Total Amount Of Fluid Research Articles

Outcomes related to intravenous fluid administration in sickle cell patients during vaso-occlusive crisis.

While fluid replacement therapy is a primary treatment modality used in vaso-occlusive crises for sickle cell disease, data is limited on its safety, efficacy, and variability. We performed a retrospective analysis on 157 unique patient encounters from 49 sickle cell patients hospitalized with a vaso-occlusive episode at our institution from 2013 to 2017. The median length of hospital stay was 4days (IQR 2-7). The mean total amount of intravenous fluid administered during the hospitalization was 7.4L (Std 9.6). The mean total amount of fluid intake including intravenous fluids, blood transfusions, and oral fluids was 14.2L (Std 18.2). Multivariate analyses revealed significant associations between the development of any adverse event (including a new oxygen requirement, acute chest syndrome, aspiration event, other hospital-acquired infection, acute kidney injury, and intensive care unit transfer)and the following variables: intravenous fluid administered in the first 24h (p = 0.001, OR 1.899, 95% CI 1.319-2.733), total amount of intravenous fluid administered (p = 0.005, OR 1.081, 95% CI 1.023-1.141), and total amount of fluid intake including oral fluids, blood transfusions, and intravenous fluids (p = 0.009, OR 1.046, 95% CI 1.011-1.081). Other factors found to be significantly associated with any adverse event were dialysis dependence prior to admission (p < 0.001, OR 12.984, 95% CI 3.660-46.056) and admission to aninpatient service versus anemergency room or observation unit (p = 0.008, OR 3.201, 95% CI 1.346-7.612). While fluid administration may theoretically slow the sickling process, this data suggests that fluid administration during a vaso-occlusive episode, and especially total volume given in the first 24h, may also lead to adverse events.

Management of Patients With Sepsis in Canadian Community Emergency Departments: A Retrospective Multicenter Observational Study.

Background:Sepsis is a life-threatening syndrome and a leading cause of morbidity and mortality representing significant financial burden on the health-care system. Early identification and intervention is crucial to maximizing positive outcomes. We studied a quality improvement initiative with the aim of reviewing the initial management of patients with sepsis in Canadian community emergency departments, to identify areas for improving the delivery of sepsis care. We present a retrospective, multicenter, observational study during 2011 to 2015 in the community setting.Methods:We collected data on baseline characteristics, clinical management metrics (triage-to-physician-assessment time, triage-to-lactate-drawn time, triage-to-antibiotic time, and volume of fluids administered within the first 6 hours of triage), and outcomes (intensive care unit [ICU] admission, in-hospital mortality) from a regional database.Results:A total of 2056 patients were analyzed. The median triage-to-physician-assessment time was 50 minutes (interquartile range [IQR]: 25-104), triage-to-lactate-drawn time was 50 minutes (IQR: 63-94), and triage-to-antibiotics time was 129 minutes (IQR: 70-221). The median total amount of fluid administered within 6 hours of triage was 2.0 L (IQR: 1.5-3.0). The ICU admission rate was 36% and in-hospital mortality was 25%. We also observed a higher ICU admission rate (51% vs 24%) and in-hospital mortality (44% vs 14%) in those with higher lactate concentration (≥4 vs ≤2 mmol/L), independent of other sepsis-related parameters.Conclusion:Time-to-physician-assessment, time-to-lactate-drawn, time-to-antibiotics, and fluid resuscitation in community emergency departments could be improved. Future quality improvement interventions are required to optimize management of patients with sepsis. Elevated lactate concentration was also independently associated with ICU admission rate and in-hospital mortality rate.

Reduction of drainage-associated complications in cardiac surgery with a digital drainage system: a randomized controlled trial.

Thoracic chest drains are placed after cardiac surgery allowing for the clearance of blood, fluid, and air to prevent post-operative complications. Despite its importance, there is little data on the application of digital chest drainage systems in cardiac surgery. Therefore, the differences between an analog and a digital chest drainage system in cardiac surgery patients were investigated in a randomized controlled trial. A total of 354 elective cardiac surgery patients were preoperatively randomized 1:1 between September 2016 and September 2017 to either an analog (Ocean) or a digital (Thopaz+) chest drainage system aiming to compare drainage-associated postoperative outcome parameters. A total of 340 patients were included in the analysis (analog: 188; digital: 152) with no significant differences in preoperative baseline parameters. Incidence of X-rays to detect air leaks was significantly lower in the digital group (analog: 20.2%; digital: 8.6%; P<0.01). Patients treated with the digital system showed a 3.3% reduction of re-thoracotomies, however, not statistically significant (analog: 5.3%; digital: 2.0%; P=0.19). Median total fluid amount did not significantly differ between study groups [median (P25; P75); analog: 705 (400; 1,333) mL; digital: 686 (404; 1,229) mL; P=0.83]; however, the use of the digital drainage system resulted in a quicker removal with a reduced median drainage duration of 16 hours (analog: 65 hours; digital: 49 hours; P≤0.01). The study provides evidence that digital drainage systems can be safely applied in cardiac surgery patients. The use of the digital management system led to a decreased incidence of drainage-associated complications as well as to shortened chest tube duration. Findings require confirmation by additional studies.

