Intravenous Fluid Restriction Research Articles

Effects of restrictive fluid therapy on the time to resolution of hyperlactatemia in ICU patients with septic shock. A secondary post hoc analysis of the CLASSIC randomized trial

PurposeThe aim of this study was to examine the effects of intravenous (IV) fluid restriction on time to resolution of hyperlactatemia in septic shock. Hyperlactatemia in sepsis is associated with worse outcome. Sepsis guidelines suggest targeting lactate clearance to guide fluid therapy despite the complexity of hyperlactatemia and the potential harm of fluid overload.MethodsWe conducted a post hoc analysis of serial plasma lactate concentrations in a sub-cohort of 777 patients from the international multicenter clinical CLASSIC trial (restriction of intravenous fluids in intensive care unit (ICU) patients with septic shock). Adult ICU patients with septic shock had been randomized to restrictive (n = 385) or standard (n = 392) intravenous fluid therapy. The primary outcome, time to resolution of hyperlactatemia, was analyzed with a competing-risks regression model. Death and discharge were competing outcomes, and administrative censoring was imposed 72 h after randomization if hyperlactatemia persisted. The regression analysis was adjusted for the same stratification variables and covariates as in the original CLASSIC trial analysis.ResultsThe hazard ratios (HRs) for the cumulative probability of resolution of hyperlactatemia, in the restrictive vs the standard group, in the unadjusted analysis, with time split, were 0.94 (confidence interval (CI) 0.78–1.14) at day 1 and 1.21 (0.89–1.65) at day 2–3. The adjusted analyses were consistent with the unadjusted results.ConclusionIn this post hoc retrospective analysis of a multicenter randomized controlled trial (RCT), a restrictive intravenous fluid strategy did not seem to affect the time to resolution of hyperlactatemia in adult ICU patients with septic shock.

Association of adherence to the enhanced recovery after surgery pathway and outcomes after laparoscopic total gastrectomy

ObjectiveThe current study used a composite outcome to investigate whether applying the ERAS protocol would enhance the recovery of patients undergoing laparoscopic total gastrectomy (LTG).ExposuresLaparoscopic total gastrectomy and perioperative interventions were the exposure. An ERAS clinical pathway consisting of 14 items was implemented and assessed. Patients were divided into either ERAS-compliant or non-ERAS-compliant group according the adherence above 9/14 or not.Main outcomes and measuresThe primary study outcome was a composite outcome called ‘optimal postoperative recovery’ with the definition as below: discharge within 6 days with no sever complications and no unplanned re-operation or readmission within 30 days postoperatively. Univariate logistic regression analysis and multivariate logistic regression analysis were used to model optimal postoperative recovery and compliance, adjusting for patient-related and disease-related characteristics.ResultsA total of 252 patients were included in this retrospective study, 129 in the ERAS compliant group and 123 in the non-ERAS-compliant group. Of these, 79.07% of the patients in ERAS compliant group achieved optimal postoperative recovery, whereas 61.79% of patients in non-ERAS-compliant group did (P = 0.0026). The incidence of sever complications was lower in the ERAS-compliant group (1.55% vs. 6.5%, P = 0.0441). No patients in ERAS compliant group had unplanned re-operation, whereas 5.69% (7/123) of patients in non-ERAS-compliant group had (p = 0.006). The median length of the postoperative hospital stay was shorter in the in the ERAS compliant group (5.51 vs. 5.68 days, P = 0.01). Both logistic (OR 2.01, 95% CI 1.21–3.34) and stepwise regression (OR 2.07, 95% CI 1.25–3.41) analysis showed that high overall compliance with the ERAS protocol facilitated optimal recovery in such patients. In bivariate analysis of compliance for patients who had an optimal postoperative recovery, carbohydrate drinks (p = 0.0196), early oral feeding (P = 0.0043), early mobilization (P = 0.0340), and restrictive intravenous fluid administration (P < 0.0001) were significantly associated with optimal postoperative recovery.Conclusions and relevancePatients with higher ERAS compliance (almost 70% of the accomplishment) suffered less severe postoperative complications and were more likely to achieve optimal postoperative recovery.

