replacement therapy was received in 7.0% of patients in the HES group (235/3,352) and 5.8% of patients in the saline group (196/3,376) (RR for HES, 1.21; 95% CI, 1.00 to 1.45; P = 0.04). In the HES and saline groups, RIFLE - Injury occurred in 34.6% and 38.0% of patients,respectively (P = 0.005), and RIFLE - Failure occurred in 10.4% and 9.2% of patients, respectively (P = 0.12). There were no differences in mortality in ICU, in hospital, or at 28 days. Hydroxyethyl starch was associated with a decrease in new cardiovascular organ failure compared with saline (36.5% vs 39.9%, respectively; RR 0.91; 95% CI, 0.84 to 0.99; P = 0.03) and an increase in new hepatic organ failure compared with saline (1.9% vs 1.2%, respectively; RR 15.6; 95% CI, 1.03 to 2.36; P = 0.03). There were no differences between HES and saline for days in ICU or hospital or for duration of mechanical ventilation or RRT. Hydroxyethyl starch was associated with more adverse events compared with saline (5.3% vs 2.8%, respectively; RR 1.86; 95% CI, 1.46 to 2.38; P < 0.001). Adverse events were predominantly accounted for by pruritis and skin rash. In critically ill patients receiving fluid resuscitation, there was no significant difference in 90-day mortality between 6% HES (130/0.4) or saline. Even so, more patients who received resuscitation with HES were treated with RRT and experienced adverse events.

The Incidence and Characteristic of Acute Kidney Injury as A Complication of Severe Burn Injury in Patients Receiving Fluid Resuscitation

&#x0D; &#x0D; &#x0D; &#x0D; Background: Acute kidney injury is important factor that can increase mortality in patient with severe burn injury. Knowledge about incidence and characteristic of acute kidney injury among severe burned patients will help medical practitioner to establish appropriate medical decision and health care protocol.&#x0D; Method: PubMed, Cochrane Library, and GoogleTM search yielded 12 articles. The articles were screened by inclusion criteria, exclusion criteria, and full text reading. Five remaining articles appraised in regard of validity, importance, and applicability.&#x0D; Result: Incidence of acute kidney injury among severely burned patients varies from 24.4% to 53.3%. According to the study with best level of evidence, a systematic review, the incidence of AKI is 28.8% (95% CI 26.8%-30.7%). AKI can occur early or late, and may progress. Progressive AKI has highest mortality rate.&#x0D; Conclusion: AKI is common complication among patients with severe burn injury. Approximately one- third to half of patients with severe burn injury will develop AKI in the course of the disease. Early clinical assessment and re-evaluation are important in severe burn injury management.&#x0D; &#x0D; &#x0D; &#x0D;

Disease-based Modeling to Predict Fluid Response in Intensive Care Units

To compare general and disease-based modeling for fluid resuscitation and vasopressor use in intensive care units. Retrospective cohort study involving 2944 adult medical and surgical intensive care unit (ICU) patients receiving fluid resuscitation. Within this cohort there were two disease-based groups, 802 patients with a diagnosis of pneumonia, and 143 patients with a diagnosis of pancreatitis. Fluid resuscitation either progressing to subsequent vasopressor administration or not was used as the primary outcome variable to compare general and disease-based modeling. Patients with pancreatitis, pneumonia and the general group all shared three common predictive features as core variables, arterial base excess, lactic acid and platelets. Patients with pneumonia also had non-invasive systolic blood pressure and white blood cells added to the core model, and pancreatitis patients additionally had temperature. Disease-based models had significantly higher values of AUC (p < 0.05) than the general group (0.82 ± 0.02 for pneumonia and 0.83 ± 0.03 for pancreatitis vs. 0.79 ± 0.02 for general patients). Disease-based predictive modeling reveals a different set of predictive variables compared to general modeling and improved performance. Our findings add support to the growing body of evidence advantaging disease specific predictive modeling.

Clinical manifestations associated with Kawasaki disease shock syndrome in Mexican children

Recently, there have been increasing reports of severe forms of Kawasaki disease (KD) associated with shock that have been managed in pediatric intensive care units. It has been suggested that KD is more severe in the Hispanic population. We conducted a study to determine the frequency of Kawasaki disease shock syndrome (KDSS) in our population and compared characteristics between patients with KD without shock and patients with KDSS. Data from 214 patients with KD treated in a tertiary pediatric hospital were collected during a 12-year period. We compared clinical and laboratory features of KD patients without shock and KDSS patients. Of 214 consecutive patients with KD, 11 (5 %) met the definition for KDSS. All of these patients received fluid resuscitation, seven (64 %) required inotropic treatment, and six (54 %), ventilatory support. On admission, seven of these patients (64 %) had an incomplete presentation of the disease, whereas in the group of patients without shock, the relative frequency of an incomplete presentation was 29 %. Twenty percent (3/11) of patients with KDSS presented giant coronary aneurysms versus none of 203 KD patients without shock (p = 0.001); myocardial infarction, 27 % (3/11), versus 1 % (2/203) (p = 0.001); and intravenous immunoglobulin (IVIG) resistance, 60 % (6/11), versus 12 % (24/203). Gastrointestinal manifestations in the acute phase occurred in 91 % of KDSS patients versus 30 % patients without shock (p = 0.001). Patients with KD presenting in shock seem to have an increase in gastrointestinal manifestations, incomplete presentation, IVIG resistance, and worse cardiac outcomes. Larger, prospective, multicentre studies should be carried out to corroborate these findings.