Urine Output Monitoring Research Articles

The Therapeutic Potential of Exosome Therapy in Sepsis Management: Addressing Complications and Improving Outcomes".

Infection occurs when pathogens penetrate tissues, reproduce, and trigger a host response to both the infectious agents and their toxins. A diverse array of pathogens, including viruses and bacteria, can cause infections. The host's immune system employs several mechanisms to combat these infections, typically involving an innate inflammatory response. Inflammation is a complex biological reaction that can affect various parts of the body and is a key component of the response to harmful stimuli. Sepsis arises when the body's response to infection leads to widespread damage to tissues and organs, potentially resulting in severe outcomes or death. The initial phase of sepsis involves immune system suppression. Early identification and targeted management are crucial for improving sepsis outcomes. Common treatment approaches include antibiotics, intravenous fluids, blood cultures, and monitoring urine output. This study explores the potential of exosome therapy in enhancing the management and alleviation of sepsis symptoms.

Acanthus Condom Catheter: A Reusable and Adjustable Silicone Male External Catheter With Pressure-Sensitive Silicone Adhesive for Urinary Drainage.

Condom catheters are also called external urinary collection devices tocollect urine and monitor urine output in hospitalized and other patients with urinary incontinence. They play an important role in reducing catheter-associated urinary tract infections by using invasive indwelling catheters that are placed inside the bladder.Currently, male external catheters come with or without adhesives. Major problems with current condom catheters are finding the right size to fit, excessive slippage needing to replace too many, urine leak, skin irritation, and damage. In some cases, it's a common practice to wrapadhesive tape around the catheter and penisto keep the catheter in place which can cause skin injury. The Acanthus condom catheter is an expandable silicone male external catheter designed and developed to reduce excessive catheter slippage and keep the catheter longer.It works by applying silicone adhesive to the inner catheter wall just below the catheter rim and applying gentle pressure after the placement. It can be adjusted after the placementand can be kept in place by applying gentle pressure around the catheter to prevent slippage. After laboratory testing of the catheter showed it was able to withstand 250% more pressure and 187% higher tensile forces, we have retrospectively reviewed a nursing survey of14 hospitalized patients using the Acanthus condom catheter for urinary drainage. The mean age was 89 years. A total of 55 evaluations were collected, of which 46 were day shift and nine were night shift responses for a total of 44 catheter days.Results showed that the catheter was easy to use (100%). There was no skin irritation or damage during the application or removal (100%). The catheter was able to drain urine and stayed in place most of the time (89%) except in a few instances it came out, especially during the night shift, but the nurse was able to place it back. There was one instance of urine leak (1.8%). Nurses felt that the catheter was better than existing products in 95% of responses. In conclusion, the Acanthus condom catheter was easy to use, can be reused for up to three days, and was safe on the skin; most importantly, nurses were able to adjust the catheter when they noticed it to be slipping and kept it in place using gentle finger pressure or adding few additional drops of silicone adhesive on the inner catheter wallbelow the rim and applying brief pressure around the catheter. One size (medium-large) fits most of the patients in the study due to elasticity and stretch dimensions, which eliminated the problem of finding the right size to use.

Base excess is superior to creatinine in predicting haemodialysis: A multicenter study conducted Kahramanmaraş earthquake victims

PurposeThis study had two main goals: to determine which rhabdomyolysis patients need haemodialysis; and to highlight the significance of blood gas parameters, particularly base excess, as predictors of the need for haemodialysis. MethodA total of 270 patients were included in this multicentre, retrospective study. Among the patients who were transferred in from the earthquake region and developed rhabdomyolysis, those with creatine kinase (CK) values >1000 U/L were included in our study. The need for renal replacement in these patients was determined via laboratory tests, urine output monitoring and clinical follow-up. FindingsA total of 270 patients were included in our study. Univariate and multivariate regression analyses of laboratory parameters were performed to identify predictors of HD treatment. According to the univariate regression analysis, BE, HCO3, creatinine, CK, lactate, alanine transaminase (ALT) and aspartate transaminase (AST) levels were found to be significantly associated with receiving HD treatment. According to multivariate regression analysis, only BE (p = 0.003) was found to be a significant predictor of HD treatment. ROC analysis revealed that the optimal cutoff value for BE was −2.6; at this value, the sensitivity and specificity of BE for predicting HD treatment were 89% and 77.1%, respectively (AUC: 0.912; 95% CI: 0.872–0.943; p < 0.001). ConclusionBase excess is an effective predictor of the need for haemodialysis in patients with crush-related injuries that cause rhabdomyolysis and in patients who develop acute renal failure due to elevated CK.

