Volume Of Fluid Resuscitation Research Articles

Effect of Hydroxyethyl Starch (HES) versus 5% Albumin Solution on Intra-Abdominal Pressure in Severe Burn Patients: A Randomized Clinical Study

Abstract Introduction Massive burn patients are at high risk of developing intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) as a complication of aggressive resuscitation. This study aimed to evaluate the effect of Hydroxyethyl starch (HES) versus 5% albumin solution on intra-abdominal pressure (IAP) in massive burn patients. Methods This was a single-center, prospective randomized clinical trial carried on at Ain Shams University (ASU) burn unit for 2 years. Where adult patients with burns 20 to 60 % of TBSA were equally randomized into HES group or albumin group. Results Fifty-two patients were equally randomized into 2 groups. There was no difference in age, sex, weight, type of burn, and TBSA between the two groups. The mean total resuscitation fluid volume in the first 48 hours was 213 ml/kg and 206.2 ml/kg for the HES group and the albumin group respectively (p = 0.674). IAP statistically was non-significantly higher in the HES group. There was no statistical difference between the two groups as regards the renal function tests. Conclusion Both HES and 5% albumin solution are effective and safe colloids for burn resuscitation. They partially have an equal effect on intra-abdominal pressure, renal involvement, and vital data stability in massive burn patients.

Does Point-of-Care Ultrasound Affect Fluid Resuscitation Volume in Patients with Septic Shock: A Retrospective Review.

Fixed, large volume resuscitation with intravenous fluids (IVFs) in septic shock can cause inadvertent hypervolemia, increased medical interventions, and death when unguided by point-of-care ultrasound (POCUS). The primary study objective was to evaluate whether total IVF volume differs for emergency department (ED) septic shock patients receiving POCUS versus no POCUS. We conducted a retrospective observational cohort study from 7/1/2018 to 8/31/2021 of atraumatic adult ED patients with septic shock. We agreed upon a priori variables and defined septic shock as lactate ≥4 and hypotension (SBP <90 or MAP <65). A sample size of 300 patients would provide 85% power to detect an IVF difference of 500 milliliters between POCUS and non-POCUS cohorts. Data are reported as frequencies, median (IQR), and associations from bivariate logistic models. 304 patients met criteria and 26% (78/304) underwent POCUS. Cardiac POCUS demonstrated reduced ejection fraction in 15.4% of patients. Lung ultrasound showed normal findings in 53% of patients. The POCUS vs. non-POCUS cohorts had statistically significant differences for the following variables: higher median lactate (6.7 [IQR 5.2-8.7] vs. 5.6], p = 0.003), lower systolic blood pressure (77.5 [IQR 61-86] vs. 85.0, p < 0.001), more vasopressor use (51% vs. 34%, p = 0.006), and more positive pressure ventilation (38% vs. 24%, p = 0.017). However, there were no statistically significant differences between POCUS and non-POCUS cohorts in total IVF volume ml/kg (33.02 vs. 32.1, p = 0.47), new oxygen requirement (68% vs. 59%, p = 0.16), ED death (3% vs. 4%, p = 0.15), or hospital death (31% vs. 27%, p = 0.48). There were similar distributions of lactate, total fluids, and vasopressors in patients with CHF and severe renal failure. Among ED patients with septic shock, POCUS was more likely to be used in sicker patients. Patients who had POCUS were given similar volume of crystalloids although these patients were more critically ill. There were no differences in new oxygen requirement or mortality in the POCUS group compared to the non-POCUS group.