Outcomes Related to Intravenous Fluid Administration in Sickle Cell Patients during Vaso-Occlusive Crisis

Introduction Fluid replacement therapy is often used as a primary treatment modality in vaso-occlusive crises for sickle cell disease. However, aggressive intravenous fluid administration can lead to complications, including pulmonary vascular congestion and acute chest syndrome. Data is limited on the safety, efficacy, and variability of fluid replacement therapy in this context. This study describes the extent of and outcomes associated with receiving fluid replacement therapy for vaso-occlusive episodes at a single institution. Methods We performed a retrospective analysis on 157 unique patient encounters from 49 sickle cell patients hospitalized with a vaso-occlusive episode at the University of California Los Angeles between 2013 and 2017. Fluid administration measurements were derived from documented intakes (both oral and intravenous fluids) in the medical record. The association between fluid administration and outcomes were analyzed using chi-squared and Fisher's exact tests followed by univariate and multivariate logistic regression. Results The mean age of the patient cohort at the time of hospital admission was 36.0 years (Std 7.9). Most encounters were from patients with hemoglobin SS disease (147 encounters, 93.6%). Twenty-two of the encounters (14.0%) were from patients on hemodialysis prior to admission. The majority of admissions were to an observation unit (99 encounters, 63.1%), whereas 53 admissions (33.8%) were to an inpatient service and 5 encounters (3.2%) were solely in the emergency room. The median length of hospital stay was 4 days (IQR 2-7). The mean total amount of intravenous fluid administered during the hospitalization was 7.4 L (Std 9.6). The mean total amount of fluid intake including intravenous fluids, blood transfusions, and oral fluids was 6.5 L (Std 10.0) (Table 1). The most common clinical outcome that occurred during the hospitalizations was a new oxygen requirement in 28 encounters (17.8%). Other clinical outcomes noted were acute chest syndrome (12 encounters, 7.6%), an aspiration event (2 encounters, 1.3%), other type of hospital-acquired infection (2 encounters, 1.3%, which included Clostridium difficile colitis and Staphylococcus epidermidis bacteremia), acute kidney injury (3 encounters, 1.9%), and intensive care unit transfer (3 encounters, 1.9%). There was a significant association between receiving more than 3 L of intravenous fluid and the development of any of the adverse events listed (p = 0.029) but no association between fluid administration and each individual adverse event (Table 2). Logistic regression analysis confirmed that patients with higher fluid intake were more likely to develop any adverse event (Table 3, Table 4). In multivariable analysis, each component including oral intake during hospitalization (p = 0.041, OR 1.065, 95% CI 1.003-1.132), intravenous fluid administered in the first 24 hours (p = 0.001, OR 1.899, 95% CI 1.319-2.733), total amount of intravenous fluid administered (p = 0.005, OR 1.081, 95% CI 1.023-1.141), and total amount of fluid intake (p = 0.040, OR 1.065, 95% CI 1.003-1.132) all revealed a statistically significant association between higher fluid administration and the development of any adverse event. Other factors found to be significantly associated with any adverse event were dialysis dependence prior to admission (p = 0.000, OR 8.686, 95% CI 2.881-26.190) and admission to inpatient service versus emergency room or observation unit (p = 0.018, OR 2.758, 95% CI 1.186-6.416). Conclusions There was a statistically significant association between higher fluid intake (both oral and intravenous) and the development of any adverse event during hospitalization for sickle cell vaso-occlusive crisis including a new oxygen requirement, acute chest syndrome, aspiration event, other hospital-acquired infection, acute kidney injury, and intensive care unit transfer. While fluid administration may theoretically slow the sickling process, our data suggests that excessive fluid administration during a vaso-occlusive episode may be harmful. Further study is necessary to further elucidate the relationships between exogenous fluids, vaso-occlusion, and adverse events in sickle cell patients. *Equal contribution from Daria Gaut and Jennifer Jones for this work. Disclosures No relevant conflicts of interest to declare.