The intraoperative management of robotic-assisted laparoscopic prostatectomy.

Robotic-assisted laparoscopic radical prostatectomy has become the second most commonly performed robotic surgical procedure worldwide, therefore, anesthesiologists should be aware of the intraoperative pathophysiological consequences. The aim of this narrative review is to report the most recent updates regarding the intraoperative management of anesthesia, ventilation, hemodynamics and central nervous system, during robotic-assisted laparoscopic radical prostatectomy. Surgical innovations and the advent of new technologies make it imperative to optimize the anesthesia management to provide the most holistic approach possible. In addition, an ageing population with an increasing burden of comorbidities requires multifocal attention to reduce the surgical stress. Total intravenous anesthesia (TIVA) and balanced general anesthesia are similar in terms of postoperative complications and hospital stay. Reversal of rocuronium is associated with shorter hospital stay and postanesthesia recovery time. Adequate PEEP levels improve oxygenation and driving pressure, and the use of a single recruitment maneuver after the intubation reduces postoperative pulmonary complications. Restrictive intravenous fluid administration minimizes bladder-urethra anastomosis complications and facial edema. TIVA maintains a better autoregulation compared with balanced general anesthesia. Anesthesiologists should be able to optimize the intraoperative management to improve outcomes.

RF25 | PMON179 Role of Apparent Strong Ion Difference in the Differential Diagnosis of Thiazide Associated Hyponatremia

Abstract Background Differential diagnosis of hyponatremia is challenging, particularly for thiazide associated hyponatremia (TAH), as patients might have either volume depletion in need for fluid substitution or syndrome of inappropriate antidiuresis (SIAD)-like presentation requiring fluid restriction. Urine indices are of little utility, because they are influenced by thiazide therapy. Apparent strong ion difference (aSID) describes the relation between sodium, potassium and chloride in serum and is used in evaluation of acid-base disorders according to Stewart model. aSID could help in the differential diagnosis of TAH because a value &amp;gt;40 identifies patients with contraction alkalosis due to relative hypochloremia, and hypochloremic alkalosis is a well-known possible adverse effect of thiazide diuretics. Material and Methods This was a post-hoc analysis of prospectively collected data of hospitalized patients with hypotonic hyponatremia &amp;lt;125 mmol/l. TAH patients were divided according to treatment response in patients needing intravenous fluid substitution or fluid restriction. Treatment response was defined as a sodium increase of at least 4 mmol/l/die or &amp;gt;130 mmol/l based on chart review. aSID at baseline was calculated with the formula serum sodium plus potassium minus chloride and a value &amp;gt;40 was used to identify volume-depleted TAH patients. Descriptive analysis was carried out to find differences between volume-depleted and SIAD-like TAH patients, and patients with SIAD without thiazide use. Logistic regression and ROC curves were computed to investigate the role of aSID&amp;gt;40 for differential diagnosis of hyponatremia in TAH patients, in addition to known factors for identifying SIAD patients as body mass index (BMI) and fractioned uric acid excretion (FUA) with the previous described cut-off of 12%. Results Out of 303 hyponatremia patients, 131 (43.2%) had a TAH and 75 (24.8%) SIAD without thiazide use. Among TAH patients, 81 (61.8%) were successfully treated with fluid substitution and 31 (23.7%) with fluid restriction. 19 patients (14.5%) were excluded as they received no treatment, or needed to switch treatment during hospitalization. No differences in baseline characteristics were seen between patients with SIAD and SIAD-like TAH patients, except for BMI, lower in SIAD patients (mean(SD) 23.5(5.1) vs 27.0(5.7) kg/m2, p=0.003). A higher BMI and a FUA&amp;lt;12% had a sensitivity of 84% with a specificity of 60% in identifying volume-depleted TAH patients. Adding aSID&amp;gt;40 improved the specificity to 74% maintaining a sensitivity to 82%. Conclusion In hospitalized patients with TAH, calculation of aSID may help differentiating patients with volume depletion in need of fluid substitution from SIAD-like manifestation requiring fluid restriction. Presentation: Monday, June 13, 2022 12:30 p.m. - 2:30 p.m., Monday, June 13, 2022 12:37 p.m. - 12:42 p.m.