Establishing a prognostic prediction model for patients with septic shock based on the completion time of fluid resuscitation and the negative fluid balance volumes

To explore the relationship between the completion time of fluid resuscitation as well as negative fluid balance volumes and the prognosis of patients with septic shock, and to try to construct a prediction model based on the completion time of fluid resuscitation and negative fluid balance volumes, and to verify the predictive efficacy of the model on the prognosis of patients with septic shock. Patients with septic shock admitted to Wuxi People's Hospital from April 2020 to April 2023 were selected. The general data (gender, age, body mass index, infection site), pathological indicators on admission, the difference of acute physiology and chronic health evaluation II (APACHE II) and sequential organ failure assessment (SOFA) between admission and 24 hours after fluid resuscitation, the completion time of fluid resuscitation and negative fluid balance volume were recorded. Multivariate Logistic analysis was used to screen the influencing factors of the prognosis of patients with septic shock, and a nomogram model was established. Bootstrap method was used for internal validation of the model. The consistency index, calibration curve and receiver operator characteristic curve (ROC curve) were used to evaluate the accuracy and prediction efficiency of the model. A total of 96 patients with septic shock were enrolled, 38 patients died and 58 patients survived at 28 days. Compared with the survival group, the difference of APACHE II score, SOFA score, the proportion of fluid resuscitation completed within 1 to 3 hours, and the proportion of negative fluid balance volume -500 to -250 mL per day in the death group were lower, and the differences were statistically significant (all P < 0.05). Multivariate Logistic analysis showed that the completion time of fluid resuscitation was a risk factor for the prognosis of patients with septic shock [odds ratio (OR) = 26.285, 95% confidence interval (95%CI) was 9.984-76.902, P < 0.05]. The difference of APACHE II score (OR = 0.045, 95%CI was 0.015-0.131), SOFA score (OR = 0.056, 95%CI was 0.019-0.165) between admission and 24 hours after fluid resuscitation, and negative fluid balance volume (OR = 0.043, 95%CI was 0.015-0.127) were protective factors for the prognosis of patients with septic shock (all P < 0.05). The model validation results showed that the consistency index was 0.681 (95%CI was 0.596-0.924), indicating good discrimination. The calibration curve showed that the calibration curve fitted well with the ideal curve. The ROC curve showed that the sensitivity of the nomogram model for predicting the death of patients with septic shock was 83.7%, the specificity was 97.2%, and the area under the ROC curve (AUC) was 0.931 (95%CI was 0.846-0.985), indicating that the model had good prediction efficiency. The completion time of fluid resuscitation and negative fluid balance volumes are related to the prognosis of septic shock patients, and the alignment diagram model improve the identification of the risk of death in septic shock patients.

Appraisal of Australian and New Zealand paediatric sepsis guidelines.

Clinical practice guidelines (CPGs) are an important tool for the management of children with sepsis. The quality, consistency and concordance of Australian and New Zealand (ANZ) childhood sepsis CPGs with the Australian Commission on Safety and Quality in Healthcare (ACSQHC) sepsis clinical care standards and international sepsis guidelines is unclear. We accessed childhood sepsis CPGs for all ANZ states and territories through Paediatric Research in Emergency Departments International Collaborative members. The guidelines were assessed for quality using the AGREE-II instrument. Consistency between CPG treatment recommendations was assessed, as was concordance with the ACSQHC sepsis clinical care standards and international sepsis guidelines. Overall, eight CPGs were identified and assessed. CPGs used a narrative and pathway format, with those using both having the highest quality overall. CPG quality was highest for description of scope and clarity of presentation, and lowest for editorial independence. Consistency between guidelines for initial treatment recommendations was poor, with substantial variation in the choice and urgency of empiric antimicrobial administration; the choice, volume and urgency of fluid resuscitation; and the choice of first-line vasoactive agent. Most CPGs were concordant with time-critical components of the ACSQHC sepsis clinical care standard, although few addressed post-acute care. Concordance with international sepsis guidelines was poor. Childhood sepsis CPGs in current use in ANZ are of variable quality and lack consistency with key treatment recommendations. CPGs are concordant with the ACSQHC care standard, but not with international sepsis guidelines. A bi-national sepsis CPG may reduce unnecessary variation in care.