Enhanced recovery after cardiac surgery: fluid balance and incidence of acute kidney injury

Introduction Enhanced Recovery after Cardiac Surgery (ERACS) pathways can increase patient satisfaction, reduce the length of hospital stay and stay in the intensive care unit. The reported incidence of acute kidney injury (AKI) after cardiac surgery varies from 2.5% to 40% and is associated with an increased 30-day mortality¹. We examined the effect of ERACS on the total amount of fluid administered and the incidence of AKI. Methods We retrospectively analyzed prospectively collected outcome data of patients undergoing cardiac surgery enrolled in the ERAS pathway (n = 107) compared to a historical standard care group (n = 173). The ERAS pathway included pre-operative patient education, multimodal pain management to minimize opioid usage, carbohydrate loading 2-4hrs before induction of anesthesia, tight glucose control, early postoperative invasive access and chest tube removal, early extubation, and early mobilization. Intraoperatively, 500mL of the cardiopulmonary bypass (CBP) priming fluid was replaced with albumin 5% and the patients received 250mL albumin 5% before initiation and 250mL after separation from CBP. Crystalloid boli were administered in the intensie care unit (ICU) for clinical signs of hypovolemia, increasing pressor requirements or worsening metabolic acidosis. The standard care group was treated per preexisting institutional guidelines. AKI was defined using modified KDIGO (Kidney Disease Improving Global Outcomes) criteria, patients with pre-existing renal injury were excluded. Data were compared using univariate analysis: parametric and non-parametric data were analyzed with Student's t-test and Wilcoxon rank-sum test, respectively. A p-value of less than 0.05 was considered statistically significant. Results The mean (SD) creatinine pre-operatively, at discharge, and the peak creatinine were not different between the ERACS and the standard care group (table). Less fluid was administered in the ERACS group, but the total fluid balance was not different. No significant difference exists between the occurrence of AKI between those groups; no patient developed AKI worse than KDIGO stage 1 (modified). Discussion Although the ERACS patients received less fluid than the standard care group during the hospital stay, the incidence of AKI did not differ, nor did the serum creatinine at discharge between both groups. A restrictive fluid management with intraoperative albumin administration does not increase the incidence of acute kidney injury for patients in the ERACS pathway.

Quantum of fluids in hospitalised patients with dengue fever and the presence of warning signs: a pilot cross-sectional study

Background: The World Health Organization in 2009 revised categories of dengue fever severity into classes A, B, and C based on the presence or absence of warning signs. The quantum of oral and intravenous fluids (IVF) in hospitalised patients with Group B (warning signs) has, to our knowledge, not been studied. Oral fluids in hospitalised patients and monitoring administration with the help of patients’ relatives have not been assessed. Methods: Consecutive patients with dengue fever and warning signs were studied for 48 hours after hospitalisation. Patients were asked to consume 4-5 l of fluids. Maintenance and bolus IVF were administered depending upon the presence of compensated or hypotensive shock. Intake and urinary output were monitored by the patient’s attendant. Total fluids (oral and intravenous) were divided by a number of anthropometric measurements. The significance of warning signs, compensated and hypotensive shock, thrombocytopenia, bleeding episodes and the need for transfusions, and organ impairment were considered in relation to the total amount of fluids received daily. Results: In total, 43 patients were studied. Patients with obesity and hypotensive shock received significantly more fluids on Day 1; taller patients and those with tachycardia, higher haematocrit and elevated creatine kinase correspondingly received more on Day 2. Hypotensive shock was significantly correlated with fluids/BSA, fluids/weight and fluids/BMI, while laboratory parameters correlated most strongly with fluids/BMI. Conclusions: Most adults with dengue and warning signs seem to require &gt;100 ml/kg/day of fluids during their stay. Advising a similar amount of fluids at home during epidemics may further reduce the need for admissions. Participation of patients and their relatives in the bedside management of fluid administration may go a long way in preventing morbidity and mortality. Adults probably need a better anthropometric measurement to decide on the quantum of fluids to be given.