Science, Medicine, and the Anesthesiologist

Science, Medicine, and the Anesthesiologist

Restriction of Intravenous Fluid in ICU Patients with Septic Shock

BackgroundIntravenous fluids are recommended for the treatment of patients who are in septic shock, but higher fluid volumes have been associated with harm in patients who are in the intensive care unit (ICU).MethodsIn this international, randomized trial, we assigned patients with septic shock in the ICU who had received at least 1 liter of intravenous fluid to receive restricted intravenous fluid or standard intravenous fluid therapy; patients were included if the onset of shock had been within 12 hours before screening. The primary outcome was death from any cause within 90 days after randomization.ResultsWe enrolled 1554 patients; 770 were assigned to the restrictive-fluid group and 784 to the standard-fluid group. Primary outcome data were available for 1545 patients (99.4%). In the ICU, the restrictive-fluid group received a median of 1798 ml of intravenous fluid (interquartile range, 500 to 4366); the standard-fluid group received a median of 3811 ml (interquartile range, 1861 to 6762). At 90 days, death had occurred in 323 of 764 patients (42.3%) in the restrictive-fluid group, as compared with 329 of 781 patients (42.1%) in the standard-fluid group (adjusted absolute difference, 0.1 percentage points; 95% confidence interval [CI], −4.7 to 4.9; P=0.96). In the ICU, serious adverse events occurred at least once in 221 of 751 patients (29.4%) in the restrictive-fluid group and in 238 of 772 patients (30.8%) in the standard-fluid group (adjusted absolute difference, −1.7 percentage points; 99% CI, −7.7 to 4.3). At 90 days after randomization, the numbers of days alive without life support and days alive and out of the hospital were similar in the two groups.ConclusionsAmong adult patients with septic shock in the ICU, intravenous fluid restriction did not result in fewer deaths at 90 days than standard intravenous fluid therapy. (Funded by the Novo Nordisk Foundation and others; CLASSIC ClinicalTrials.gov number, NCT03668236.)

Restrictive Fluid Administration vs. Standard of Care in Emergency Department Sepsis Patients (REFACED Sepsis)\u2014protocol for a multicenter, randomized, clinical, proof-of-concept trial

BackgroundIntravenous fluids are often used in the treatment of sepsis. The better strategy regarding fluid volume is debated, but preliminary data in patients with septic shock or sepsis-related hypotension favor restrictive fluid administration. We describe the protocol and statistical analysis plan for the Restrictive Fluid Administration vs. Standard of Care in Emergency Department Sepsis Patients (REFACED Sepsis)—a multicenter, randomized clinical proof-of-concept trial. The aim of the REFACED Sepsis trial is to test if a restrictive intravenous fluid protocol in emergency department patients with sepsis without shock is feasible and decreases the intravenous fluid volume administered in comparison to standard care.MethodsThis is an investigator-initiated, multicenter, randomized, parallel-group, open-labeled, feasibility trial investigating volumes of crystalloid fluid within 24 h in 124 patients with sepsis without shock enrolled at three emergency departments in the Central Denmark Region. Patients are allocated to two different intravenous fluid regimens: a restrictive approach using four trigger criteria for fluid administration vs. standard care.The primary, feasibility outcome is total intravenous, crystalloid fluid volume within 24 h, and key secondary outcomes include protocol violations, total fluids (intravenous and oral) within 24 h, and serious adverse reactions and suspected unexpected serious adverse reactions.Status: The trial started in November 2021, and the last patient is anticipated to be included in January 2022.DiscussionSepsis is very common in emergency department patients and fluid administration is very frequently administered in these patients. However, the evidence to guide fluid administration is very sparse. This feasibility trial will be the foundation for a potential future large-scale trial investigating restrictive vs. standard fluid administration in patients with sepsis.Trial registrationEudraCT number: 2021-000224-35 (date: 2021 May 03), ClinicalTrials.gov number: NCT05076435 (date: 2021 October 13), Committee on Health Research Ethics – Central Denmark Region: 1-10-72-163-21 (date: 2021 June 28).

