Crystalloid Volume Research Articles

High crystalloid volumes negate benefit of hemostatic resuscitation in pediatric wartime trauma casualties.

Recent data for adult trauma patients suggest improved survival when using hemostatic resuscitation, which includes limiting crystalloids and using closer to 1:1 ratios for both fresh frozen plasma (FFP) and platelets (PLTs) relative to packed red blood cells (PRBCs). Pediatric studies have shown similar but mixed results and often lack measuring crystalloids. We seek to evaluate in-hospital survival based on crystalloid administration and different blood product ratios in pediatric casualties during the recent conflicts. We queried the Department of Defense Trauma Registry for all pediatric encounters in Iraq and Afghanistan from January 2007 to January 2016 and included those with at least 40 mL/kg of total blood products administered provided that they received at least 1 U of PRBC. We grouped children as younger (0-7 years) and older (8-17 years). We grouped low versus high ratios for FFP/PRBC (≤1:2 vs. >1:2) and PLT/PRBC (≤1:6 vs. >1.6). We used a threshold of 40 mL/kg to for high versus low crystalloid resuscitation. During this time, there were 3,439 encounters in the registry with 521 (15.1%) that met the inclusion criteria. The median age of casualties that met the inclusion was 10 years (interquartile range, 5-13), most were male (73.5%), with a moderate median injury severity score (17; interquartile range, 13-25). We performed regression modeling with adjustments for mechanism of injury, composite injury severity score, and total blood product volume (mL/kg based), grouping children based on high versus low fluid resuscitation. In the low-volume crystalloid group, we found that higher (>1:2) FFP/PRBC was associated with improved survival (odds ratio [OR], 3.42). However, in the high fluid crystalloid resuscitation group, we found that that higher ratios for PLT/PRBC (>1:6) overall (OR, 0.46) and the FFP/PRBC (>1:2) in younger children (OR, 0.28) was associated with worse survival. The remaining associations were not statistically significant. We found an association with survival in massively transfused pediatric trauma patients who received both a high FFP/PRBC ratio and low crystalloid administration. The benefit of this high ratio is negated, in patients receiving high crystalloid volumes, particularly among smaller children. Future studies on hemostatic resuscitation evaluating blood product ratios should also account for crystalloid and colloid administration. Retrospective, comparative, level III.

Emergency Surgery for Blunt Cardiac Injury: Experience in 43 Cases

Blunt cardiac injury (BCI) increases with traffic accidents and is an important cause of death in trauma patients. In particular, for patients who need surgical treatment, the mortality rate is extremely high unless the patient is promptly operated on. This study aimed to explore early recognition and expeditious surgical intervention to increase survival. All patients with BCIs during the past 15years were reviewed, and those who underwent operative treatment were analyzed retrospectively regarding the mechanism of injury, diagnostic and therapeutic methods, and outcome. A total of 348 patients with BCIs accounted for 18.3% of 1903 patients with blunt thoracic injury (BTI). Of 348 patients, 43 underwent operative treatment. The main cause of injury was traffic accidents, with an incidence of 48.8%. Of them, steering wheel injuries occurred in 15 patients. In 26 patients, a preoperative diagnosis was obtained by echocardiography, CT scanning, etc. In the remaining 17, who had to undergo urgent thoracotomy without any preoperative imaging, a definitive diagnosis of BCI was proven during the operation. The volume of preoperative infusion or crystalloid was <1000ml in 31 cases. Preoperative pericardiocentesis was not used in anyone. In 12 patients, the operation commenced within 1h. Overall mortality was 32.6%. The death was caused by BCI in 9. Facing a patient with BTI, a high index of suspicion for BCI must be maintained. To manage those requiring operations, early recognition and expeditious thoracotomy are essential. Preoperatively, limited fluid resuscitation is emphasized. We do not advocate preoperative pericardiocentesis.

Comparative study of preloading and Co-loading with ringer lactate for prevention of spinal hypotension in elective cesarean section

Background: Prevention of spinal induced hypotension was remained challenge to anaesthesiologist for years as it poses risk to mother as well as baby. Prehydration with various volumes of crystalloid or colloids was attempted in the past variable success rate. Recently the principle of preloading with fluids has been challenged by various studies. This prompted us to evaluate the effectiveness of crystalloid preloading compared to preloading for prevention of spinal hypotension. We evaluated vasopressor requirement and neonatal Outcome in the form of APGAR score as well. Material and method: ASA grade I parturients posted for elective cesarean section were randomly allocated in two study groups of 30 each to receive either preload or co-load with Ringers lactate solution. Blood pressure, heart rate, SpO2, vasopressor requirement and other outcomes recorded at regular interval. Results: Hypotension was observed significantly less in co-loading group (36%) than preloading group (60%). Mean vasopressor requirement was also significantly more in preload group. Heart rate change, nausea, vomiting and fetal outcome remained same across both the groups. Conclusion: Co-loading with crystalloids is more effective strategy than preloading in prevention of spinal induced hypotension. We can save valuable time given for preloading in case of emergency cesarean sections.