Goal-directed fluid therapy on laparoscopic colorectal surgery within enhanced recovery after surgery program

Abstract Introduction Enhanced recovery after surgery protocols (ERAS) are used in peri-operative care to reduce the stress response to surgical aggression. As fluid overload has been associated with increased morbidity and delayed hospital discharge, a major aspect of this is fluid management. Intra-operative goal-directed fluid protocols have been shown to reduce post-operative complications, particularly in high risk patients. Objective To compare 2 fluid therapy models (zero-balance versus goal-directed fluid therapy) in patients who were scheduled for laparoscopic colorectal surgery within an ERAS program, recording the rate of complications such as surgical site infection, ileus, post-operative nausea and vomiting, and variability of the estimated glomerular filtration rate (eGFR). Materials and methods An observational, retrospective study was conducted including adults who were scheduled for elective laparoscopic colorectal surgery within an ERAS program, and to investigate the postoperative complication rate. Results A total of 128 patients were included in this study; 43 (33.6%) in the zero-balance group and 85 (66.4%) in the goal-directed fluid therapy group. The total fluids administered was lower in the goal-directed fluid therapy group, as well as the incidence of post-operative complications (surgical site infection, anastomotic leak, ileus, and postoperative nausea and vomiting). No significant differences were found for length of stay, intra-operative urine output, and variability of the eGFR. Conclusion The results of this study show that by using a goal-directed fluid therapy algorithm, the total amount of fluids administered can be reduced, as well as obtaining a lower incidence of post-operative complications.

Efecto de la fluidoterapia guiada por objetivos en cirugía colorrectal laparoscópica dentro de un protocolo de rehabilitación multimodal

IntroductionEnhanced recovery after surgery protocols (ERAS) are used in peri-operative care to reduce the stress response to surgical aggression. As fluid overload has been associated with increased morbidity and delayed hospital discharge, a major aspect of this is fluid management. Intra-operative goal-directed fluid protocols have been shown to reduce post-operative complications, particularly in high risk patients.?. ObjectiveTo compare 2fluid therapy models (zero-balance versus goal-directed fluid therapy) in patients who were scheduled for laparoscopic colorectal surgery within an ERAS program, recording the rate of complications such as surgical site infection, ileus, post-operative náusea and vomiting, and variability of the estimated glomerular filtration rate (eGFR). Materials and methodsAn observational, retrospective study was conducted including adults who were scheduled for elective laparoscopic colorectal surgery within an ERAS program, and to investigate the postoperative complication rate. ResultsA total of 128 patients were included in this study; 43 (33.6%) in the zero-balance group and 85 (66.4%) in the goal-directed fluid therapy group. The total fluids administered was lower in the goal-directed fluid therapy group, as well as the incidence of post-operative complications (surgical site infection, anastomotic leak, ileus, and postoperative náusea and vomiting). No significant differences were found for length of stay, intra-operative urine output, and variability of the eGFR.?. ConclusionThe results of this study show that by using a goal-directed fluid therapy algorithm, the total amount of fluids administered can be reduced, as well as obtaining a lower incidence of post-operative complications.

Quantum of fluids in hospitalised patients with dengue fever and the presence of warning signs: a pilot cross-sectional study

Background: The World Health Organization in 2009 revised categories of dengue fever severity into classes A, B, and C based on the presence or absence of warning signs. The quantum of oral and intravenous fluids (IVF) in hospitalised patients with Group B (warning signs) have, to our knowledge, not been studied. Oral fluids in hospitalised patients and monitoring administration with the help of patients’ relatives have not been assessed. Methods: Consecutive patients with dengue fever and warning signs were studied for 48 hours after hospitalisation. Patients were asked to consume 4-5 l of fluids. Maintenance and bolus IVF were administered depending upon the presence of compensated or hypotensive shock. Intake and urinary output were monitored by the patient’s attendant. Total fluids (oral and intravenous) were divided by a number of anthropometric measurements. Significance of compensated and hypotensive shock, thrombocytopenia and 20% change in haematocrit, bleeding episodes and the need for transfusions, and organ impairment were considered in relation to the total amount of fluids received daily. Results: In total, 41 patients were studied. Patients with obesity and hypotensive shock received significantly more fluids on Day 1; taller patients and those with tachycardia, higher haematocrit and elevated creatine kinase correspondingly received more on Day 2. Hypotensive shock was significantly correlated with fluids/BSA and fluids/weight, while laboratory parameters correlated most strongly with fluids/BMI. Conclusions: Most adults with dengue and warning signs seem to require &gt;100 ml/kg/day of fluids during their stay. Advising a similar amount of fluids at home during epidemics may further reduce the need for admissions. Participation of patients and their relatives in the bedside management of fluid administration may go a long way in preventing morbidity and mortality. Adults probably need a better anthropometric measurement to decide on the quantum of fluids to be given.