Perioperative challenges in the management of a Jehovah’s Witness patient undergoing parenchyma sparing hepatectomy

Jehovah’s Witness patients presenting for liver surgery pose challenges to the anesthetists as well as the surgeons, due to their abstinence from receiving blood products. Despite this, surgery is the only curative option for operable colorectal liver metastases (CRLM). We report a case of a Jehovah’s Witness with multiple comorbidities who had a parenchyma sparing hepatectomy (PSH) complicated by intraoperative bleeding. A 52-year-old ASA II patient with hypertension, diabetes and ischemic heart disease on dual antiplatelet therapy was scheduled for open PSH for multiple bilobar CRLMs. He was prehabilitated with an emphasis on enhancing erythropoiesis and improving his functional capacity. PSH was done using a Cavitron ultrasonic surgical aspirator (CUSA) with intermittent Pringle maneuver, a low central venous pressure and restricted intravenous fluids. His postoperative recovery was complicated by a minor upper gastrointestinal bleed that was managed conservatively.&#x0D; The authors certify that informed written consent has been obtained from patient for publication.&#x0D; Keywords: Jehovah’s Witness; Liver surgery; Anesthesia; Hepatectomy&#x0D; Citation: Dassanayake V, Sivaganesh S, Subasinghe D, Pitigala P. Perioperative challenges in the management of a Jehovah’s Witness patient undergoing parenchyma sparing hepatectomy. Anaesth. pain intensive care 2021;26(1):119–122 ;&#x0D; DOI: 10.35975/apic.v26i1.1787&#x0D; Received: October 16, 2021, Reviewed: October 28, 2021, Accepted: November 07, 2021

A COMPARATIVE STUDY OF BIOCHEMICAL PARAMETERS AND ELECTROLYTES IN PATIENTS UNDERGOING MAJOR ABDOMINAL AND GYNAECOLOGICAL SURGERIES

To compare Biochemical Parameters and Electrolytes in patients undergoing major abdominal &amp; gynaecological surgeries. 60 patients of either gender of ASA grade I and II scheduled for abdominal &amp; gynaecological surgeries in 9 months durations at AIIMS, Rishikesh were recruited for the study. Patients were divided into 2 groups. Group I was conventional (‘traditional practice’) intravenous fluid group in which balanced salt solution was given as 10 mL/kg bolus followed by 8 mL/kg/hour as infusion until the end of surgery. Group II was restrictive (‘zero balance’) intravenous fluid group in which balanced salt crystalloid at 5 mL/kg/hour as infusion was administered until the end of surgery. Parameters studied were weight, height, BMI, blood urea level, serum creatinine, serum cystatin C levels, serum sodium, serum potassium, serum chloride and eGFR level. Mean age of patients in group I was 47.7 years and in group II was 47.6 years. The mean weight was 54.7 Kgs in group I and 57. Kgs in group II. The mean height was 162.2 cms in group I and 162.6 cms in group II. The mean BMI was 15.1 kg/m2 in group I and 16.04 kg/m2 in group II. The difference found to be non- significant (P&gt; 0.05). Restricted fluid therapy resulted in an increased risk of renal injury as depicted by higher increase in cystatin C levels and resultant fall in estimated GFR.