Battlefield Extracorporeal Cardiopulmonary Resuscitation for Out-of-Hospital Cardiac Arrest: A Feasibility Study During Military Exercises.

To evaluate the feasibility of prehospital extracorporeal cardiopulmonary resuscitation (E-CPR) in the military exercise setting. Three 40kg Sus scrofa (wild swine) underwent controlled 35% blood loss and administration of potassium chloride to achieve cardiac arrest (CA). During CPR, initiated 1 minute after CA, the animals were transported to Role 1. Femoral vessels were cannulated, followed by E-CPR using a portable perfusion device. Crystalloid and blood transfusions were initiated, followed by tactical evacuation to Role 2 and 4-hour observation. All animals developed sustained asystole. Chest compressions supported effective but gradually deteriorating blood circulation. Two animals underwent successful E-CPR, with restoration of perfusion pressure to 80mmHg (70-90mmHg) 25 and 23 minutes after the induction of CA. After transportation to Role 2, one animal developed abdominal compartment syndrome as a result of extensive (9L) fluid replacement. The other animal received a lower volume of crystalloids (4L), and no complications occurred. In the third animal, multiple attempts to cannulate arteries were unsuccessful because of spasm and hypotension. Open aortic cannulation enabled the circuit to commence. No return of spontaneous circulation was ultimately achieved in either of the remaining animals. Our study demonstrates both the potential feasibility of battlefield E-CPR and the evolving capability in the care of severey injured combat casualties.

Intraoperative Resuscitation by Specialized Trauma Nurse Clinicians Improves Adherence to Massive Transfusion Protocol

A massive transfusion protocol (MTP) was implemented at a Level I trauma center in 2007 for patients with massive blood loss. A goal ratio of plasma to pheresed platelets to packed red blood cells (PRBCs) of 1:1:1 was established. From 2007 to 2014, trauma nurse clinicians (TNCs) administered the MTP during initial resuscitation and anesthesia personnel administered the MTP intraoperatively. In 2015, TNCs began administering the MTP intraoperatively. This study evaluates intraoperative blood product ratios and crystalloid volume administered by anesthesia personnel or TNCs. A retrospective review of trauma registry patients requiring MTP from 2007 to 2017 was performed. Patient data were stratified according to MTP administration by either anesthesia personnel (2007-2015) or TNCs (2015-2017). Ninety-seven patients were included with 54 anesthesia patients and 44 TNC patients. Patients undergoing resuscitation by MTP administered by TNCs received less median crystalloid (3000 mL vs 1500 mL, P < 0.001). The ratio of plasma:PRBC (0.75 vs 0.93, P = 0.027) and platelets:PRBC (0.75 vs 1.04, P = 0.003) was found to be significantly closer to 1:1 for TNC patients. MTP intraoperative blood product administration by TNCs reduced the amount of infused crystalloid and improved adherence to MTP in achieving a 1:1:1 ratio of blood products.

Estudio de validación de los parámetros dinámicos de onda de pulso en cirugía de resección pulmonar

IntroductionIn lung resection surgery, restrictive fluid therapy is recommended due to the risk of acute lung injury. In contrast, this recommendation increases the risk of hypoperfusion. Guided fluid therapy allows individualization of fluid intake. The use of dynamic volume response parameters is not validated during one-lung ventilation. The main objective is the validation of dynamic parameters, stroke volume variation (SVV) and pulse pressure variation (PPV), during lung resection surgery as fluid response predictors, after the administration of 250ml crystalloid volume loads, if IC<2.5ml/min/m2 and if SVV≥8% and/or PPV≥10%. Material and methodsPilot, prospective, observational and single centre study. Twenty-five patients monitored with the PiCCO system were included during open lung resection surgery with the patient in a lateral position, one lung ventilation with tidal volume (TV): 6ml/kg and open chest. Hemodynamic variables were collected before and after volume loading. The results were classified into two groups: volume responders (increase IC≥10% and/or VSI≥10% after volume loading) and non-responders (no increase or increase IC<10% and/or VSI<10% after volume loading). We assess the diagnostic efficacy of SVV and PPV by analyzing the AUC (area under curve) in the ROC curves. ResultsIn the analysis of ROC curves, SVV and PPV did not reach a discriminative value (AUCSVV: 0.47; AUCPPV: 0.50), despite the decrease in the threshold value of SVV and PPV to initiate an overload of volume during one-lung ventilation, in lateral position and open chest. ConclusionsThe results obtained show that the values of the dynamic parameters of volume response (SVV≥8% and PPV≥10%) do not discriminate against responders patients and non-responders during open lung resection surgery.