Crystalloid Fluid Management of Non-Traumatic Hypotension by New South Wales Ambulance

Introduction Shock is circulatory insufficiency, inadequate oxygen delivery, and cellular hypoxia. Intravenous fluids are essential for shock management. Despite treatment, patients can face persistent shock with ongoing hypotension, contributing to higher mortality. This analysis aims to quantify hypotensive non-traumatic cases in an Australian ambulance service, determine persistent hypotension prevalence, and assess paramedic-administered intravascular fluids’ impact on blood pressure changes. Methods This study is a retrospective analysis of prehospital fluid resuscitation by New South Wales Ambulance paramedics during 2022. Hypotension is defined as a systolic blood pressure of ≤ 90 mmHg, and persistent hypotension is a systolic blood pressure consistently below 90 mmHg across all observations, with a final blood pressure below 90 mmHg. This study aimed to determine the volume of fluid resuscitation at which a plateau in population-level systolic blood pressure response is observed, by calculating the derivative of the fitted logistic regression model. Moreover, this analysis identified the relative contribution of factors influencing the probability of an attempt at intravenous or intraosseous access using machine learning. Results Among 796,865 attendances, 23,049 (2.9%) involved non-traumatic patients with hypotension. In total 7,388 (32.1%) of the hypotensive cases resulted in persistent hypotension, of which 3,235 (43.8%) received Hartmann’s solution and 1,745 (53.9%) received at least 500 ml of fluids but still had hypotension. The model showed that systolic blood pressure tends to stop increasing after 500–600 milliliters of fluid are given. This suggests that, on average, giving more fluid than this may not raise blood pressure further in a prehospital setting, though individual patient needs can differ. The top four factors from the machine learning shows that as initial respiratory rate goes up, the probability of intravascular access rises. Transport times less than 20 min are associated with a smaller chance of access and younger patients are less likely to receive an attempt. Finally, extremes of systolic blood pressure are more likely to receive access attempts. Conclusion This study found that three percent of non-traumatic attendances have at least one episode of hypotension, and that more than half of these have persistent hypotension. Only 44% of persistently hypotensive received fluids, and half of persistently hypotensive patients stayed hypotensive despite a reasonable volume of prehospital crystalloids.

American Burn Association Clinical Practice Guidelines on Burn Shock Resuscitation.

This Clinical Practice Guideline (CPG) addresses the topic of acute fluid resuscitation during the first 48 hours following a burn injury for adults with burns ≥20% of the total body surface area (%TBSA). The listed authors formed an investigation panel and developed clinically relevant PICO (Population, Intervention, Comparator, Outcome) questions. A systematic literature search returned 5978 titles related to this topic and after 3 levels of screening, 24 studies met criteria to address the PICO questions and were critically reviewed. We recommend that clinicians consider the use of human albumin solution, especially in patients with larger burns, to lower resuscitation volumes and improve urine output. We recommend initiating resuscitation based on providing 2 mL/kg/% TBSA burn in order to reduce resuscitation fluid volumes. We recommend selective monitoring of intra-abdominal and intraocular pressure during burn shock resuscitation. We make a weak recommendation for clinicians to consider the use of computer decision support software to guide fluid titration and lower resuscitation fluid volumes. We do not recommend the use of transpulmonary thermodilution-derived variables to guide burn shock resuscitation. We are unable to make any recommendations on the use of high-dose vitamin C (ascorbic acid), fresh frozen plasma (FFP), early continuous renal replacement therapy, or vasopressors as adjuncts during acute burn shock resuscitation. Mortality is an important outcome in burn shock resuscitation, but it was not formally included as a PICO outcome because the available scientific literature is missing studies of sufficient population size and quality to allow us to confidently make recommendations related to the outcome of survival at this time.

Using a Fluid Resuscitation Algorithm to Reduce the Incidence of Abdominal Compartment Syndrome in the Burn Intensive Care Unit.