Male sex, ostomy, infection, and intravenous fluids are associated with increased risk of postoperative ileus in elective colorectal surgery

BackgroundPostoperative ileus is a common and costly complication after elective colorectal surgery. Effects of intravenous fluid administration remain controversial, and the effect of ostomy construction has not been fully evaluated. Various restrictive intravenous fluid protocols may adversely affect renal function. We aimed to investigate the impact of intestinal reconstruction and intravenous fluid on ileus and renal function after colorectal resection under an enhanced recovery protocol. MethodsA retrospective study of a prospectively maintained institutional database for a tertiary academic medical center following National Surgical Quality Improvement Program standards was reviewed, analyzing elective colorectal resections performed under enhanced recovery protocol from 2015 to 2018. Postoperative ileus was defined as nasogastric decompression, nil per os >3 days postoperatively, or nasogastric tube insertion. Patients with and without ileus were compared. Intravenous fluid and different anastomoses and ostomies were investigated. Acute kidney injury was a secondary outcome, due to the potential of renal damage with restriction of intravenous fluid volume during and after surgery and controversy in current literature in this matter. ResultsPostoperative ileus occurred in 18.5% of patients (n = 464). Male sex (odds ratio 1.97, 95% confidence interval 1.12–3.52) and postoperative infection (odds ratio 2.13, 95% confidence interval 1.03–4.35) were associated with ileus. Compared to colorectal anastomosis, ileostomy/ileorectal anastomosis had the highest risk of ileus (odds ratio 4.9, 95% confidence interval 2.33–11.3), colostomy second highest (odds ratio 3.3, 95% confidence interval 1.35–8.39), while ileocolic anastomosis did not significantly differ (odds ratio 2.06, 95% confidence interval 0.69–5.85) on multivariate analysis. Each liter of intravenous fluid within the first 72 hours significantly correlated with postoperative ileus (odds ratio 1.41, 95% confidence interval 1.27–1.59). Rates of acute kidney injury did not differ (P = .18). ConclusionEach additional liter of intravenous fluid given in the first 72 hours increased the risk of postoperative ileus 1.4-fold. There is substantially higher risk of ileus with male sex, infection, ileostomy/ileorectal anastomosis, and colostomy. Judicious use of intravenous fluid, as described in our enhanced recovery protocol, is not detrimental for renal function in the setting of normal baseline.

The predictors of Enhanced Recovery After Surgery utilization and practice variations in elective colorectal surgery: a provincial survey

Enhanced Recovery After Surgery (ERAS) protocols use evidence-based perioperative practices that reduce morbidity and length of stay and improve patient satisfaction. ERAS is considered standard of care; however, utilization remains low and substantial practice variation exists. The aim of this study was to pragmatically characterize variation in colorectal surgery practice and identify predictors of ERAS utilization. A survey of general surgeons identified using the Ontario College of Physicians and Surgeons database was conducted. Information on basic demographic characteristics, utilization of ERAS and predictors of ERAS implementation was collected. Nine ERAS behaviours were analyzed. Multivariable analysis was used to determine effects of demographic, hospital and surgeon covariates on ERAS utilization. Seven hundred and ninety-seven general surgeons were invited to participate in the survey, and 235 general surgeons representing 84 Ontario hospitals responded (30% response rate). Surgeons practising in academic settings and in large community hospitals represented 30% and 47% of the respondents, respectively. A total of 20% of the respondents used all 9 ERAS behaviours consistently. Rates of diet advancement on postoperative day 0, intravenous fluid restriction and having catheter and line procedures were significantly higher among respondents who adhered to ERAS protocols than among those who did not (74% v. 54%, p = 0.004; 92% v. 80%, p = 0.01; and 91% v. 41%, p < 0.001, respectively). Respondents from academic settings reported practising nearly 1 more ERAS behaviour than those from small community hospitals (odds ratio [OR] 0.86, 95% confidence interval [CI] 0.42 to 1.31, p < 0.001). Multivariable analysis demonstrated that colorectal fellowship training or exposure to ERAS during training did not significantly affect ERAS behaviour utilization (OR 0.32, 95% CI -0.31 to 0.94, p = 0.16; OR 0.28, 95% CI -0.26 to 0.82, p = 0.16, respectively). Substantial practice variation in colorectal surgery still exists. Individual ERAS principles are commonly followed; however, ERAS behaviours are not widely formalized into hospital protocols.