Plasma and Urinary Glycosaminoglycans as Evidence for Endotheliopathy in a Swine Burn Model

BackgroundThe endothelial glycocalyx controls vascular permeability, cellular signaling, blood-endothelial cell adhesion, extravasation, and transmission of shear stress signals. Burn injury compromises integrity of this layer increasing vascular permeability, which is further exacerbated by large volumes of (intravenous) crystalloids. We have shown that enteral resuscitation is able to reverse burn-induced acute kidney injury (AKI), and herein, we present a follow-up examination of the integrity of the glycocalyx layer and its relationship with renal dysfunction after burn injury. Materials and methodsAnesthetized Yorkshire pigs sustained 40% total body surface area full-thickness contact burns and recovered in metabolic cages for one of three treatments: no fluids (oral or intravenous); (n = 6), ad libitum water (n = 6), or volume-matched oral rehydration solution (ORS; n = 6) for 48 h. Urine and blood were collected at baseline (BL), 6, 12, 24, 32, and 48 h after burn at which point kidneys were harvested. ResultsIn no fluid and water groups (but not ORS), plasma levels of glycosaminoglycans (GAGs) were elevated after burn (P ≤ 0.031). Syndecan-1 was elevated by 6 h after burn in all animals, but levels declined by 24 h with enteral fluids. Urinary GAGs in the no-fluid group were elevated after burn. No differences among treatments were detected in syndecan-1 levels, or glomerular lectin within the kidney. ConclusionsCollectively, these data demonstrate that ORS prevented increases in circulating GAGs. Furthermore, an inexpensive and simple method for detecting GAGs provides a sensitive measure of endotheliopathy after burn.

Quantifying the effects of wound healing risk and potential on clinical measurements and outcomes of severely burned patients: A data-driven approach

IntroductionGiven recent advances in computational power, the goal of this study was to quantify the effects of wound healing risk and potential on clinical measurements and outcomes of severely burned patients, with the hope of providing more insight on factors that affect wound healing. MethodsThis retrospective study involved patients who had at least 10% TBSA% “burned” and three burn mappings each. To model risk to wounds, we defined the variable θ, a hypothetical threshold for TBSA% “open wound” used to demarcate “low-risk” from “high-risk” patients. Low-risk patients denoted those patients whose actual TBSA% “open wound” ≤θ, whereas high-risk patients denoted those patients whose actual TBSA% “open wound” >θ. To consider all possibilities of risk, 100 sub analyses were performed by (1) varying θ from 100% to 1% in decrements of 1%, (2) grouping all patients as either “low-risk” or “high-risk” for each θ, and (3) comparing all means and deviations of variables and outcomes between the two groups for each θ. Hence, this study employed a data-driven approach to capture trends in clinical measurements and outcomes. Plots and tables were also obtained. ResultsFor 303 patients, median age and weight were 43 [29–59] years and 85 [72–99]kg, respectively. Mean TBSA% “burned” was 25 [17–39] %, with a full-thickness burn of 4 [0–15] %. Average crystalloid volumes were 4.25±2.27mL/kg/TBSA% “burned” in the first 24h. Importantly, for high-risk patients, decreasing θ was matched by significant increases in PaO2-FiO2 ratio, platelet count, Glasgow coma score (GCS), and MAP. On the other hand, increasing their risk θ was also matched by significant increases in creatinine, bilirubin, lactate, blood, estimated blood loss, and 24-h and total fluid volumes. As expected, for low-risk patients, clinical measurements were more stable, despite decreasing or increasing θ. At a θ of 80%, statistical tests indicated much disparity between high-risk and low-risk patients for TBSA% “burned”, full thickness burn, bilirubin (1.66±1.16mg/dL versus 0.83±0.65mg/dL, p=0.005), GCS (7±2 versus 12±3, p<0.001), MAP (42±22mm Hg versus 59±22mm Hg, p=0.004), 24-h blood, estimated blood loss, 24-h fluid, total fluid, and ICU length of stay (81±113 days versus 24±27 days, p=0.002). These differences were all statistically significant and remained significant down to θ=10%. ConclusionWound healing risk and potential may be forecasted by many different clinical measurements and outcomes and has many implications on multi-organ function. Future work will be needed to further explain and understand these effects, in order to facilitate development of new predictive models for wound healing.