Patients with large burns must be carefully resuscitated to balance adequate tissue perfusion with the risk of end-organ damage. One devastating complication of overresuscitation is abdominal compartment syndrome. Reducing the volume of fluids given during resuscitation may reduce the incidence of abdominal compartment syndrome and improve outcomes. To determine whether decreasing fluid resuscitation volume in a burn center reduced the incidence of abdominal compartment syndrome. This retrospective cohort study involved all patients with severe burns (total body surface area ≥20%) who were admitted to a burn intensive care unit over 4 years (n = 166). Primary outcomes were required fluid volume, whether differences in the patient characteristics measured affected outcomes, rate of abdominal compartment syndrome, and incidence of abdominal hypertension. After the first 2 years, the Parkland fluid resuscitation algorithm was modified to decrease the volume goal, and patients were assessed for the incidence of abdominal compartment syndrome and related complications such as kidney failure, abdominal hypertension, and ventilator days. A total of 16% of patients resuscitated using the Parkland equation experienced abdominal compartment syndrome compared with 10% of patients resuscitated using the modified algorithm, a difference of 6 percentage points (P = .39). Average volume administered was 11.8 L using the Parkland formula and 9.4 L using the modified algorithm (P = .03). Despite a significant decrease in the amount of fluid administered, no significant difference was found in incidence of abdominal compartment syndrome or urine output. Matched prospective studies are needed to improve resuscitation care for patients with large burns.

Hypertension during transfer is associated with poor outcomes in unstable patients with ruptured abdominal aortic aneurysm

ObjectiveLimited data exist for optimal blood pressure (BP) management during transfer of patients with ruptured abdominal aortic aneurysm (rAAA). This study evaluates the effects of hypertension and severe hypotension during interhospital transfers in a cohort of patients with rAAA in hemorrhagic shock. MethodsWe performed a retrospective, single-institution review of patients with rAAA transferred via air ambulance to a quaternary referral center for repair (2003-2019). Vitals were recorded every 5 minutes in transit. Hypertension was defined as a systolic BP of ≥140 mm Hg. The primary cohort included patients with rAAA with hemorrhagic shock (≥1 episode of a systolic BP of <90 mm Hg) during transfer. The primary analysis compared those who experienced any hypertensive episode to those who did not. A secondary analysis evaluated those with either hypertension or severe hypotension <70 mm Hg. The primary outcome was 30-day mortality. ResultsDetailed BP data were available for 271 patients, of which 125 (46.1%) had evidence of hemorrhagic shock. The mean age was 74.2 ± 9.1 years, 93 (74.4%) were male, and the median total transport time from helicopter dispatch to arrival at the treatment facility was 65 minutes (interquartile range, 46-79 minutes). Among the cohort with shock, 26.4% (n = 33) had at least one episode of hypertension. There were no significant differences in age, sex, comorbidities, AAA repair type, AAA anatomic location, fluid resuscitation volume, blood transfusion volume, or vasopressor administration between the hypertensive and nonhypertensive groups. Patients with hypertension more frequently received prehospital antihypertensives (15% vs 2%; P = .01) and pain medication (64% vs 24%; P < .001), and had longer transit times (36.3 minutes vs 26.0 minutes; P = .006). Episodes of hypertension were associated with significantly increased 30-day mortality on multivariable logistic regression (adjusted odds ratio [aOR], 4.71; 95% confidence interval [CI], 1.54-14.39; P = .007; 59.4% [n = 19] vs 40.2% [n = 37]; P = .01). Severe hypotension (46%; n = 57) was also associated with higher 30-day mortality (aOR, 2.82; 95% CI, 1.27-6.28; P = .01; 60% [n = 34] vs 32% [n = 22]; P = .01). Those with either hypertension or severe hypotension (54%; n = 66) also had an increased odds of mortality (aOR, 2.95; 95% CI, 1.08-8.11; P = .04; 58% [n = 38] vs 31% [n = 18]; P < .01). Level of hypertension, BP fluctuation, and timing of hypertension were not significantly associated with mortality. ConclusionsHypertensive and severely hypotensive episodes during interhospital transfer were independently associated with increased 30-day mortality in patients with rAAA with shock. Hypertension should be avoided in these patients, but permissive hypotension approaches should also maintain systolic BPs above 70 mm Hg whenever possible.

Pediatric Profound Dengue Shock Syndrome and Use of Point-of-Care Ultrasound During Mechanical Ventilation to Guide Treatment: Single-Center Retrospective Study, 2013-2021.