Effect of restrictive fluid therapy with hydroxyethyl starch during esophagectomy on postoperative outcomes: a retrospective cohort study

BackgroundTo improve prognosis after esophageal surgery, intraoperative fluid optimization is important. Herein, we hypothesized that hydroxyethyl starch administration during esophagectomy reduce the total amount of fluid infused and it could have a positive effect on postoperative complication occurrence and mortality.MethodsAll consecutive adult patients who underwent elective esophageal surgery for cancer were studied. The primary outcome was the development of composite complications including death, cardio-cerebrovascular complications, respiratory complications, renal complications, gastrointestinal complications, sepsis, empyema or abscess, and multi-organ failure. The relationship between perioperative variables and composite complication was evaluated using multivariable logistic regression.ResultsOf 892 patients analyzed, composite complications developed in 271 (30.4%). The higher hydroxyethyl starch ratio in total fluid had a negative relationship with the total fluid infusion amount (r = − 0.256, P < 0.001). In multivariable analysis, intraoperatively administered total fluid per weight per hour (odds ratio, 1.248; 95% CI, 1.153–1.351; P < 0.001) and HES-to-crystalloid ratio (odds ratio, 2.125; 95% CI, 1.521–2.969; P < 0.001) were associated with increased risks of postoperative composite outcomes.ConclusionsAlthough hydroxyethyl starch administration reduces the total fluid infusion amount during esophageal surgery for cancer, intravenous hydroxyethyl starch infusion is associated with an increasing risk of postoperative composite complications.

Predictive value of serum albumin levels on noradrenaline and fluid requirements in the first 24 h after admission to the Intensive Care Unit — A prospective observational study

PurposeTo determine the predictive value of serum albumin (SA) at admission to the intensive care unit (ICU) on the cumulative dose of noradrenaline, the fluids administered, the lactate level, and mortality during the first 24 h of ICU admission. MethodsA total of 100 ICU patients were included. The association between SA and the cumulative dose of noradrenaline was analyzed using logistic regression. For the total amount of fluids administered linear regression, for the lactate level and for 24 h mortality logistic regression was used. Age, gender, patient category, type of surgery, severe sepsis, lactate level, estimated glomerular filtration rate, c-reactive protein level, and the target mean arterial pressure were considered effect modifiers. ResultsSA was significantly associated with the dose of noradrenaline (OR 0.92, 95% CI 0.84–0.99, p = 0.028), lower lactate levels (OR 1.14, 95% CI 1.00–1.30, p = 0.049), and with the amount of fluids administered (B -0.02, 95% CI −0.03/−0.00, p = 0.016), but not with mortality (OR 0.95, 95% CI 0.85–1.07, p = 0.41). ConclusionsSA significantly predicts noradrenaline and fluid requirements as well as the change in lactate level during the first 24 h of ICU admission. Our observations have to be validated in another large cohort.

Practical impact of a decision support for goal-directed fluid therapy on protocol adherence: a clinical implementation study in patients undergoing major abdominal surgery.

The purpose of this study was to assess the effects of using a real time clinical decision-support system, "Assisted Fluid Management" (AFM), to guide goal-directed fluid therapy (GDFT) during major abdominal surgery. We compared a group of patients managed using the AFM system with a historical cohort of patients (control group) who had been managed using a manual GDFT strategy. Adherence to the protocol was defined as the relative intraoperative time spent with a stroke volume variation (SVV) < 13%. We hypothesised that patients in the AFM group would have more time during surgery with a SVV < 13% compared to the control group. All patients had a radial arterial line connected to a pulse contour analysis monitor and received a 2ml/kg/h maintenance crystalloid infusion. Additional 250ml crystalloid boluses were administered whenever measured SVV ≥ 13% in the control group, and when the software suggested a fluid bolus in the AFM group. We compared 46 AFM-guided patients to 38 controls. Patients in the AFM group spent significantly more time during surgery with a SVV < 13% compared to the control group (median 92% [82, 96] vs. 76% [54, 86]; P < 0.0005), and received less fluid overall (1775ml [1225, 2425] vs. 2350ml [1825, 3250]; P = 0.010). The incidence of postoperative complications was comparable in the two groups. Implementation of a decision support system for GDFT guidance resulted in a significantly longer period during surgery with a SVV < 13% with a reduced total amount of fluid administered. Trial registration: Clinical Trials.gov (NCT03141411).