Intravenous Fluid Boluses Are Commonly Administered to Adults with Sickle Cell Disease and Vaso-Occlusive Pain

Background: Sickle cell disease (SCD) affects 100,000 adults and children in the United States (USA). Painful, uncomplicated vaso-occlusive episodes (VOE) are the most common complication of SCD and the #1 reason adults with SCD seek medical attention in the ED. The NHLBI guidelines suggest encouraging oral hydration, along with analgesics, during VOE but to give intravenous (IV) fluids only if the patient cannot drink. However, there exists a clinical equipoise regarding the choice of IV fluids to use during the treatment of VOE in the ED, along with the rate or volume given. Despite lack of guidelines or evidence, the use of large IV volumes of crystalloids given over short periods of time (i.e. bolus) in the ED is common practice and we recently showed normal saline (NS) boluses in particular may be associated with inferior pain control and higher admission rates in pediatric patients with VOE (Carden etal., Am J Hem, 2019). Importantly, investigations into the use and impact these different IV fluids, including IV boluses, and how they may impact clinical outcomes among adult patients with SCD and VOE who present to the ED are lacking. Methods: We conducted a cross-sectional survey of emergency providers at the 2011 annual American College of Emergency Physicians Scientific Assembly, where ED providers from across the United States attend, regarding IV fluid practices during VOE. We specifically used a validated instrument to assess self-reported practices toward patients with SCD regarding IV fluid use, including volumes and rates, during uncomplicated VOE. Basic demographic information was obtained and providers were specifically asked: "Please indicate which type of fluids and rate of administration you give to patients with acute sickle cell pain who are not hypotensive and not severely hypovolemic". Providers responded never, rarely, frequently or always to each fluid type and rate. Results: Of 795 respondents to the survey, 722 indicated they took care of patients with SCD, 669 completely responded to the survey, and of those, 244 respondents only took care of adult patients with SCD. Demographic and experience with SCD patients, as well as preferred fluid type and rate of administration is reported in Table 1. IV fluid use during uncomplicated VOE varied among adult providers, but 83% of providers surveyed used IV fluid crystalloid boluses during VOE. Only 45% of providers recommended oral hydration during VOE among adults. Conclusions: Among adults ED providers who care for patients with SCD in the USA, wide variations in practice utilizing IV fluids are common. Despite no guidelines, IV fluid boluses are commonly given, as was seen in pediatric ED studies, and oral hydration is less commonly recommended among adult ED providers. Further investigation is needed to determine if these practices have an impact on clinical outcomes among euvolemic adult patients with SCD and VOE who present to the ED. Disclosures Carden: GBT: Honoraria; NIH: Research Funding. Tanabe:NIH: Research Funding; AHRQ: Research Funding. Glassberg:ACEP: Research Funding; NHLBI: Research Funding; Pfizer: Research Funding.

Anesthesiological support of cytoreducative operations using hyperthermic intraperitoneal chemotherapy (hipec) in patients with ovaryan cancer

The objective of the study : to analyze the experience of anesthesia when performing cytoreductive surgeries using hyperthermic intraperitoneal chemotherapy in patients with advanced forms of ovarian cancer. Subjects and methods . A pilot study of anesthetic management was conducted in 30 patients with ovarian cancer who underwent multiorgan cytoreductive abdominal resection with hyperthermic intraperitoneal chemotherapy. Results . The risk of anesthesia was 5.18 ± 0.39 points (which corresponded to the III degree of risk) according to the recommendations of the Moscow Scientific Society of Anesthesiology Reanimatology (MSSAR). The total volume of infusion‒transfusion therapy (ITT) was 11.070,0 ± 2.243,5 ml. with the hour rate of 21.7 ± 6.1 ml/kg-1/h-1, due to increase in the volume of crystalloids. Important components of anesthetic management were the patient's thermal stability and antiemetic therapy. Conclusion . As a result of the study, it was revealed that anesthesia in patients during cytoreductive operations with HIPEC was fairly complex and required the participation of a well-trained anesthesiological team. The issue of choosing the scale to assess anesthetic risk due to the lack of optimal one for this type of operations, requires further research. Although in our opinion, the scale of anesthesiological risk of the Moscow Scientific Society of Anesthesiologists-Resuscitators is more preferable. In such operations, the volume of ITT should be increased primarily through balanced crystalloids.