Profound dengue shock syndrome (DSS) complicated by severe respiratory failure necessitating mechanical ventilation (MV) accounts for high case fatality rates among PICU-admitted patients. A major challenge to management is the assessment of intravascular volume, which can be hampered by severe plasma leakage and the use of MV. Retrospective cohort, from 2013 to 2021. Sixty-seven children with profound DSS supported by MV, some of whom underwent bedside point-of-care ultrasound (POCUS) for assessment and monitoring of hemodynamics and fluid administration. PICU of the tertiary Children's Hospital No. 2 in Vietnam. None. We analyzed data clinical and laboratory data during PICU stay. In particular, during use of MV (i.e., at times 0-, 6-, and 24-hr after commencement) and fluid resuscitation. The primary study outcome was 28-day in-hospital mortality, and the secondary outcomes were associations with changes in hemodynamics, blood lactate, and vasoactive-inotrope score (VIS). Patients had a median age of 7 years (interquartile range, 4-9). Use of POCUS during fluid management (39/67), as opposed to not using (28/67), was associated with lower mortality (6/39 [15%] vs. 18/28 [64%]; difference 49 % [95% CI, 28-70%], p < 0.001). Use of POCUS was associated with lower odds of death (adjusted odds ratio 0.17 [95% CI, 0.04-0.76], p = 0.02). The utilization of POCUS, versus not, was associated with greater use of resuscitation fluid, and reductions in VIS and pediatric logistic organ dysfunction (PELOD-2) score at 24 hours after MV and PICU discharge. In our experience of pediatric patients with profound DSS and undergoing MV (2013-2021), POCUS use was associated with lower odds of death, a higher volume of resuscitation fluid, and improvements in the blood lactate levels, VIS, and PELOD-2 score.

Fluid resuscitation and relation to respiratory support escalation in patients with and without pulmonary hypertension with sepsis.

To compare guideline-based fluid resuscitation and need for respiratory support escalation in septic patients with pulmonary hypertension (PH) to those without PH. Single-center, retrospective cohort study. Tertiary care academic medical center in Detroit, Michigan. Adult patients with or without PH hospitalized and diagnosed with sepsis from November 1, 2013 through December 31, 2019. Patients with sepsis were assigned to one of two groups based on a previous PH diagnosis or no PH diagnosis. None. The primary outcome was incidence of respiratory support escalation within 72 h from sepsis time zero. Respiratory support escalation included high-flow nasal cannula, bilevel positive airway pressure, or intubation. One-hundred and four patients were included with 52 patients in each study group. Patients with PH were more likely to require escalation of respiratory support compared to non-PH patients (32.7% vs. 11.5%; p = 0.009). Fewer patients with PH received 30 mL/kg of crystalloid within 6 h of time zero compared with non-PH patients (3.8% vs. 42.3%; p < 0.001). Vasopressor initiation was more common in patients with PH compared with the non-PH group (40.4% vs. 19.2%; p = 0.018). PH diagnosis was the only independent predictor of respiratory support escalation. During initial sepsis management when compared with patients without PH, patients with PH had increased instances of respiratory support escalation within 72 h of sepsis time zero despite lower fluid resuscitation volumes.

The effect of dehydration, hyperchloremia and volume of fluid resuscitation on acute kidney injury in children admitted to hospital with diabetic ketoacidosis.