Prevention of arterial hypotension after spinal anaesthesia using vena cava ultrasound to guide fluid management

BackgroundSignificant hypotension is frequent after spinal anaesthesia and fluid administration as therapy is usually empirical. Inferior vena cava (IVC) ultrasound (US) is effective to assess fluid responsiveness in critical care patients. The aim of this study was to evaluate the IVCUS-guided volume optimization to prevent post-spinal hypotension. MethodsIn this prospective, randomized, cohort study, 160 patients scheduled for surgery under spinal anaesthesia were randomized into a study group (IVCUS-group), consisting of an IVCUS analysis before spinal anaesthesia with IVCUS-guided volume management and a control group (group C) with no IVCUS assessment. The primary outcome was a relative risk reduction in the incidence of hypotension between the groups; secondary outcomes were the need for vasoactive drugs and the amounts of fluids required after spinal anaesthesia. We also tested the hypothesis of a correlation between IVC collapsibility index and hypotension after spinal anaesthesia. ResultsThe relative risk reduction of hypotension between the groups was 35% (IVCUS-group 27.5%, Group C 42.5%, P=0.044, CI=95%). The need for vasoactive drugs in the IVCUS-group was significantly lower compared to the C-group (P=0.015), while the total amount of fluids was significantly superior higher in the IVCUS group (P<0.0001) compared to Group C. IVC collapsibility index was correlated with the amount of fluid administered (r2=0.32), but could not be used to predict postspinal anaesthesia hypotension. ConclusionsIVCUS is an effective method to prevent postspinal anaesthesia hypotension by IVCUS-guided fluid administration before spinal anaesthesia. Clinical trial registrationwww.clinicaltrials.gov - NCT02271477.

383 A Novel Technique for Improving Fluid Resuscitation in Septic Shock

Rapid fluid delivery is commonly required in sepsis and other conditions leading to shock and hypotension. Since gravity flow and infusion pumps are unable to deliver a fluid bolus rapidly, pressure bags are commonly used to increase flow rates. Disadvantages of this technique include progressive decrease in flow rate without continuous re-inflation of the bag, difficulty administering accurate doses, particularly with smaller volumes, and the risk of inadvertent air embolism. LifeFlow is an intuitive single-use device that provides rapid and controlled infusion, enabling a health care provider to administer a measured fluid bolus and quickly assess clinical response. This study will compare the LifeFlow to pressure bag in simulated out-of-hospital and hospital settings. Registered nurses and paramedics participated in a simulated septic shock resuscitation and were randomly assigned to administer repeated fluid boluses with the LifeFlow or pressure bag. Training was provided if the participant was not familiar with either method. Participants were given a clinical sepsis scenario that required administration of three, 500 ml boluses (totaling 1500 ml) through a 20G IV catheter into simulated patient. The scenario involved a variety of clinical tasks including a physical exam, vitals assessment, delivery of oxygen via nasal cannula, medication administration, manual charting, and fluid administration. Total scenario time and fluid infusion times were determined by video recording of the scenario. Fluid volume was measured by weight to determine the accuracy of each bolus. Variance was defined as difference between actual and desired fluid bolus volume. Fourteen providers (8 RNs, 6 Paramedics) delivered three 500 ml normal saline boluses during the septic shock scenario. Average time to completion of each bolus was 2.5 minutes for LifeFlow vs. 7.6 minutes for pressure bag. Total infusion time for 1500 ml was almost 3 times as fast for LifeFlow vs pressure bag (7.8 vs 22.8 minutes). Total time to completion of the sepsis scenario was 1.8 times as fast for LifeFlow compared pressure bag (20 vs. 36.3 minutes). Total fluid amount variance, above or below 1500ml, was greater for pressure bag infusion (1500 + 39.1 vs 184 ml, p=0.04). When compared to pressure bag, use of the LifeFlow device resulted in significantly faster time to completion of the septic shock resuscitation scenario. Times to completion of each bolus, and infusion time for the total 1500 ml, were significantly faster. The LifeFlow also reduced variance in the size of fluid bolus administered, indicating that clinicians can more accurately deliver the correct fluid volume and avoid inadvertently providing more fluid than is needed. This technique may offer a faster and more efficient method of fluid resuscitation in sepsis and septic shock.

Early enteral nutrition on the nursing of elderly patient with gastric cancer after total gastrectomy