Pragmatic Pediatric Trial of Balanced Versus Normal Saline Fluid in Sepsis: The PRoMPT BOLUS Randomized Controlled Trial Pilot Feasibility Study.

Resuscitation with crystalloid fluid is a cornerstone of pediatric septic shock treatment. However, the optimal type of crystalloid fluid is unknown. We aimed to determine the feasibility of conducting a pragmatic randomized trial to compare balanced (lactated Ringer's [LR]) with 0.9% normal saline (NS) fluid resuscitation in children with suspected septic shock. Open-label pragmatic randomized controlled trial at a single academic children's hospital from January to August 2018. Eligible patients were>6 months to<18 years old who were treated in the emergency department for suspected septic shock, operationalized as blood culture, parenteral antibiotics, and fluid resuscitation for abnormal perfusion. Screening, enrollment, and randomization were carried out by the clinical team as part of routine care. Patients were randomized to receive either LR or NS for up to 48 hours following randomization. Other than fluid type, all treatment decisions were at the clinical team's discretion. Feasibility outcomes included proportion of eligible patients enrolled, acceptability of enrollment via the U.S. federal exception from informed consent (EFIC) regulations, and adherence to randomized study fluid administration. Of 59 eligible patients, 50 (85%) were enrolled and randomized. Twenty-four were randomized to LR and 26 to NS. Only one (2%) of 44 patients enrolled using EFIC withdrew before study completion. Total median (interquartile range [IQR]) crystalloid fluid volume received during the intervention window was 107 (60 to 155) mL/kg and 98 (63 to 128) mL/kg in the LR and NS arms, respectively (p=0.50). Patients randomized to LR received a median (IQR) of only 20% (13 to 32) of all study fluid as NS compared to 99% (64% to 100%) of study fluid as NS in the NS arm (absolute difference= 79%, 95% CI= 48% to 85%). A pragmatic study design proved feasible to study comparative effectiveness of LR versus NS fluid resuscitation for pediatric septic shock.

A Dose-Response Analysis of Crystalloid Administration during Esophageal Resection.

The purpose of this retrospective study was to investigate the role of intraoperative crystalloid administration on postoperative hospital length of stay (phLOS) and on the incidence of previously reported adverse events in 100 consecutive patients who underwent esophageal resection. The role of previously reported patient demographics, clinical characteristics, and intraoperative crystalloid administration on the duration of phLOS underwent statistical screening criteria for multivariable analysis, including the use of an instrumental variable to measure the role of unmeasured confounders on phLOS. Tests to assess the likelihood of causality also were performed. When the volumes of intraoperative crystalloids were expressed as dose-response relationships to outcomes, progressive decreases in phLOS, variances in phLOS, and the incidences of unplanned surgical intensive care unit admission, postoperative pneumonia, respiratory failure requiring orotracheal intubation, nonsinus cardiac dysrhythmias, and anastomotic leak were observed. Intraoperative transfusion of packed red blood cells greatly increased the duration of phLOS, which was not associated with estimated blood loss, length of surgical operation, or unplanned surgical intensive care unit admission. Instrumental variable analysis revealed no significant influence on phLOS. Causality tests supported the role of intraoperative crystalloid administration in reducing the duration and variance of phLOS. A dose-response relationship was clinically observed between intraoperative crystalloid administration and the duration and variance of phLOS and with commonly reported postoperative adverse events. Intraoperative transfusion of packed red blood cells greatly increased phLOS that was not associated with the severity of the surgical operation. Instrumental variables and tests for causality further supported the role of intraoperative crystalloid administration in reducing the duration and variance of phLOS.

Prehospital Blood Product and Crystalloid Resuscitation in the Severely Injured Patient: A Secondary Analysis of the Prehospital Air Medical Plasma Trial.