Acute kidney injury (AKI) is a recognized comorbidity in pediatric diabetic ketoacidosis (DKA), although the exact etiology is unclear. The unique physiology of DKA makes dehydration assessments challenging, and these patients potentially receive excessive amounts of intravenous fluids (IVF). We hypothesized that dehydration is over-estimated in pediatric DKA, leading to over-administration of IVF and hyperchloremia that worsens AKI. Retrospective cohort of all DKA inpatients at a tertiary pediatric hospital from 2014 to 2019. A total of 145 children were included; reasons for exclusion were pre-existing kidney disease or incomplete medical records. AKI was determined by change in creatinine during admission, and comparison to a calculated baseline value. Linear regression multivariable analysis was used to identify factors associated with AKI. True dehydration was calculated from patients' change in weight, as previously validated. Fluid over-resuscitation was defined as total fluids given above the true dehydration. A total of 19% of patients met KDIGO serum creatinine criteria for AKI on admission. Only 2% had AKI on hospital discharge. True dehydration and high serumurea levels were associated with high serumcreatinine levels on admission (p = 0.042; p < 0.001, respectively). Fluid over-resuscitation and hyperchloremia were associated with delayed kidney recovery (p < 0.001). Severity of initial AKI was associated with cerebral edema (p = 0.018). Dehydration was associated with initial AKI in children with DKA. Persistent AKI and delay to recovery was associated with hyperchloremia and over-resuscitation with IVF, potentially modifiable clinical variables for earlier AKI recovery and reduction in long-term morbidity. This highlights the need to re-address fluid protocols in pediatric DKA.

Albumin as Early Fluid Bolus Therapy after Cardiac Surgery in the Critical Care Units

Abstract Introduction After cardiac surgery, the use of intravenous fluids to reach specific goals is associated with improved clinical outcomes and shortened intensive care units (ICU) stay. Although type of fluid doesn’t seem to be of a great importance. Clinicians will have been involved in many local debates about the best fluid. Absence of evidence about what is the ideal fluid in this situation push researchers to conduct clinical trials in this context. Aim of the Work The aim of this study is to investigate the cardiovascular effect of using 20% albumin in patients after cardiac surgery. Methods This was a double blinded RCT that was conducted at Department of Critical Care Medicine, Ain Shams University Hospital over 6 months on post-cardiac surgery mechanically ventilated patients with a clinical decision to administer fluid bolus therapy, that was assessed for enrollment. Results There was no statistically significant difference between two groups regarding delta serum chloride at 24 h post-op (mmol/L) and renal replacement therapy post-operatively in ICU, and there was statistically significant difference found between two groups regarding ICU, and Hospital stay, duration of mechanical ventilation, total dose nor epinephrine/kg in the first 24 h post-op (microg/kg), time to cessation of nor epinephrine infusion (h) and Delta serum creatinine at 24 h post-op (mg/dl). Conclusion In patients admitted to ICU following cardiac surgery, FBT with 20% albumin, when compared to crystalloid FBT, achieved equivalent cardiovascular optimization with smaller volumes of resuscitation fluid, less positive cumulative balance, and without evidence of any negative sequelae. Moreover, the use of 20% albumin for FBT was associated with lower amounts of vasopressor being delivered and shorter duration.

Effect of Hydroxyethyl starch (HES) versus 5% albumin solution on intra-abdominal pressure in severe burn patients: A prospective randomized clinical trial

IntroductionMassive burn patients are at risk of developing intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) as a complication of resuscitation. ObjectiveThis study aimed to evaluate the effect of Hydroxyethyl starch (HES) versus 5% albumin solution on intra-abdominal pressure (IAP) in massive burn patients. MethodsThis was a prospective randomized clinical trial carried on at Ain Shams University (ASU) burn unit for 2 years. Where adult patients with burns more than 20% of TBSA were equally randomized into HES group or albumin group. ResultsFifty-two patients were equally randomized into 2 groups. We found no difference in age, sex, weight, type of burn, and TBSA between the two groups. The mean total resuscitation fluid volume in the first 48 h was 213 ml/kg and 206.2 ml/kg for the HES group and the albumin group respectively (p = 0.674). IAP statistically was non-significantly higher in the HES group. We found no statistical difference between the two groups as regards the renal function tests. ConclusionBoth HES and 5% albumin solution are effective and safe colloids for burn resuscitation. As regards the IAP, it seems that both 5% albumin and HES have comparable effect regarding IAH in severely burn patients. Both HES and 5% albumin were partially equal in terms of renal involvement and vital data stability.