The Importance of Monitoring Blood Glucose Test in Patients Post-operative Coronary Artery Bypass Graft Surgery

Hyperglycemia is a risk factor for cardiac surgery-associated acute kidney injury in post-operative coronary artery bypass graft surgery patients. Glycemic control is important to prevent cardiac surgery-associated acute kidney injury. Postoperative glycemic control suggested 110-150 mg/dL. The aims of this study were to lower blood glucose levels and reduce the risk of occurrence or severity of cardiac surgery-associated acute kidney injury in post coronary artery bypass graft surgery patients. This study was conducted with a case study design involving 2 post operative coronary artery bypass graft patients who experienced hyperglycemia on the 1st to the 3rd day of treatment. Data collection was carried out from May 22 to May 23, 2023. The results of the case study showed that monitoring blood glucose in post-cardiac surgery patients is very important. Both patients experienced hyperglycemia in the early postoperative phase. With close monitoring and administration of insulin therapy according to the doctor's advice, the blood sugar levels of both patients were controlled. Monitoring urine output and evaluating serum creatinine levels showed that the first patient had cardiac surgery-associated acute kidney injury stage 1 on day 2 and showed improvement on day 3. The second patient did not develop cardiac surgery-associated acute kidney injury. The role of critical nurses in monitoring blood glucose levels and administering insulin doses is supported by related research. Strict monitoring and target ranges of blood glucose levels, in collaboration with the medical team are necessary to reduce the risk of cardiac surgery-associated acute kidney injury events.

#523 Continuous electronic urine output monitoring for the management of acute cardio-renal syndrome in patients with acute decompensated heart failure

Abstract Background and aims : Patients admitted for acute decompensated heart failure (ADHF) are at high risk for type I cardio-renal syndrome (CRS) related to venous congestion and diuretic resistance. Positive fluid balance has been associated with adverse outcomes including acute kidney injury (AKI) and mortality. In critically ill patients urine output (UO) is used both to assess deterioration of renal function as well as for management of fluid balance. We investigated the possible effect of real-time UO monitoring, fluid balance, renal outcomes and 30-day mortality of patients admitted to the cardiac intensive care unit (ICU) with ADHF. Methods We performed a case series of 50 patients admitted to the cardiac ICU from July 2021 and June 2023 with ADHF. Their standard foley catheter was connected to an electronic monitoring system (Clarity-RMS sensor kit) that continuously monitors UO in real-time. Its technology is described elsewhere (1). The UO monitoring system displays UO trends on the consoles that are updated in real-time. UO trends were utilized to guide an individualized approach for the pharmacologic management of each patient, based on blood pressure, hourly UO and total fluid balance. Daily and accumulated fluid balance was registered at up to 72 hours following admission. Patient outcomes included change in fluid balance, incidence of AKI and 30-day mortality. The case series group was than compared to a historical group of 50 matched controlled patients admitted between 2019-2020. Patients were matched according to cause of admission, age and glomerular filtration rate. Results In the study cohort the median age was 71 ± 12 years, and 36 (72%) were men. In the historical cohort the median age was 71 ± 13 years, and 36 (72%) were men. Patients in the electronic urinary monitoring cohort demonstrated significantly more negative daily and cumulative fluid balance as compared to the historical cohort, (P &amp;lt; 0.001 for all, Fig. 1). Incidence of AKI and the combined endpoint of AKI and 30-day mortality was significantly lower in the electronic UO monitoring cohort (24% vs. 46%, p = 0.0197 and 40% vs 78%, P &amp;lt; 0.0001 respectively). These changes were more prominent in the subgroup of patients with chronic kidney disease (Fig. 2). Conclusion We demonstrated that real time monitoring of UO was associated with better prevention of fluid overload and the management of type I CRS in patients with ADHF. Further studies on larger populations are required to validate the potential utility of UO trending in the management of critically ill patients with ADHF.