Does a restrictive intravenous fluid strategy lead to improved outcomes in patients undergoing major abdominal surgery as compared with liberal intravenous fluids?

University of Missouri School of Medicine, Columbia, MO The authors declare no conflicts of interest.

El Proyecto ACERTO: un protocolo multimodal barato y eficaz para América Latina

The ACERTO project is a multimodal peri-operative care program. The set of routines and prescriptions of the ACERTO project is based on evidence-based medicine as opposed to traditional care, often empirical and taught in the same routine by successive generations of surgeons. Traditional care such as the use of nasogastric tube, abdominal drainage, preoperative colonic preparation, preoperative fasting of 6-8 hours are modified in the project based on evidence from randomized studies and meta-analysis. In addition, the project reinforces the restriction of intravenous fluids and the use of nutritional therapy in the peri-operative. The application of the ACERTO project since 2005 has been modifying results, showing significant reduction of hospitalization days and postoperative morbidity in successive clinical studies. The ACERTO project is free to use.

Restrictive versus Liberal Fluid Therapy for Post-Cesarean Acute Kidney Injury in Severe Preeclampsia: a Pilot Randomized Clinical Trial

OBJECTIVES:The aim of this study was to determine whether a restrictive compared to a liberal fluid therapy will increase postoperative acute kidney injury (AKI) in patients with severe preeclampsia.METHODS:A total of 46 patients (mean age, 32 years; standard deviation, 6.8 years) with severe preeclampsia were randomized to liberal (1500 ml of lactated Ringer’s, n=23) or restrictive (250 ml of lactated Ringer’s, n=23) intravenous fluid regimen during cesarean section. The primary outcome was the development of a postoperative renal dysfunction defined by AKI Network stage ≥1. Serum cystatin C and neutrophil gelatinase-associated lipocalin (NGAL) were evaluated at postoperative days 1 and 2. ClinicalTrials.gov: NCT02214186.RESULTS:The rate of postoperative AKI was 43.5% in the liberal fluid group and 43.5% in the restrictive fluid group (p=1.0). Intraoperative urine output was higher in the liberal (116 ml/h, IQR 69-191) than in the restrictive fluid group (80 ml/h, IQR 37-110, p<0.05). In both groups, serum cystatin C did not change from postoperative day 1 compared to the preoperative period and significantly decreased on postoperative day 2 compared to postoperative day 1 (p<0.05). In the restrictive fluid group, NGAL levels increased on postoperative day 1 compared to the preoperative period (p<0.05) and decreased on postoperative day 2 compared to postoperative day 1 (p<0.05).CONCLUSION:Among patients with severe preeclampsia, a restrictive fluid regimen during cesarean section was not associated with increased postoperative AKI.

Impact of left ventricular dysfunction and fluid balance on the outcomes of patients with sepsis

ObjectiveLeft ventricular (LV) dysfunction is a predictor of mortality in patients with sepsis. However, whether the adverse impact of LV dysfunction depends on fluid balance remains unclear. We retrospectively investigated the impact of LV dysfunction and fluid balance on various outcomes of patients with sepsis. MethodsCritically ill patients with sepsis were classified according to their LV function: normal LV function, diastolic dysfunction (septal e′ of <10 and E/e′ of ≥15 with ejection fraction of ≥50%), and systolic dysfunction (ejection fraction of <50%). ResultsThere were 83 (51.2%) patients with normal LV function, 39 (24.1%) with diastolic dysfunction, and 40 (24.7%) with systolic dysfunction. The cumulative and daily fluid balances after intensive care unit admission did not differ. However, acute kidney injury was more prevalent in the patients with diastolic and systolic dysfunction than in those with normal LV function (82.1%, 87.5%, and 69.9%, respectively; P = 0.065). LV dysfunction lengthened the duration of renal replacement therapy, independent of baseline renal dysfunction and the daily fluid balance (P = 0.008). Moreover, both diastolic and systolic dysfunction were associated with mortality (hazard ratio: 2.7 and 3.0; P = 0.047 and P = 0.028, respectively), regardless of the daily fluid balance, which was also a significant predictor of mortality (P < 0.001). ConclusionsLV dysfunction has an adverse impact on renal outcomes and mortality in patients with sepsis and seems to be independent of fluid balance. Additional therapeutic options to restore organ perfusion are needed for patients with sepsis who have LV dysfunction, in addition to intravenous fluid restriction.