Objective To discuss the clinical effects of early enteral nutrition on elderly patient with gastric cancer after total gastrectomy. Methods A total of 138 elderly patients with gastric cancer after total gastrectomy in Renji Hospital Shanghai Jiaotong University School of Medicine from September 2014 to September 2016 were selected using purposive sampling. They were divided into the observation (n=73) and control (n=65) groups using random number table. Patients in the control group were given parenteral nutritional support. The energy was 125 KJ/ (kg.d) ; nitrogen content was 0.15 g/ (kg.d) ; total fluid amount was 50 ml/ (kg.d) . They were prepared to bags of 3 L and given by intravenous dripping through internal jugular vein. After the anal exhaust and removing gastric tube, patients were routinely given from water to clear fluid diet, fluid diet, semi-fluid diet until normal diet. Patients in the observation group received indwelling three-lumen gastrojejunal tube. At 12 h after the operation, heating 100 ml 5% glucose were given through three-lumen gastrojejunal tube. At 24 h after the operation, Ruidai (enteral nutritional suspension-TPF) were given at the total 500 ml and increased by 500 ml/d until 1 500 ml at 4 d after the operation. The drop speed increased from 20 ml/h to 100 ml/h. The incidence of postoperative complications, the anal exhaust time, the leaving bed time, hospital days and nutritive indexes were compared between the two groups. Results The hospital days, anal exhaust time and the leaving bed time in the observation group were (12.9±5.9) d, (70.3±16.7) h and (15.24±13.28) h, which were significantly lower than those in the control group [ (18.6±6.9) d, (97.5±22.3) h and (29.95±15.23) h] (P<0.05) . There was 1 case of diarrhea in the observation group, while 2 cases of anastomotic leakage, 2 case of infection, 1 case of obstruction and 2 cases of diarrhea were observed in the control group. The incidence of postoperative complications in the observation group was significantly lower than that in the control group (P<0.05) . The nutritive indexes at 7 d and 14 d after the operation in the observation group were statistically significantly better than those in the control group (P<0.05) . Conclusions Early enteral nutrition on elderly patient with gastric cancer after total gastrectomy can reduce the incidence of postoperative complications, improve the postoperative nutrition status, shorten the time of anal exhaust and leaving bed, and reduce the hospital days. Key words: Aged; Gastric neoplasms; Total gastrectomy; Early enteral nutrition

A randomized controlled trial evaluating the efficacy of mastectomy flap quilting sutures in reducing post modified radical mastectomy seroma formation

Background: One of the most common complication post modified radical mastectomy is the formation of seroma. Seroma formation in-turn delays wound healing, increases susceptibility to infection, skin flap necrosis, persistent pain and thus prolongs convalescence. For this, several techniques have been tried and trialed to improve primary healing and decrease the formation of seroma.Methods: Between Aug 2014 and July 2016, 60 patients with carcinoma of the breast, posted for modified radical mastectomy at KR Hospital, Mysuru, Karnataka, India were randomly divided into 2 groups, the study group (30) and the control group (30). In the study group; the mastectomy flap quilting sutures were put between the flap and the pectoral fascia and muscle at different parts of the flap and at the flap edge with absorbable sutures (polyglactin 3-0). In the control group; the flaps were approximated by the conventional method at the edges. Closed suction drains were placed in both the groups. Patients, tumour characteristics and operative related factors were documented. The volume and colour of the fluid drained was recorded everyday. The drains were removed when the amount became less than 30 cc in a 24 hour period. The total volume and duration (number of days) of fluid drained and the complications were recorded and compared.Results: In the study group, the drain was removed much earlier when compared to the control group (p &lt; 0.001). The total amount of fluid drained was much lower in the study group (p &lt; 0.001). The study group showed a much lower frequency of seroma formation when compared to the control group.Conclusions: The mastectomy quilting suture technique is an effective procedure that considerably reduces the incidence of seroma formation in patients undergoing modified radical mastectomy.

Fluid circulation and reservoir conditions of the Los Humeros Geothermal Field (LHGF), Mexico, as revealed by a noble gas survey

Los Humeros Geothermal Field (LHGF) is one of four geothermal fields currently operating in Mexico, in exploitation since 1990. Located in a caldera complex filled with very low-permeability rhyolitic ignimbrites that are the reservoir cap-rock, recharge of the geothermal field is both limited and localized. Because of this, planning of any future geothermal exploitation must be based on a clear understanding of the fluid circulation. To this end, a first noble gas survey was carried out in which twenty-two production wells were sampled for He, Ne, Ar, Kr, and Xe isotope analysis. Air-corrected 3He/4He ratios (Rc) measured in the fluid, normalized to the helium atmospheric ratio (Ra; 1.384×10−6), are consistently high across the field, with an average value of 7.03±0.40 Ra. This value is close to that of the sub-continental upper mantle, indicating that LHGF mines heat from an active magmatic system. Freshwater recharge does not significantly affect He isotopic ratios, contributing 1–10% of the total fluid amount. The presence of radiogenic 40Ar* in the fluid suggests a fossil fluid component that might have circulated within the metacarbonate basement with radiogenic argon produced from detrital dispersed illite. Solubility-driven elemental fractionation of Ne/Ar, Kr/Ar, and Xe/Ar confirm extreme boiling in the reservoir. However, a combined analysis of these ratios with 40Ar/36Ar reveals mixing with an air component, possibly introduced by re-injected geothermal fluids.