Using continuous electronic urine output monitoring for the management of acute cardio-renal syndrome in patients with acute decompensated heart failure

Abstract Funding Acknowledgements None. Background Patients admitted for acute decompensated heart failure (ADHF) are at high risk for type I cardio-renal syndrome (CRS) related to venous congestion and diuretic resistance. Positive fluid balance has been associated with adverse outcomes including acute kidney injury (AKI) and mortality. In critically ill patients urine output (UO) is used both to assess deterioration of renal function as well as for management of fluid balance .We investigated the possible effect of real-time UO monitoring, fluid balance, renal outcomes and 30-day mortality of patients admitted to the cardiac intensive care unit (ICU) with ADHF. Methods We performed a case series of 50 patients admitted to the cardiac ICU from July 2021 and June 2023 with ADHF. Their standard foley catheter was connected to an electronic monitoring system that continuously monitors UO in real-time. Its technology is described elsewhere (1). The UO monitoring system displays UO trends on the consoles that are updated in real-time. UO trends were utilized to guide an individualized approach for the pharmacologic management of each patient, based on blood pressure, hourly UO and total fluid balance. Daily and accumulated fluid balance was registered at up to 72 hours following admission. Patient outcomes included change in fluid balance, incidence of AKI and 30-day mortality. The case series group was than compared to a historical group of 50 matched controlled patients admitted between 2019-2020. Patients were matched according to cause of admission, age and glomerular filtration rate. Results In the study cohort the median age was 71±12 years, and 36 (72%) were men. In the historical cohort the median age was 71±13 years, and 36 (72%) were men. Patients in the electronic urinary monitoring cohort demonstrated significantly more negative daily and cumulative fluid balance as compared to the historical cohort, (P&amp;lt;0.001 for all, Figure 1). Incidence of AKI and the combined endpoint of AKI and 30-day mortality was significantly lower in the electronic UO monitoring cohort (24% vs. 46%, p=0.0197 and 40% vs 78%, P&amp;lt;0.0001 respectively). These changes were more prominent in the subgroup of patients with chronic kidney disease (Figure 2). Conclusion We demonstrated that real time monitoring of UO was associated with better prevention of fluid overload and the management of type I CRS in patients with ADHF. Further studies on larger populations are required to validate the potential utility of UO trending in the management of critically ill patients with ADHF.Fluid balance renal senseAKI and 30-day mortality

Evaluation and Management of Exertional Rhabdomyolysis Following a Spin Class

Exertional rhabdomyolysis (ER) has become prevalent over the last decade after performing spin classes. ER is characterized by the plasma elevation of creatine kinase as a marker of severe muscle damage. This case study highlights a 26-year-old healthy male that suffered from ER after performing their first ever spin class. The acute and chronic management of the ER is described, along with follow-up assessments that tracked the recovery following discharge from the hospital. Symptoms, such as localized swelling with complete loss of mobility and pain disproportionate to soreness, were characteristic in this individual with ER. Examining the concentration of plasma creatine kinase and monitoring urine output and color provided a good measure to determine when to discharge the patient. Management wise, ambulation should be minimized, and complete bed rest is ideal in conjunction with fluid replacement therapy. Although the individual in this case study did not develop compartment syndrome, its occurrence is always a possibility that should be routinely screened for. Lastly, further research is warranted to determine if there are any dietary interventions to promote a steadfast recovery from ER.