Understanding Gene Therapy in Acute Respiratory Distress Syndrome.

Acute Respiratory Distress Syndrome (ARDS) and its complications remain lifethreatening conditions for critically ill patients. The present therapeutic strategies such as prone positioning ventilation strategies, nitric oxide inhalation, restrictive intravenous fluid management, and extracorporeal membrane oxygenation (ECMO) do not contribute much to improving the mortality of ARDS. The advanced understanding of the pathophysiology of acute respiratory distress syndrome suggests that gene-based therapy may be an innovative method for this disease. Many scientists have made beneficial attempts to regulate the immune response genes of ARDS, maintain the normal functions of alveolar epithelial cells and endothelial cells, and inhibit the fibrosis and proliferation of ARDS. Limitations to effective pulmonary gene therapy still exist, including the security of viral vectors and the pulmonary defense mechanisms against inhaled particles. Here, we summarize and review the mechanism of gene therapy for acute respiratory distress syndrome and its application.

PERioperative Fluid Management in Elective ColecTomy (PERFECT)—a national prospective cohort study

There is contradictory evidence regarding the merits of restricted versus liberal perioperative intravenous (IV) fluid administration in bowel surgery. This study sought to audit perioperative fluid management in elective colectomy in Ireland and to analyse the impact of such onoperative outcomes. A national surgical trainee collaborative audit of perioperative fluid management was performed. Data from each site was collected prospectively over a selected 3-week period within a pre-defined 2-month block. Collected variables included demographics, type of operation/anaesthethic, volume/type of fluid administration pre-, intra- and post-operatively, 30-day morbidity and mortality. Primary outcome was fluid balance 24-h post-operatively with further analysis to identify the impact of this on 30-day morbidity. ROC curves were generated to identify the critical volume at which fluid balance was associated with 30-day morbidity. Ninety-four patients were enrolled from 17 hospitals. Mean age was 64years. A total of 48.9% (N = 46) were managed by ERAS and 51.1% (N = 48) received bowel preparation. Almost 70% of cases (N = 63) were completed by minimally invasive techniques. Significant 30-day morbidity requiring hospital readmission was low [6.4% (n = 6)]. Median fluid balance at 24h was + 715ml (IQR 165-1486ml). On multivariate analysis, high BMI (p = 0.02), indication for surgery (p = 0.02) and critical care admission (p = 0.008) were significantly predictive of 30-day morbidity. Twenty-four hour fluid balance >+ 665ml was associated with increased risk of 30-day morbidity on univariate but not multivariate analysis, implying association but not causation. Overall, perioperative fluid management was within an acceptable range with minimal impact on 30-day morbidity following elective colorectal surgery.

Conservative Fluid Management After Sepsis Resuscitation: A Pilot Randomized Trial.

The feasibility and clinical outcomes of conservative fluid management after sepsis resuscitation remain unknown. To evaluate the effect of a conservative fluid management protocol on fluid balance and intensive care unit (ICU)-free days among patients with sepsis. In a single-center phase II/III randomized trial, we enrolled adults with suspected infection, ≥2 systemic inflammatory response syndrome criteria, and either shock (mean arterial pressure <60 mm Hg or vasopressors) or respiratory insufficiency (mechanical ventilation or oxygen saturation <97% and fraction of inspired oxygen ≥0.3). Patients were randomized 1:1 to usual care or a conservative fluid management protocol. The protocol restricted intravenous fluid administration during shock to treatment of oliguria or increasing vasopressor requirement. In the absence of shock, loop diuretic infusion targeted equal fluid input and output each study day. The primary outcomes were mean daily fluid balance (phase II) and ICU-free days (phase III). At the completion of phase II (n = 30), the difference in mean daily fluid balance between groups (-398 mL) was less than the prespecified threshold (-500 mL) and the trial was stopped. Patients in the conservative fluid management (n = 15) and usual care (n = 15) groups experienced similar cumulative fluid input (8450 mL vs 7049 mL; P = .90) of which only 14% was intravenous crystalloid or colloid. Loop diuretic infusion occurred more frequently in the conservative fluid management group (40% vs 0%; P = .02), and cumulative fluid output was 10 645 mL in the conservative fluid management group compared to 6286 mL in the usual care group (P = .39). Hemodynamic, respiratory, and renal function did not differ between the groups. In this phase II trial, a conservative fluid management protocol did not decrease mean daily fluid balance by more than 500 mL among patients with sepsis. Clinicaltrials.gov; NCT02159079.

Implementation of Enhanced Recovery after Surgery (ERAS) Program in Perioperative Management of Gastric Cancer Surgery: a Nationwide Survey in Korea.

PurposeDespite its clinical benefits, enhanced recovery after surgery (ERAS) is less widely implemented for gastric cancer surgery. This nationwide survey investigated the current status of the implementation of ERAS in perioperative care for gastric cancer surgery in South Korea.Materials and MethodsThis survey enrolled 89 gastric surgeons from 52 institutions in South Korea. The questionnaire consisted of 24 questions about the implementation of the ERAS protocols in the management of gastric cancer surgery. The survey was carried out using an electronic form sent via email.ResultsOf the 89 gastric surgeons, 58 (65.2%) answered that they have knowledge of the concept and details of ERAS, 45 (50.6%) of whom were currently applying ERAS for their patients. Of the ERAS protocols, preoperative education (91.0%), avoidance of preoperative fasting (68.5%), maintenance of intraoperative normothermia (79.8%), thromboprophylaxis (96.5%), early active ambulation (64.4%), and early removal of urinary catheter (68.5%) were relatively well adopted in perioperative care. However, other practices, such as avoidance of preoperative bowel preparation (41.6%), provision of preoperative carbohydrate-rich drink (10.1%), avoidance of routine abdominal drainage (31.4%), epidural anesthesia (15.9%), single-dose prophylactic antibiotics (19.3%), postoperative high oxygen therapy (36.8%), early postoperative diet (14.6%), restricted intravenous fluid administration (53.9%), and application of discharge criteria (57.3%) were not very well adopted for patients.ConclusionsPerioperative management of gastric cancer surgery is largely heterogeneous among gastric surgeons in South Korea. Standard perioperative care based on scientific evidence needs to be established to improve the quality of surgical care and patient outcomes.

Cortical Blindness in Eclampsia

Visual disturbances are common with severe preeclampsia, however, blindness either alone or with convulsions is uncommon. Most women with varying degree of amaurosis are found to have radiographic evidence of extensive occipital lobe hypodensities.In this case report, we present the clinical course of a women in whom preeclampsia was further complicated by blindness.These were managed by standard pre eclampsia- eclampsia regimen used at our hospital which includes Diazepam /Phenytoin/Magnesium sulphate, therapy to control seizures, inj. labetelol to lower elevated blood pressure,intravenous fluid restriction and termination of pregnancy. Abnormal findings in these women were seen by magnetic resonance imaging technique. MRI demonstrated hyperdense lesion in both tempoparietal and occipital regions on T1W sequence.Total blindness persisted for 72 hrs and vision statrted improving and at the time of discharge vision improved significantly, however there was not much difference was seen on MRI.International Journal of Human and Health Sciences Vol. 03 No. 01 January’19. Page : 26-28