The aim of this study was to determine whether prehospital blood products reduce 30-day mortality in patients at risk for hemorrhagic shock compared with crystalloid only resuscitation. Hemorrhage is the primary cause of preventable death after injury. Large volume crystalloid resuscitation can be deleterious. The benefits of prehospital packed red blood cells (PRBCs), plasma, or transfusion of both products among trauma patients is unknown compared with crystalloid. Secondary analysis of the multicenter PAMPer trial was performed on hypotensive injured patients from the scene. The trial randomized 27 helicopter bases to prehospital plasma or standard resuscitation. Standard resuscitation at the sites was equally divided between crystalloid and crystalloid + PRBC. This led to 4 prehospital resuscitation groups: crystalloid only; PRBC; plasma; and PRBC+plasma. Cox regression determined the association between resuscitation groups and risk-adjusted 30-day mortality. The dose effect of resuscitation fluids was also explored. Four hundred seven patients were included. PRBC+plasma had the greatest benefit [hazard ratio (HR) 0.38; 95% confidence interval (95% CI) 0.26-0.55, P < 0.001], followed by plasma (HR 0.57; 95% CI 0.36-0.91, P = 0.017) and PRBC (HR 0.68; 95% CI 0.49-0.95, P = 0.025) versus crystalloid only. Mortality was lower per-unit of PRBC (HR 0.69; 95% CI 0.52-0.92, p = 0.009) and plasma (HR 0.68; 95% CI 0.54-0.88, P = 0.003). Crystalloid volume was associated with increased mortality among patients receiving blood products (HR 1.65; 95% CI 1.17-2.32, P = 0.004). Patients receiving prehospital PRBC+plasma had the greatest mortality benefit. Crystalloid only had the worst survival. Patients with hemorrhagic shock should receive prehospital blood products when available, preferably PRBC+plasma. Prehospital whole blood may be ideal in this population.

Association between perioperative surgical home implementation and transfusion patterns in adolescents with idiopathic scoliosis undergoing spinal fusion.

Blood transfusions in patients with adolescent idiopathic scoliosis after fusion have been associated with increased morbidity, mortality, and cost. The aim of this study was to evaluate the association between implementation of blood-conservation strategies within the perioperative surgical home on transfusion rates for patients with adolescent idiopathic scoliosis undergoing spinal fusion. Two hundred and thirteen patients (44 preperioperative surgical home, 169 postperioperative surgical home) who underwent posterior spine fusion for adolescent idiopathic scoliosis between 23 June 2014, and 30 July 2017, were enrolled in this case control study. The perioperative surgical home implemented in March 2015 involved evidence-based perioperative interventions to create a standardized clinical pathway including judicious use of crystalloid management, restrictive transfusion strategy, routine use of cell saver, and standardized administration of anti-fibrinolytics. The primary outcome was odds of perioperative transfusion. Secondary outcomes included volumes of crystalloid, albumin, cell saver, packed red blood cells as well as calculated blood loss. Other variables that were documented included antibrinolytic total dose, mean arterial pressure, temperature, laboratory values, intrathecal morphine dosing, and surgical time. Statistical methods included t test and logistic regression. For the postperioperative surgical home, the odds of perioperative transfusion were 0.30 (95% CI 0.13-0.70), as compared to preperioperative surgical home. In terms of secondary outcomes, calculated blood loss was significantly lower in the postperioperative surgical home patients (27.0mL/kg preperioperative surgical home vs 22.8mL/kg postperioperative surgical home; mean difference=-0.24 [-0.44, -0.04]). Although no difference was noted in the amount of intraoperative cell saver or albumin administered, a reduction was noted in mean intraoperative crystalloid given postperioperative surgical home (41.4mL/kg±20.4mL/kg preperioperative surgical home vs 28.0mL/kg±13.7mL/kg postperioperative surgical home; log mean difference=0.37 [95% CI 0.21-0.53], P<0.001). Postperioperative surgical home patients also had a significantly higher temperature nadir (mean difference=-0.47 [95% CI -0.70 to -0.23]; P<0.001), received a significantly higher total anti-fibrinolytic dose (mean difference=-3939 [95% CI -5364 to -2495]; P<0.001), and were exposed to shorter surgical times (mean difference=0.72 [95% CI 0.36-1.09]; P<0.001). Implementation of blood-conservation strategies as part of a perioperative surgical home for patients with adolescent idiopathic scoliosis undergoing posterior spine fusion resulted in significant decrease in perioperative blood transfusions.

The impact of standardized protocol implementation for surgical damage control and temporary abdominal closure after emergent laparotomy.