A315 A QUALITY ASSESSMENT OF THE ADEQUACY OF FLUID REPLACEMENT THERAPY FOR PATIENTS DIAGNOSED WITH ACUTE PANCREATITIS

Abstract Background For acute pancreatitis (AP), aggressive fluid resuscitation therapy (FRT) is the cornerstone for initial management. However, results from the recent WATERFALL study show a higher incidence of fluid overload with aggressive FRT (bolus of 20 ml/kg followed by infusion of 3 ml/kg/hr of Ringer’s lactate [RL]) compared with moderate FRT (infusion of 1.5 ml/kg/hr RL preceded by a bolus of 10 ml/kg only in those with hypovolemia). Given this evidence, we conducted a study to assess whether patients with AP received appropriate fluid therapy and monitoring at our institution. Aims To assess whether fluid replacement therapy in patients with AP was aligned with updated clinical practice at our centre. Methods We completed a chart audit of all adult (≥ 18 years old) patients who presented to the ED from April 1, 2021 through March 31, 2022 and were diagnosed with AP. Patients were identified based on ICD-10 codes for a primary admission or discharge diagnosis of AP. Data variables collected included demographic information, cause of AP, comorbidities, laboratory tests, type and volume of fluids replaced, urine output, complications, and hospital length of stay (HLOS). Severity of AP was categorized as mild, moderate, or severe based on the revised Atlanta classification of AP. Descriptive statistics were completed. Results A total of 250 patients (121 F, 129 M), mean age 53±19 years (range 19-96 years) were diagnosed with AP. Body weight was not available for 4 patients and thus excluded from this analysis. FRT variables stratified for the severity of AP are below in Table 1. Conclusions Our quality assessment has identified a knowledge-to-practice gap in the use of FRT for patients with AP. To assist physicians in the decision-making process, we have developed an algorithm to improve FRT in AP. This will be implemented via an order set to standardize the amount of FRT and to improve monitoring of urine output. This algorithm will be tested using an improvement science approach in collaboration with healthcare professionals. Table 1. Summary of fluid management in AP patients as stratified by severity of disease. Funding Agencies None

Automatic Double Check Monitoring of Continuous Fluid Excretion and Urine Output

Automatic Double Check Monitoring of Continuous Fluid Excretion and Urine Output

Clinical Factors Affecting Daily Dosage of Desmopressin Orally Disintegrating Tablets in Arginine Vasopressin Deficiency.

Desmopressin orally disintegrating tablets (ODTs) are widely used to treat arginine vasopressin deficiency (AVP-D). However, limited information is available on the dosage regimen; the dosage for each patient is selected based on their response to the initiation dose. To investigate the relationships between clinical characteristics and the daily dose of ODTs and to identify factors that affect ODT dosages. This retrospective study included 209 adult patients with AVP-D. Patients were administered ODTs sublingually and instructed to restrict eating and drinking for 30 minutes after taking ODTs using a patient leaflet. ODT dose titration was conducted during hospitalization with close monitoring of urine output, body weight, and serum sodium levels. Multivariable linear regression models were applied to identify clinical factors associated with the daily dose of ODTs at discharge. We also evaluated the dosage at 1 year in 134 patients who were followed up in our hospital. The median daily dose of ODTs at discharge was 90 µg (IQR 60-120 µg). Multivariable linear regression models identified sex, age, and estimated creatinine clearance (eCCr) as significant factors associated with the daily dose of ODTs, with eCCr having the strongest effect. After excluding patients recovering from AVP-D, 71% of those followed up at our hospital took the same daily dose at 1 year after discharge. To achieve the safe and stable treatment of AVP-D, the daily dose of ODT needs to be selected based on a patient's sex, age, and eCCr under appropriate sublingual administration by patient education.

A multi-national survey to identify health professionals' opinions for the appropriate frequency of urine output monitoring in post-operative patients.

Urine output is an important clinical measurement and oliguria may highlight the development of acute kidney injury (AKI) earlier than serum creatinine (sCr). Despite the importance of urine output monitoring, there are no definitive guidelines or recommendations for best practice. A survey was sent to healthcare professionals with a specialist interest in AKI to gather opinions of what constitutes a good standard of urine output monitoring and by corollary missed care, post- major surgery. Data was gathered from 221 respondents. Results will inform audit and improvement projects in post-operative nursing care.