Impact of initial fluid resuscitation volume on clinical outcomes in patients with heart failure and septic shock

BackgroundFluid resuscitation is a key treatment for sepsis, but limited data exists in patients with existing heart failure (HF) and septic shock. The objective of this study was to determine the impact of initial fluid resuscitation volume on outcomes in HF patients with reduced or mildly reduced left ventricular ejection fraction (LVEF) with septic shock. MethodsThis multicenter, retrospective, cohort study included patients with known HF (LVEF ≤50%) presenting with septic shock. Patients were divided into two groups based on the volume of fluid resuscitation in the first 6 h; <30 mL/kg or ≥30 mL/kg. The primary outcome was a composite of in-hospital mortality or renal replacement therapy (RRT) within 7 days. Secondary outcomes included acute kidney injury (AKI), initiation of mechanical ventilation, and length of stay (LOS). All related data were collected and compared between the two groups. A generalized logistic mixed model was used to assess the association between fluid groups and the primary outcome while adjusting for baseline LVEF, Acute Physiology and Chronic Health Evaluation (APACHE) II score, inappropriate empiric antibiotics, and receipt of corticosteroids. ResultsOne hundred and fifty-four patients were included (93 patients in <30 mL/kg group and 61 patients in ≥30 mL/kg group). The median weight-based volume in the first 6 h was 17.7 (12.2–23.0) mL/kg in the <30 mL/kg group vs. 40.5 (34.2–53.1) mL/kg in the ≥30 mL/kg group (P <0.01). No statistical difference was detected in the composite of in-hospital mortality or RRT between the <30 mL/kg group compared to the ≥30 mL/kg group (55.9% vs. 45.9%, P=0.25), respectively. The <30 mL/kg group had a higher incidence of AKI, mechanical ventilation, and longer hospital LOS. ConclusionsIn patients with known reduced or mildly reduced LVEF presenting with septic shock, no difference was detected for in-hospital mortality or RRT in patients who received ≥30 mL/kg of resuscitation fluid compared to less fluid, although this study was underpowered to detect a difference. Importantly, ≥30 mL/kg fluid did not result in a higher need for mechanical ventilation.

99 Retrospective Review of Pediatric Fluid Resuscitation at a Large Burn Center

Abstract Introduction Foundational approaches to burn fluid resuscitation were largely developed with the adult patient in mind. Experience has shown, however, that physiologic nuances between adults and children necessitate an adjusted approach to resuscitation for pediatric patients. As practice has advanced to account for these differences, our burn center sought to evaluate efficacy of resuscitation for our pediatric patient population. The purpose of this study was to examine pediatric fluid resuscitation including trends and complications, and to establish a baseline for future quality improvement initiatives. Methods This was a retrospective review of pediatric patients &amp;lt;14 years of age treated with resuscitation in a burn center between 2017 and 2021. Descriptive statistics were calculated. Results Over a five-year period, 42 pediatric patients were admitted with a burn total body surface area (TBSA) &amp;gt;20%, of which 23 met inclusion/exclusion criteria. Average admission weight was 31.8 kg and average TBSA of 39%. Contributing mechanisms of injury were flame (61%), scald (35%) and chemical (4%). Concomitant inhalation injury was diagnosed in 17% of patients. Average hourly fluid resuscitation volume was 6.9 mL/kg/TBSA with a mean resuscitation duration of 25.7 hours. Total volume administered throughout resuscitation exceeded recommendations per the Parkland formula for 83% of the sample. Continuous albumin was administered for 74% of patients and was initiated on average at 10 hours post-injury. Boluses of lactated ringer’s and albumin were administered for 30% and 9% of patients, respectively. Urine output for the pediatric patients averaged 60 mL/hr with a mean low optimal urine output of 15.9mL/hr and high optimal output of 25.5 mL/hr. Adverse events occurring during fluid resuscitation included temperature &amp;lt; 36◦C (35%), vasopressor administration (9%), intra-abdominal pressure &amp;gt;12 (13%) and/or &amp;gt;19 (9%), and peripheral vascular pulses &amp;lt; +1 (61%). