Received Fluid Resuscitation Research Articles

Resuscitation strategies with different arterial pressure targets after surgical management of traumatic shock.

IntroductionHypotensive fluid resuscitation has a better effect before and during surgical intervention for multiple trauma patients with haemorrhagic shock. However, it is questionable whether hypotensive fluid resuscitation is suitable after surgical intervention for these patients, and whether resuscitation with different mean arterial pressure (MAP) targets after surgical intervention can obtain different results. The aim of this study was to investigate these questions and to explore the underlying mechanisms.MethodsA total of 30 anesthetized piglets were randomly divided into 3 groups (n = 10 per group): low MAP, middle MAP, and high MAP, which had MAP targets of 60, 80, and 100 mmHg, respectively. All animals underwent femur fracture, intestine and liver injury, haemorrhagic shock, early hypotensive resuscitation, and surgical intervention. Then, the animals received fluid resuscitation with different MAP targets as mentioned above for 24 hours. Hemodynamic parameters and vital organ functions were evaluated.ResultsFluid resuscitation in the 80 mmHg MAP group maintained haemodynamic stability, tissue perfusion, and organ function better than that in the other groups. The 60 mmHg MAP group presented with profound metabolic acidosis and organ histopathologic damage. In addition, animals in the 100 mmHg MAP group exhibited severe tissue oedema, organ function failure, and histopathologic damage.ConclusionsIn our porcine model of resuscitation, targeting high MAP by fluid administration alone resulted in a huge increase in the infusion volume, severe tissue oedema, and organ dysfunction. Meanwhile, targeting low MAP resulted in persistent tissue hypoperfusion and metabolic stress. Hence, a resuscitation strategy of targeting appropriate MAP might be compatible with maintaining haemodynamic stability, tissue perfusion, and organ function.

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.

Improved sepsis bundles in the treatment of septic shock: a prospective clinical study

BackgroundSepsis bundles can decrease mortality in patients with severe sepsis or septic shock. However, current methods of measuring pressure, such as central venous pressure, are inadequate. This study investigated the effect of improved sepsis bundles informed by pulse-indicated continuous cardiac output. MethodsWe compared the outcome of treatment with sepsis bundles informed by either conventional pressure measurements or pulse-indicated continuous cardiac output. Patients in 2 groups received fluid resuscitation, standard antibiotics, and oxygen therapy. ResultsA total of 105 patients with septic shock were randomly divided into 2 groups: the conventional sepsis bundle group (n = 52) or the improved sepsis bundle group (ISBG, n =53). The ISBG significantly reduced the mean Acute Physiology and Chronic Health Evaluation II and Sepsis-related Organ Failure Assessment scores. Significantly fewer ISBG-treated patients received vasoactive drugs compared to conventional sepsis bundle group–treated patients. In addition, patients in the ISBG exhibited a significantly increased arterial blood lactate clearance rate and required less total fluid resuscitation and a shorter duration of mechanical ventilation and stay in the intensive care unit. ConclusionsPulse-indicated continuous cardiac output–directed sepsis bundles can reduce the severity of septic shock, provide more accurate fluid resuscitation, and reduce the duration of mechanical ventilation and stay in the intensive care unit.

Effect of synthetic colloid administration on coagulation in healthy dogs and dogs with systemic inflammation.

BackgroundSynthetic colloids are often used during fluid resuscitation and affect coagulation.ObjectiveTo compare the effects of an isotonic crystalloid and synthetic colloid on coagulation in healthy dogs and dogs with systemic inflammation.AnimalsSixteen adult purpose‐bred Beagles.MethodsRandomized, placebo‐controlled, blinded study. Dogs were randomized into one of two groups receiving fluid resuscitation with either 40 mL/kg IV 0.9% NaCl or tetrastarch after administration of lipopolysaccharide or an equal volume of placebo. After a 14‐day washout period, the study was repeated such that dogs received the opposite treatment (LPS or placebo) but the same resuscitation fluid. Blood samples were collected at 0, 1, 2, 4, and 24 hours for measurement of coagulation variables.ResultsAdministration of either fluid to healthy dogs and dogs with systemic inflammation resulted in similar increases in prothrombin time and activated clotting time. In comparison to saline administration, tetrastarch administration resulted in significantly decreased R (P = .017) in healthy dogs, as well as significantly increased activated partial thromboplastin time (P ≤ .016), CL30% (P ≤ .016), and K (P < .001) and significantly decreased platelet count (P = .019), α (P ≤ .001), MA (P < .001), and von Willebrand factor antigen (P < .001) and collagen binding activity (P ≤ .003) in both healthy dogs and dogs with systemic inflammation.Conclusions and Clinical ImportanceTetrastarch bolus administration to dogs with systemic inflammation resulted in a transient hypocoagulability characterized by a prolonged activated partial thromboplastin time, decreased clot formation speed and clot strength, and acquired type 1 von Willebrand disease.

Association between intravenous chloride load during resuscitation and in-hospital mortality among patients with SIRS.

PurposeRecent data suggest that both elevated serum chloride levels and volume overload may be harmful during fluid resuscitation. The purpose of this study was to examine the relationship between the intravenous chloride load and in-hospital mortality among patients with systemic inflammatory response syndrome (SIRS), with and without adjustment for the crystalloid volume administered.MethodsWe conducted a retrospective analysis of 109,836 patients ≥18 years old that met criteria for SIRS and received fluid resuscitation with crystalloids. We examined the association between changes in serum chloride concentration, the administered chloride load and fluid volume, and the ‘volume-adjusted chloride load’ and in-hospital mortality.ResultsIn general, increases in the serum chloride concentration were associated with increased mortality. Mortality was lowest (3.7 %) among patients with minimal increases in serum chloride concentration (0–10 mmol/L) and when the total administered chloride load was low (3.5 % among patients receiving 100–200 mmol; P < 0.05 versus patients receiving ≥500 mmol). After controlling for crystalloid fluid volume, mortality was lowest (2.6 %) when the volume-adjusted chloride load was 105–115 mmol/L. With adjustment for severity of illness, the odds of mortality increased (1.094, 95 % CI 1.062, 1.127) with increasing volume-adjusted chloride load (≥105 mmol/L).ConclusionsAmong patients with SIRS, a fluid resuscitation strategy employing lower chloride loads was associated with lower in-hospital mortality. This association was independent of the total fluid volume administered and remained significant after adjustment for severity of illness, supporting the hypothesis that crystalloids with lower chloride content may be preferable for managing patients with SIRS.Electronic supplementary materialThe online version of this article (doi:10.1007/s00134-014-3505-3) contains supplementary material, which is available to authorized users.

PMM.72 Metformin in Gestational Diabetic Women, Is It Really That Safe?

Metformin is widely used in the management of gestational diabetes mellitus (GDM). The major toxicity from the use metformin is lactic acidosis. Metformin increases lactate accumulation by inhibiting conversion of...

Effect of synthetic colloid administration on hemodynamic and laboratory variables in healthy dogs and dogs with systemic inflammation.

To compare the effects of administering equal volumes of isotonic crystalloids and synthetic colloids on hemodynamic and laboratory variables in healthy dogs and dogs with systemic inflammation. Randomized, placebo-controlled, blinded study. Comparative clinical research facility. Sixteen adult purpose-bred Beagles. Dogs were first randomized to receive either lipopolysaccharide (LPS; 5 μg/kg, IV) or an equal volume of placebo (0.9% NaCl, IV). Dogs were then randomized into 1 of 2 groups receiving fluid resuscitation with either 40 mL/kg IV isotonic crystalloid (0.9% NaCl) or synthetic colloid (tetrastarch). After a 14-day washout, the study was repeated such that dogs received the opposite treatment (LPS or placebo) and the same resuscitation fluid regimen. Vital signs (heart rate (HR), oscillometric blood pressure) were measured and blood samples were collected for PCV, total plasma protein (TPP), serum lactate concentration, and colloid osmotic pressure (COP) measurements. Healthy (placebo) dogs had similar decreases in PCV and TPP after administration of either fluid. Tetrastarch administration was associated with a larger increase in HR, systolic blood pressure, and mean blood pressure. Dogs with systemic inflammation had similar increases in systolic blood pressure and decreases in PCV, TPP, and lactate after administration of either fluid. Tetrastarch administration caused greater immediate increase in HR and mean blood pressure compared to 0.9% NaCl. In all dogs, 0.9% NaCl administration decreased COP and tetrastarch administration increased COP. Resuscitation with equal volumes of 0.9% NaCl and tetrastarch caused similar changes in hemodynamic and laboratory variables in dogs with LPS-induced systemic inflammation; however, larger increases in HR and blood pressure were seen within the first 2 hours following tetrastarch administration compared to 0.9% NaCl. Tetrastarch administration increased COP in all dogs, despite a decrease in TPP.

Effects of Fluid Resuscitation With 0.9% Saline Versus a Balanced Electrolyte Solution on Acute Kidney Injury in a Rat Model of Sepsis*

To compare the acute effects of 0.9% saline versus a balanced electrolyte solution on acute kidney injury in a rat model of sepsis. Controlled laboratory experiment. University laboratory. Sixty adult, male Sprague-Dawley rats. We induced sepsis by cecal ligation and puncture and randomized animals to receive fluid resuscitation with either 0.9% saline or Plasma-Lyte solution for 4 hours after 18 hours of cecal ligation and puncture (10 mL/kg in the first hour and 5 mL/kg in the next 3 hr). Blood and urine specimens were obtained from baseline, 18 hours after cecal ligation and puncture, immediately after 4 hours fluid resuscitation, and 24 hours later. We measured blood gas, plasma electrolytes, creatinine, interleukin-6, cystatin C, and neutrophil gelatinase-associated lipocalin concentrations. We also analyzed urine for cystatin C and neutrophil gelatinase-associated lipocalin. We used Risk, Injury, Failure, Loss and End-stage criteria for creatinine to assess severity of acute kidney injury. We observed all animals for survival up to 1 day after resuscitation. Surviving animals were killed for kidney histology. Finally, we carried out an identical study in 12 healthy animals. Compared with Plasma-Lyte, 0.9% saline resuscitation resulted in significantly greater blood chloride concentrations (p < 0.05) and significantly decreased pH and base excess. Acute kidney injury severity measured by RIFLE criteria was increased with 0.9% saline compared with Plasma-Lyte resuscitation (p < 0.05), and these results were consistent with kidney histology and biomarkers of acute kidney injury. Twenty-four-hour survival favored Plasma-Lyte resuscitation (76.6% vs 53.3%; p = 0.03). Finally, in healthy animals, we found no differences between fluids and no evidence of acute kidney injury. Volume resuscitation with Plasma-Lyte resulted in less acidosis and less kidney injury and improved short-term survival when compared with 0.9% saline in this experimental animal model of sepsis.

Fluid Resuscitation and Standard Drug Treatment Strategies in Heatstroke Chinese Patients

The objective of the present study was to evaluate different stage fluid and standard drug treatment strategies in 47 heatstroke patients. 47 adults with Heatstroke received fluid resuscitation treatment guided by transpulmonary thermodilution (PiCCO) in our intensive care unit. Systemic hemodynamics, microvascular indices and measures of acidosis, renal function, and pulmonary edema were followed prospectively. The speed of recovery and the component change was compared during the 6 h, 48 h and 96 h after the 3 stage fluid therapy. All patients were hyperpyrexia (core temperature>41°C), and on ventilation when enrolled in the ICU. Patients received a 6.17 (±1.8) ml/kg/h of crystal fluid and 3.31 (±0.5) ml/kg/h of colloidal fluid in the first 6 h; (3.41±1.2) ml/kg/h crystal fluid along with 2.27 (±0.3) ml/kg/h colloidal fluid in the first 48 h; 2.27 (±0.6) ml/kg/h crystal fluid along with 2.06 (±0.3) ml/kg/h colloidal fluid in the next 48 h. With resuscitation, acid-base status deteriorated in 25 of 47 patients (53.1%), extravascular lung water increased in 36 of 47 resuscitated patients (77%); 21 of these patients developed pulmonary edema though guided by transpulmonary thermodilution, 30 (63.8%) patients survived. All patients with pulmonary edema during the study were hypovolemic or euvolemic at the time pulmonary edema developed. Plasma lactate was lower in hypovolemic patients before (p<0.05) and after (p<0.05) resuscitation. Acute kidney injury was evident in 21 of 47 patients (47%) 48 h after enrollment. In conclusion, our study revealed that fluid resuscitation post heatstroke should be adjusted according to different stages.

Decreased central venous oxygen saturation despite normalization of heart rate and blood pressure post shock resuscitation in sick dogs.

To evaluate traditional and global perfusion parameters in clinical canine shock patients, and to evaluate for occult hypoperfusion as evidenced by low central venous oxygen saturation or high plasma lactate concentrations in clinical patients resuscitated to traditional endpoints. Clinical observational trial designed with a 1-year data entry period and patient follow-up of 28 days posthospital presentation. Large, private urban teaching hospital, and emergency and critical care center. Adult canine patients presenting to the emergency department with untreated shock. None. Patients received fluid resuscitation to normalize perfusion parameters based on physical examination and arterial blood pressure (BP). Monitoring of central venous pressure (CVP) and central venous oxygen saturation (ScvO2 ) was feasible with current standard of care interventions in critically ill, client-owned dogs. Decreased ScvO2 was observed in 37.8% of patients resuscitated to normal traditional perfusion parameters. Hyperlactatemia was commonly recorded. Decreased ScvO2 exists in a significant proportion of critically ill dogs following standard fluid resuscitation for shock, providing a relevant target population for implementation of a more standardized early goal-directed therapy bundle in veterinary patients. Normalization of heart rate, blood pressure, mentation, and perfusion parameters directed by physical examination may be attained despite the persistence of significant tissue hypoperfusion and oxygen debt.

The effect of levosimendan combined with 20% lipid emulsion treatment on survival from bupivacaine induced toxicity in experiment.

Recent reports demonstrated that levosimendan improved post-resuscitation myocardial function in rat and pig models. Rabbits were randomized into 4 groups as 12 rabbits in each group. Bupivacaine 10 mg/kg was injected as an intravenous bolus to all groups. Basic life support was performed by mechanical ventilation and manual external chest compressions. After 1 min, animals in the group 1 received 1.5 ml/ kg saline 0.9% solution, and animals in the groups 2 and 4 received 5 ml/kg 20% lipid emulsion for 1 min through the ear vein followed by continuous infusion at 0.25 ml/kg/min. Three additional boluses of 1.5 ml/ kg lipid emulsion were repeated at 5-min intervals. The group 3 received fluid resuscitation plus levosimendan (3 µg/kg/min) 1 min after asystole and the group 4 received both levosimendan and lipid emulsion treatment. Return of spontaneous circulation and hemodynamic metrics were obtained in 20 minutes. The number of rabbits that survived after cardiac resuscitation was lower in the Groups 1 (0%) and 3 (33.3%) than in the Group 4 (91.7%) with a statistically significant difference (p < 0.001). The number of rabbits that survived resuscitation was higher in the Group 4 than in the Group 2 (66.7%), though not with a statistically significant difference (p = 0.317). The median duration of cardiac arrest in the Group 4 was significantly shorter than that in the other three groups (p < 0.001). In this rabbit model of bupivacaine-induced cardiac arrest, resuscitation with combined iv lipid emulsion and levosimendan was more efficacious than lipid alone (Tab. 3, Ref. 24).

Activated protein C ameliorates impaired renal microvascular oxygenation and sodium reabsorption in endotoxemic rats.

IntroductionWe aimed to test whether continuous recombinant human activated protein C (APC) administration would be able to protect renal oxygenation and function during endotoxemia in order to provide more insight into the role of coagulation and inflammation in the development of septic acute kidney injury.MethodsIn anesthetized, mechanically ventilated Wistar rats, endotoxemia was induced by lipopolysaccharide administration (10 mg/kg i.v. over 30 min). One hour later, the rats received fluid resuscitation with 0 (LPS + FR group; n = 8), 10 (APC10 group; n = 8), or 100 (APC100 group; n = 8) μg/kg/h APC for 2 h. Renal microvascular oxygenation in the cortex and medulla were measured using phosphorimetry, and renal creatinine clearance rate and sodium reabsorption were measured as indicators of renal function. Statistical significance of differences between groups was tested using two-way ANOVA with Bonferroni post hoc tests.ResultsAPC did not have notable effects on systemic and renal hemodynamic and oxygenation variables or creatinine clearance. The changes in renal microvascular oxygenation in both the cortex (r = 0.66; p < 0.001) and medulla (r = 0.80; p < 0.001) were correlated to renal sodium reabsorption.ConclusionRenal sodium reabsorption is closely correlated to renal microvascular oxygenation during endotoxemia. In this study, fluid resuscitation and APC supplementation were not significantly effective in protecting renal microvascular oxygenation and renal function. The specific mechanisms responsible for these effects of APC warrant further study.Electronic supplementary materialThe online version of this article (doi:10.1186/2197-425X-1-5) contains supplementary material, which is available to authorized users.

Reposição volêmica com hidroxietilamido ou solução de ringer lactato em cães com gastroenterite hemorrágica por parvovírus

Parvovirus is an infectious viral disease, highly contagious, affecting dogs causing acute enteritis. Dehydration is a minor problem and acute evolution, which is the main focus of treatment. The objective of this study was to evaluate two treatments volume replacement in dogs with confirmed diagnosis of parvovirus infection by antigen detection in stool by ELISA. A total of 15 dogs, mixed, male and female, aged from 3 to 6 months, these four they had died during treatment and 11 were included in the study. Patients were randomly divided into two groups: hydroxyethyl starch 130/0.4 (HES, n=6) and Group Ringer Lactate (RL, n=5), which received fluid resuscitation with hydroxyethyl starch 130/0.4 and Ringer’s solution lactate, respectively, based on calculations of fluid deficit. All animals received intravenously: cephalothin, metronidazole, ranitidine and metoclopramide. During hospitalization, every 12 hours were evaluated arterial blood gas, electrolyte dosing and clinical examination (heart rate, respiratory rate, rectal temperature, capillary refill time, vomiting, appetite, dehydration, weight gain, hematochezia, melena, hematemesis and presence abdominal pain) and 24 hours each blood count was performed. In group RL was increase in the values of PaO2 and decreases in hemoglobin, hematocrit, phosphorus and magnesium, and group HES, a decrease in the percentage of dehydration, hemoglobin, phosphorus and potassium. There were no differences in other parameters between the groups. Both treatments were effective in fluid replacement of patients, no difference in any variable analyzed.

Use of a Modified Pediatric Early Warning Score in a Department of Pediatric and Adolescent Medicine

BackgroundSeveral versions of the Pediatric Early Warning Score (PEWS) exist, but there is limited information available on the use of such systems in different contexts. In the present study, we aimed to examine the relationship between a modified version of The Brighton Paediatric Early Warning Score (PEWS) and patient characteristics in a Norwegian department of pediatric and adolescent medicine. In addition, we sought to establish guidelines for escalation in patient care based on the PEWS in our patient population.MethodsThe medical records of patients referred for acute care from March to May 2011 were retrospectively reviewed. Children with a PEWS ≥3 were compared to children with a PEWS 0–2 with regard to age, diagnostic group and indicators of severe disease.ResultsA total of 761 patients (0−18 years of age) were included in the analysis. A younger age and diagnostic groups such as lower airway and cardiovascular disease were associated with PEWS ≥3. Upper airway disease and minor injury were more frequent in patients with PEWS 0−2. Children with PEWS ≥3 received fluid resuscitation, intravenous antibiotics, and oxygen supplementation, and were transferred to a higher level of care more often than children with PEWS 0−2.ConclusionsA PEWS ≥3 was associated with severe illnesses and surrogate markers of cardio-respiratory compromise. Patients with PEWS ≥3 should be carefully monitored to prevent further deterioration.

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.

Fluid Resuscitation Guided by Sublingual Partial Pressure of Carbon Dioxide During Hemorrhagic Shock in a Porcine Model

To avoid aggressive fluid resuscitation during hemorrhagic shock, fluid resuscitation is best guided by a specific measurement of tissue perfusion. We investigated whether fluid resuscitation guided by sublingual PCO2 would reduce the amount of resuscitation fluid without compromising the outcomes of hemorrhagic shock. Ten male domestic pigs weighing between 34 and 37 kg were used. Forty-five percent of estimated blood volume was removed during an interval of 1 h. The animals were then randomized to receive fluid resuscitation based on either sublingual PCO2 or blood pressure (BP). In the sublingual PCO2-guided group, resuscitation was initiated when sublingual PCO2 exceeded 70 Torr and stopped when it decreased to 50 Torr. In the BP-guided group, resuscitation was initiated when mean aortic pressure decreased to 60 mmHg and stopped when it increased to 90 mmHg. First, Ringer's lactate solution (RLS) of 30 mL kg was administered; subsequently, the shed blood was transfused if sublingual PCO2 remained greater than 50 Torr in the sublingual PCO2-guided group or mean aortic pressure was less than 90 mmHg in the BP-guided group. All the animals were monitored for 4 h and observed for an additional 68 h. In the sublingual PCO2-guided group, fluid resuscitation was required in only 40% of the animals. In addition, a significantly lower volume of RLS (170 ± 239 mL, P = 0.005 vs. BP-guided group) was administered without the need for blood infusion in this group. However, in the BP-guided group, all the animals required a significantly larger volume of fluid (955 ± 381 mL), including both RLS and blood. There were no differences in postresuscitation tissue microcirculation, myocardial and neurologic function, and 72-h survival between groups. During hemorrhagic shock, fluid resuscitation guided by sublingual PCO2 significantly reduced the amount of resuscitation fluid without compromising the outcomes of hemorrhagic shock.

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;

Timing, predictors, and progress of third space fluid accumulation during preliminary phase fluid resuscitation in adult patients with dengue

Fluid leakage remains the hallmark of dengue hemorrhagic fever (DHF). The applicability of currently recommended predictors of DHF for adults with dengue is questionable as these are based on studies conducted in children. One hundred and two adults with dengue were prospectively followed up to investigate whether home-based or hospital-based early phase fluid resuscitation has an impact on clinical and hematological parameters used for the diagnosis of early or critical phase fluid leakage. In the majority of subjects, third space fluid accumulation (TSFA) was detected on the fifth and sixth days of infection. The quantity and quality of fluids administered played no role in TSFA. A reduction in systolic blood pressure appeared to be more helpful than a reduction in pulse pressure in predicting fluid leakage. TSFA occurred with lower percentage rises in packed cell volume (PCV) than stated in the current recommendations. A rapid reduction in platelets, progressive reduction in white blood cells, percentage rises in Haemoglobin (Hb), and PCV, and rises in aspartate aminotransferase and alanine aminotransferase were observed in patients with TSFA and therefore with the development of severe illness. Clinicians should be aware of the limitations of currently recommended predictors of DHF in adult patients who are receiving fluid resuscitation.

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.

Volume Overload of Fluid Resuscitation in Acutely Burned Patients Using Transpulmonary Thermodilution Technique

In recent years, transpulmonary thermodilution techniques (PICCO) offer an attractive and more ideal end point for fluid resuscitation. The study included 30 adult burned patients between 25 and 60% TBSA. The study group received fluid resuscitation guided by the PICCO. The control group resuscitated using Parkland formula, guided by traditional monitoring parameters. Fluid administration in the initial 72 hours after burn injury was significantly higher in the study group. Furthermore, it was difficult, perhaps even impossible, to achieve the goals of normovolemia and cardiac output normalization during the early postburn period. Nevertheless, the attempt to achieve them was associated with a significant tissue edema. Although PICCO is a very beneficial tool in the estimation of amounts of fluid resuscitation, the values of ideal end points need to be adjusted in burn patients. The traditional values of intrathoracic blood volume, extravascular lung water, and cardiac index are associated with significant tissue edema that can easily complicate sepsis in these immunocompromised patients.