Correlation of urinary neutrophil gelatinase-associated lipocalin levels as an early diagnostic marker for acute kidney injury in patients with sepsis

Background. The exact association between urinary neutrophil gelatinase-associated lipocalin (uNGAL) and acute kidney injury (AKI) is unknown in a critical care setting, in which the population is heterogeneous and the aetiology of AKI is unclear. Aim of this study is to clarify if uNGAL level is an early diagnostic marker for AKI in patients with sepsis. Materials and methods. The current study was conducted on 86 sepsis patients. The prevalence of AKI was identified among them. The role of uNGAL in predicting AKI development, mortality rate and length of the intensive care unit (ICU) stay were analyzed. Sensitivity and specificity were calculated, and the area under the receiver operating characteristic curve was considered as the optimal uNGAL cut-off level for detecting all classifications of AKI. Results. Most patients belonged to the age group of 51–60 years and their mean age was 54.6 years. Most patients (65.11 %) were males. 26.75 % had both type 2 diabetes mellitus and hypertension. AKI was detected in 89 % of subjects in the current study, as per KDIGO definition. 15.12 % of patients had stage 1 CKD, 15.12 % had stage 2 CKD, and stage 3 CKD was diagnosed in 4.65 % of cases. Mortality rate was 11 %, and 89 % of patients were discharged. The mean ICU length of stay among patients with AKI is 8.9 days. There is significant association between the mean ICU length of stay and AKI presence (p = 0.03). 17.4 % (n = 15) of patients required renal replacement therapy. There is a very significant difference in mean baseline uNGAL in patients with and without AKI: 149.9 and 73.2 ng/ml, respectively (p = 0.0006). This indicated that baseline uNGAL levels predict AKI. The mean uNGAL in people with AKI was 356 ng/ml and in those without AKI, it was 95 ng/ml. There is a very significant difference in mean uNGAL 48 hours after in patients with and without AKI (p &lt; 0.0001). At a cut-off value of 120, there were 69 true positive cases, 9 true negative cases, 0 false positive cases, and 8 false negative cases. Based on these, the sensitivity of uNGAL at baseline in detecting AKI is 89.61 %, specificity is 100 %, and accuracy is 90.70 %. At a cut-off point of 120, there were 77 true positive cases, 8 true negative cases, 1 false positive case, and 0 false negative cases. Based on these, the sensitivity of uNGAL 48 hours after was 100 %, specificity 88.89 %, and accuracy was 98.84 %. There is a significant association between uNGAL levels and the ICU length of stay (p = 0.00). Conclusions. Sensitivity analysis was done in cut-off value of 120 for urinary NGAL in predicting AKI. From these results we conclude that urinary NGAL at the time of ICU admission is a reliable marker of renal function in sepsis patients. There is a significant correlation between AKI presence and urinary NGAL, and the ICU length of stay. We recommend not to use uNGAL alone in predicting AKI. It should be combined with glomerular filtration rate to reliably detect AKI development. Study findings indicate that sepsis patients with elevated uNGAL require proper management with close monitoring of blood pressure, urine output and appropriate doses of diuretics to avoid the development of AKI.

Acute Kidney Injury in Neonates who Develop Asphyxia at the Time of Delivery

Objective: To determine the frequency of acute kidney injury in neonates who develop asphyxia at delivery.&#x0D; Study Design: Cross-sectional study.&#x0D; Place and Duration of Study: Department of Paediatrics, Pak-Emirates Military Hospital, Rawalpindi Pakistan, Aug 2021 to Feb 2022.&#x0D; Methodology: This study was based on 69 patients diagnosed with birth asphyxia on the basis of APGAR score at 5 minutes. Patients underwent testing for serum creatinine levels at 24 hours post-delivery, as well as the monitoring of urine output, and acute kidney injury was classified according to the KDIGO classification, based on the increase in serum creatinine levels and urine output.&#x0D; Results: Acute kidney injury was observed in 12(17.4%) cases and 3(4.3%) neonates died. Lower gestational age at birth was associated with acute kidney injury (p=0.038), and acute kidney injury was associated with a higher chance for mortality (p&lt;0.001). Additionally, male infants had a lower head circumference (p=0.001), a lower total body length (p&lt;0.001) and a lower APGAR score at birth (p=0.004) when compared to females. However, they did not appear to have a higher risk for acute kidney injury (p=0.121).&#x0D; Conclusion: Acute kidney injury following the development of birth asphyxia is a common occurrence in our population efforts should be made to identify pregnancies at risk to mitigate this potentially devastating complication.

Accuracy and availability of automated urine output monitoring in the operating room using a smart scale

PurposeUrine output (UO) is an important intraoperative parameter that is not yet electronically monitored. We compared an automatic urinometer (AU) based on a smart scale with a manual urinometer (MU). Patients and methodsThis prospective study investigated the hourly UO of 35 preoperative patients with an indwelling urinary catheter using AU, MU, and cylinder measurements. Data were analyzed using the Bland-Altman method. A questionnaire related to the use of the AU was completed by medical staff (n=25). ResultsCompared to the cylinder measurements, the differences in measurements by the AU and the MU were −6.31 ​± ​15.03 ​mL/h (p=0.018) and 20.26 ​± ​26.81 ​mL/h (p=0.001), respectively. The r values for the comparison of cylinder measurements with AU and MU values were 0.985 (p<0.001) and 0.968 (p<0.001), respectively. Bland-Altman analyses showed that cylinder measurements had better agreement with the AU measurements than with the MU measurements. Also, the medical staff reported that the use of the AU was easier to learn than the use of the MU (p<0.001). ConclusionsCompared to the MU values, AU values were noninferior; they had significantly less bias and temporal deviation. Additionally, the medical staff reported that the use of the AU was easier to learn than the use of the MU.

A Foley catheter 'the jack of all trades': a literature review of its common and novel uses.

The Foley catheter is one of the most commonly used devices in modern surgical practice. Developed for draining the urinary bladder, this humble catheter has been employed for many other purposes ranging from urine output monitoring to complex urological investigations. Over time, it has evolved into being applied in more complex and innovative ways in various other specialties apart from urology. In this review article, we describe some of the common and novel uses of this deceptively simple device, and discuss the scope of its application in modern medicine.

309 Reducing the Catheter Associated Infection Rate Within a Burn Intensive Care Unit

Abstract Introduction Catheter-associated urinary tract infections (CAUTIs) are the most common hospital-onset healthcare-associated infections (HAI) in the United States. HAIs are key quality and safety metrics publicly reported in the acute-care space and linked to hospital reimbursement by the Centers for Medicare and Medicaid Services. CAUTIs, represent approximately 9% of all HAIs, and are associated with increased morbidity, mortality, and cost in intensive care units (ICUs). CAUTIs are thought to impact patient outcomes and healthcare costs significantly. A recent analysis concluded that CAUTIs accounted for only 0.3% of HAI costs in the United States, or approximately $28 million/year. Per patient, CAUTI costs are described in wide ranges from $876 (for inpatient costs to the hospital for additional diagnostic tests and medications) to $10,197 (for inpatient costs to Medicare for ICU patients). The objective of this study was to analyze CAUTI incidences before and after the introduction of a novel urinary catheter with an integrated active drain line clearance system for continuous urine output in a burn intensive care unit. Methods Retrospective cohort study following the implementation of a novel urine output monitoring system with integrated drain line and urine clearance. Data from a 48-month (from January 2015-December 2018) historical control (period 1) were compared to data from a 28-month (from January 2020 to April 2022) post-implementation period (period 2). Pre- and post-implementation CAUTI event incidences were compared. Charts were reviewed to characterize the patients. Results A total of 42 CAUTIs in 2243 patients were identified using the National Health and Safety Network (NHSN) definition during the analyzed period. There were 40 CAUTI events in period 1 and two CAUTIs in period 2. The incidence of CAUTI events pre-implementation was 0.030 (mean of 10 CAUTI events per year) compared to 0.002 (mean of 1 CAUTI event per year) post-implementation of an automatic drain line clearing UO monitoring system showing a significant reduction in CAUTI events (P&amp;lt; 0.01, risk ratio novel vs. gravity bladder catheter 0.071, 95% confidence interval: 0.017-0.294). Conclusions CAUTIs were reduced in the period following the implementation of a novel urinary catheter system with an integrated active drain line and urine clearance in burn patients. Applicability of Research to Practice Implementation of a urinary catheter system with integrated drain line and urine clearance could reduce