Effectiveness of Intravenous Prophylactic Phenylephrine for the Prevention of Spinal Anaesthesia Induced Hypotension during Caesarean Section. A Prospective Observational Study

Background: Hypotension is one of the common complications of spinal anaesthesia. It has many detrimental effects to the mother and fetus if left untreated. Recently, phenylephrine is introduced for the treatment of hypotension in our hospital. However, its efficacy on the prevention of spinal anaesthesia induced hypotension is still under controversy. We aimed to assess the effectiveness of phenylephrine prophylaxis on spinal hypotension after caesarean section. Methods: A prospective observational study was conducted at the University of Gondar Hospital. Patients were allocated based on treatment received; 50/100 μgm phenylephrine prophylaxis vs. no prophylaxis. PR, SBP, DBP, SPO2 and APGAR score were measured before, immediately after spinal anaesthesia, every 2 min intra operatively till the delivery of the baby and every 5 min after delivery for 20 min, and every 10 min for 1 h in postoperative period. Results: The incidence of hypotension was significantly lower for those participants with prophylactic phenylephrine (26% vs. 81.6%, p<0.001) compared to the non-treatment group. Systolic and diastolic blood pressures immediately after spinal anaesthesia till delivery and after delivery of the baby were significantly lower in the none treatment group at all times (p<0.05). Moreover, the number of rescue treatments and total amount of fluid given during the intraoperative period for the treatment of hypotension were more in the non-treatment group P=0.001). The APGAR scores at 1 and 5 min and postoperative vital signs were comparable between groups. Conclusion and recommendation: The incidence of spinal anaesthesia induced hypotension was high. Prophylactic intravenous phenylephrine bolus remarkably reduced the incidence of spinal induced hypotension compared to the non-treatment group. We recommend prophylactic phenylephrine for parturients undergoing caesarean section under spinal anaesthesia. Moreover, other pharmacological and non-pharmacological methods need to be considered as the incidence of hypotension is still high in the treatment group.

Imaging guided streptokinase injected through small bore pigtail tail catheter in management of complicated empyema in pediatrics

PurposeThis study was done targeting the role of streptokinase injected through pigtail catheter in treatment of pleural empyema in pediatric. Subjects and methods15 patients were involved in this study of age ranged from 5months to 15years were subjected to STK injection once daily until the drainage don’t exceed 100ml/day and managed by ultrasound guided insertion of pigtail catheter. Broad spectrum antibiotics were given to all patients, after that the antibiotics were adapted according to result of microbial culture because of failed chest tube drainage intrapleural STK is recommended. Results13 cases show significant improvement, as the total amount of fluid before streptokinase injection was 5cc in average and significantly rose to 220cc after streptokinase instillation, while 2 cases do not response to this treatment. ConclusionImaging guided streptokinase injected through a pigtail catheter provides a powerful protocol for managing of complicated empyema in pediatrics.

PROtocolized care to reduce HYpotension after spinal anaesthesia (ProCRHYSA randomized trial): Study protocol for a randomized controlled trial

BackgroundThe PROtocolized Care to Reduce HYpotension after Spinal Anaesthesia (ProCRHYSA trial) is an unblinded, randomized, monocentric, prospective, three-arm, parallel-group trial aimed at assessing the role of a controlled volemic repletion in reducing both clinically significant hypotension rate and total amount of fluid administered in patients undergoing spinal anaesthesia.Methods/DesignAim of the study is assessing the effectiveness of a non-invasive tests to guide a titrated volemic repletion before spinal anesthesia in order to reduce post-spinal hypotension rate. After local ethical committee approval of the study (Comitato Etico Cantonale Ref. N. CE2796), we will randomize patients undergoing elective surgery under spinal anesthesia into two parallel groups: in the first vena cava ultrasound will be used in order to assess adequacy of patients’ volemic status and consequently guide the administration of crystalloids boluses; in the second passive legs raising test will be used instead of ultrasound for the same purpose.DiscussionThe hypothesis we want to test is that the using of these two experimental methods before spinal anaesthesia, compared to the standard method (empirical fluid administration) can reduce the impact of systemic hypotension through an adequate titrated volemic repletion, avoiding both hypotension and fluid overload. The final purpose is to ensure that spinal anaesthesia is performed in the safest way possible.ConclusionsThe study will offer a new insight on the possible role of vena cava ultrasound and passive legs raising test as screening tools to prevent hypotension after spinal anesthesia. These tests were already validated in a critical environment, but to the best of our knowledge this is the first time they are applied to an elective surgical population.Trial registrationThe trial was registered on May 2014 on www.clinicalstrial.gov with the number NCT02070276.