To standardize care and promote early fascial closure among patients undergoing emergent laparotomy and temporary abdominal closure (TAC), we developed a protocol addressing patient selection, operative technique, resuscitation strategies, and critical care provisions. We hypothesized that primary fascial closure rates would increase following protocol implementation with no difference in complication rates. We performed a retrospective cohort analysis of 138 adult trauma and emergency general surgery patients who underwent emergent laparotomy and TAC, comparing protocol patients (n = 60) to recent historic controls (n = 78) who would have met protocol inclusion criteria. The protocol includes low-volume 3% hypertonic saline resuscitation, judicious wound vacuum fluid replacement, and early relaparotomy with sequential fascial closure. Demographics, baseline characteristics, illness severity, resuscitation course, operative management, and outcomes were compared. The primary outcome was fascial closure. Baseline characteristics, including age, American Society of Anesthesiologists class, and postoperative lactate levels, were similar between groups. Within 48 hours of initial laparotomy and TAC, protocol patients received significantly lower total intravenous fluid resuscitation volumes (9.7 vs. 11.4 L, p = 0.044) and exhibited higher serum osmolarity (303 vs. 293 mOsm/kg, p = 0.001). The interval between abdominal operations was significantly shorter following protocol implementation (28.2 vs. 32.2 hours, p = 0.027). The incidence of primary fascial closure was significantly higher in the protocol group (93% vs. 81%, p = 0.045, number needed to treat = 8.3). Complication rates were similar between groups. Protocol implementation was associated with lower crystalloid resuscitation volumes, a transient hyperosmolar state, shorter intervals between operations, and higher fascial closure rates with no difference in complications. Therapeutic study, level IV.

The haemodynamic effects of crystalloid and colloid volume resuscitation on primary, derived and efficiency variables in post-CABG patients

BackgroundRecent studies in haemodynamic management have focused on fluid management and assessed its effects in terms of increase in cardiac output based on fluid challenges or variations in pulse pressure caused by cyclical positive pressure ventilation. The theoretical scope may be characterised as Starling-oriented. This approach ignores the actual events of right-sided excitation and left-sided response which is consistently described in a Guyton-oriented model of the cardiovascular system.AimBased on data from a previous study, we aim to elucidate the primary response to crystalloid and colloid fluids in terms of cardiac output, mean blood pressure and right atrial pressure as well as derived and efficiency variables defined in terms of Guyton venous return physiology.MethodRe-analyses of previously published data.ResultsCardiac output invariably increased on infusion of crystalloid and colloid solutions, whereas static and dynamic efficiency measures declined in spite of increasing pressure gradient for venous return.DiscussionWe argue that primary as well as derived and efficiency measures should be reported and discussed when haemodynamic studies are reported involving fluid administrations.

Nurses' Indications for Administration of Perioperative Intravenous Fluid Therapy—A Prospective, Descriptive, Single-Center Cohort Study

To examine whether nurse anesthetists and postanesthesia nurses' administration of intravenous (IV) fluid therapy during surgery and in the postanesthesia care unit is based on evidence. Secondarily to investigate if providing indications for IV fluid administration changed nursing practice. Prospective, descriptive, single-center study in Scandinavia comparing two cohorts. Descriptive, fluid volume, and type data were obtained in both cohorts. Cohort 1 (n=126) was used as baseline data. In cohort 2 (n=130), nurses recorded indications for type and volume of fluid therapy using a validated list. Analysis compared median volumes of crystalloid or colloid fluids of surgical types by cohort. Analysis compared frequency of given indication reasons for each IV fluid by surgical type. Basic static variables were chosen most frequently for indications of IV fluid needed for all surgeries except high-risk abdominal surgery where dynamic variables were more frequent. Signs and symptoms of inadequate tissue perfusion were only sparsely indicated. The volume of intraoperative crystalloid fluids was statistically different for patients with hip fracture surgery in cohort 2. Volumes of both colloid and crystalloid fluids were significantly higher for high-risk abdominal surgery in cohort2. Nurse anesthetists and nurses in the postanesthesia care unit rely more on basic static parameters than signs of inadequate tissue perfusion when they make decisions about fluid administration. The indications cited for fluid administered to high-risk abdominal surgery and hip fracture patients did not always fit guidelines. This indicates the need of a stronger intervention to change practice to follow evidence-based clinical guidelines.

Postoperative Blood Loss and Coagulation Changes After Balanced 6% Hydroxyethyl Starch 130/0.4 Administration During Spine Surgery: A Retrospective Study.

Retrospective analysis. The objective of this study was to investigate the effects of intraoperative balanced 6% hydroxyethyl starch (HES) 130/0.4 on postoperative blood loss and the coagulation profile. The safety of colloid versus crystalloid transfusion for bleeding and coagulation during major spine surgery remains controversial and only a few studies exist. Thus, we compared the effects of balanced 6% HES 130/0.4 and crystalloid on postoperative bleeding and coagulation. Patients undergoing spine surgery between February 1, 2015 and February 28, 2017 were divided into 2 groups: patients receiving intraoperative balanced 6% HES 130/0.4 and patients receiving crystalloid. We compared the postoperative bleeding volume with changes in the coagulation profile and length of hospital stay between these 2 groups. Propensity score (PS)-matching and multivariate stepwise linear regression were performed. A total of 169 patients who met the inclusion criteria were analyzed. The quantity of total colloid per patient was 10-15 mL/kg. A significant difference was observed in the total intraoperative transfused crystalloid volume between the 2 groups (colloid group, 1.394.6±1.414.0 mL; crystalloid group, 2.027.3±1.114.1 mL; P<0.001). Postoperative blood loss and coagulation profile changes were not significantly different in the 60 PS-matched paired patients. Furthermore, no differences in either postoperative transfusion requirement or length of hospital stay were observed between the groups. Multivariate stepwise linear regression revealed that operation time (β=0.549; P<0.001) and intraoperative transfusion of packed red blood cells (β=0.466; P=0.003) or fresh frozen plasma (β=-0.263; P=0.041) were independently associated with postoperative blood loss. However, intraoperative colloid administration was not a predictive factor. Intraoperative infusion of balanced 6% HES 130/0.4 in patients undergoing spine surgery presented clinically insignificant changes in postoperative blood loss and coagulation compared to crystalloid. Level III.

Optimal crystalloid volume ratio for blood replacement for maintaining hemodynamic stability and lung function: an experimental randomized controlled study

BackgroundCrystalloids are first line in fluid resuscitation therapy, however there is a lack of evidence-based recommendations on the volume to be administered. Therefore, we aimed at comparing the systemic hemodynamic and respiratory effects of volume replacement therapy with a 1:1 ratio to the historical 1:3 ratio.MethodsAnesthetized, ventilated rats randomly included in 3 groups: blood withdrawal and replacement with crystalloid in 1:1 ratio (Group 1, n = 11), traditional 1:3 ratio (Group 3, n = 12) and a control group with no interventions (Group C, n = 9). Arterial blood of 5% of the total blood volume was withdrawn 7 times, and replaced stepwise with different volume rations of Ringer’s acetate, according to group assignments. Airway resistance (Raw), respiratory tissue damping (G) and tissue elastance (H), mean arterial pressure (MAP) and heart rate (HR) were assessed following each step of fluid replacement with a crystalloid (CR1-CR6). Lung edema index was measured from histological samples.ResultsRaw decreased in Groups 1 and 3 following CR3 (p < 0.02) without differences between the groups. H elevated in all groups (p < 0.02), with significantly higher changes in Group 3 compared to Groups C and 1 (both p = 0.03). No differences in MAP or HR were present between Groups 1 and 3. Lung edema was noted in Group 3 (p < 0.05).ConclusionsFluid resuscitation therapy by administering a 1:1 blood replacement ratio revealed adequate compensation capacity and physiological homeostasis similar with no lung stiffening and pulmonary edema. Therefore, considering this ratio promotes the restrictive fluid administration in the presence of continuous and occult bleeding.

Fluid resuscitation during persistent postpartum haemorrhage and maternal outcome: A nationwide cohort study

ObjectiveTo determine the association between increasing volumes of crystalloids and colloids administered before transfusion of packed red blood cells in women with persistent postpartum haemorrhage and adverse maternal outcomes. Study designRetrospective cohort study in the Netherlands. Women with persistent postpartum haemorrhage and known clear fluids volume for resuscitation were included. Women who received ≤2 L of clear fluids were the reference group. We determined the effect of every additional litre of clear fluids on total blood loss, severe maternal morbidity and mortality. Results were adjusted for patient and bleeding characteristics. ResultsOf the 883 included women, 199 received ≤2 L of clear fluids. Median blood loss for the reference group was 2.9 L (interquartile range 2.2–3.4). Adjusted mean difference in blood loss compared with the reference group was 0.2 L (95% confidence interval −0.1 to 0.5) for women in the >2 to ≤3 L, 0.4 L (0.1–0.7) for the >3 to ≤4 L category, 0.6 L (0.5–0.7) for the >4 to ≤5 L category, and 1.9 L (1.5–2.3) for the >5 to ≤7 L category. Adjusted odds ratios for adverse maternal outcomes were 1.0 (0.7–1.6), 1.2 (0.8–1.9), 1.8 (1.1–3.1) and 4.4 (2.6–7.5) for women in the 2 to ≤3 L category, >3 to ≤4 L, >4 to ≤5 L, and >5 to ≤7 L volume categories respectively. Results were similar in strata of different severities of bleeding. ConclusionClear fluids volume >4 L was independently associated with adverse maternal outcome in women with persistent postpartum haemorrhage.