Using urine output tending to manage fluid balance among patients with acute decompensated heart failure

Abstract Funding Acknowledgements Type of funding sources: None. Background Positive fluid balance has been associated with adverse outcomes in patients admitted to intensive care units (ICU). Urine output (UO) is used both to assess deterioration of renal function as well as for management of fluid balance in patients admitted to the general ICU. In the cardiac ICU, patients admitted for acute decompensated heart failure (ADHF) are at high risk for type I cardio-renal syndrome and increased morbidity and mortality. Studies have shown that poor fluid management in these patients contributes to worse outcomes in this patient population (1). Aim To investigate the possible effect of real-time monitoring of UO trends on the individualized pharmacologic management, fluid balance, and clinical outcomes of patients admitted to the cardiac ICU with ADHF. Methods We performed a case series of 35 patients admitted to the cardiac ICU from July 2021 and January 2022 with ADHF. Their standard Foley catheter was connected to an electronic monitoring system (Clarity-RMS sensor kit) that continuously monitors UO in real-time. Its technology is described elsewhere (2). The UO monitoring system displays UO trends on the consoles that are updated in real-time. UO trends were utilized to detect dynamic changes in urine output and guide an individualized approach for the pharmacologic management of each patient, based on blood pressure, hourly UO and total fluid balance. Daily and accumulated fluid balance was registered at up to 72 hours following admission. Patient outcomes included incidence of acute kidney injury (AKI), as defined by the KDIGO criteria for changes in serum creatinine (SCr), and 30-day mortality. The case series group was than compared to a historical group of 35 matched controlled patients admitted between 2018-2019. Patients were matched according to cause of admission, age and glomerular filtration rate. Results Mean age was 71 ± 11 years and 49 (70%) were men. Patients in the electronic urinary monitoring cohort demonstrated significantly more negative daily and cumulative fluid balance as compared to the historical cohort, (P&amp;lt;0.001 for all, Figure 1). Incidence of AKI and AKI combined with 30-day mortality was significantly lower in the electronic UO monitoring cohort (23% vs. 57%, p&amp;lt;0.001, and 34% vs. 63%, p&amp;lt;0.001, respectively). These changes were more prominent in the subgroup of patients with chronic kidney disease (CKD) (Figure 2). Conclusion We demonstrated that real time monitoring of UO trends may be used for goal-directed care for the prevention of fluid overload and adverse outcomes in patients with ADHF. Further studies on larger populations are required to validate the potential utility of UO trending in the management of critically ill patients with ADHF.

Acute supratherapeutic vancomycin serum concentration in a premature neonate: a case report

Vancomycin, a glycopeptide, is a first-line agent in the neonatal population for the treatment of suspected or confirmed Gram-positive infections, including methicillin-resistant Staphylococcus aureus (MRSA) and coagulase-negative Staphylococci (CoNS).1,2 Vancomycin dosing strategies vary greatly and are generally based on factors such as post-menstrual age (PMA), post-natal age (PNA), and serum creatinine (SCr). Recommended starting doses can range from 10 to 15 mg/kg/dose every 6 to 48 hours, depending upon infection site, suspected organism, desired serum vancomycin trough concentration/area under the curve (AUC), and/or minimal inhibitory concentration (MIC) to vancomycin. Nephrotoxicity in patients receiving vancomycin has been systematically documented in adults and less often in neonates, with a reported occurrence of 1-9% when receiving recommended dosing.1 Risk of toxicity can be minimized through dosage modifications and close monitoring of SCr and urine output at baseline and throughout therapy.2 This case report describes the use of vancomycin, dosed at 10 mg/kg, in a premature infant born at 26 weeks and 4 days gestation for CoNS pneumonia. The infant showed signs of renal dysfunction, prompting a pre-steady state vancomycin serum concentration lab draw, resulting in a concentration of 102.2 µg/mL. Serial repeat vancomycin serum concentrations showed a linear excretion pattern and an ARCHITECT iVancomycin assay completed by medical laboratory scientists confirmed the concentration of the vancomycin aliquot prepared by the inpatient pharmacy department. Renal ultrasound established return to normal renal function; however, the infant failed routine newborn hearing screening upon NICU (neonatal intensive care unit) discharge due to suspected vancomycin-induced ototoxicity.

Abstract #1392589: Triphasic Response of Pituitary Stalk Injury Post Traumatic Brain Injury – A Rare and Often Unrecognized Endocrine Phenomenon

The triphasic response to pituitary stalk injury encompasses an initial phase of diabetes insipidus (DI), followed by anti-diuretic hormone (ADH) mediated hyponatremia and a subsequent phase of diabetes insipidus. It is uncommonly seen post-pituitary surgery and its occurrence after traumatic brain injury (TBI) is even less recognized. We present a case of classic triphasic response post TBI. A 24-year-old Female presented to the Emergency Department after a road traffic accident where she had been flung from a motorcycle. She sustained bilateral maxillary and facial fractures, dental injuries, mild lung contusions and lacerations. She was adjudged to have mild traumatic brain injury based on computed tomography findings of small subarachnoid hemorrhage. She had initial hypernatremia with peak serum sodium of 160mmol/L, serum osmolality of 340mmol/kg and urine osmolality of 225 mmol/kg. This suggests partial DI, which improved with hypotonic fluid administration and did not require desmopressin therapy. Serum cortisol and thyroid function tests were normal. No features of pituitary apoplexy were seen on the computed tomography scan. Magnetic resonance imaging was contraindicated post-facial fracture fixation. On day 7 post injury, she developed severe hyponatremia with serum sodium nadir of 118mmol/L. The serum osmolality was 256mmol/kg and the urine osmolality was 864mmol/kg, which suggests severe ADH mediated hyponatremia. She was managed aggressively with fluid restriction, nutritional supplementation and high dose oral salt loading with good effect. After 7 days of hyponatremic phase, she developed polyuria with mild hypernatremia and dilute urine. She responded well to a trial of oral desmopressin and was discharged to a rehabilitation facility. Diabetes insipidus is an uncommon sequela of TBI. It has been attributed to pituitary vascular injury, diffuse axonal injury to the hypothalamus or direct pituitary stalk damage from trauma. It can occur in the absence of anterior pituitary failure. While severity of brain injury does correlate to likelihood of DI, permanent DI has been described even in mild TBI. As symptoms of hyponatremia or hypernatremia may be non-specific and may be masked by depressed consciousness post-injury, careful laboratory and urine output monitoring coupled with clinical vigilance is required to make the diagnosis. To avoid significant morbidity and mortality, careful use of desmopressin, sodium supplementation and fluid restriction is required. Knowledge of the expected time course and expectant titration of intervention can help to avoid rapid fluctuations in serum sodium levels.

Acute kidney injury post-abdominal surgery in infants: implications for prevention and management.

Acute kidney injury (AKI) is common in critically ill infants and is associated with long-term sequelae including hypertension and chronic kidney disease. The etiology of AKI in infants is multifactorial. There is robust literature highlighting the risk of AKI after cardiothoracic surgery in infants. However, risk factors and outcomes for AKI in infants after abdominal surgery remains limited. This article reviews the epidemiology and association of abdominal surgery with postoperative AKI and suggests methods for AKI management and prevention. Postoperative AKI may result from hemodynamic shifts, hypoxia, exposure to nephrotoxic medications, and inflammation. Infants in the intensive care unit after intraabdominal surgeries have a unique set of risk factors that predispose them to AKI development. Prematurity, sepsis, prolonged operation time, emergent nature of the procedure, and diagnosis of necrotizing enterocolitis increase risk of AKI after intrabdominal surgeries. Prevention, early diagnosis, and management of AKI post-abdominal surgery is imperative to clinical practice. Close monitoring of urine output, serum creatinine, and fluid status is necessary in infants after abdominal surgery. A recent study suggests elevated levels of a urinary biomarker, neutrophil gelatinase-associated lipocalin (NGAL), 24 h after an abdominal procedure may improve early prediction of AKI. Identification of risk factors, avoidance of nephrotoxic medications, careful fluid balance, early detection of AKI, and maintenance of hemodynamic stability is imperative to potentially prevent and/or mitigate AKI.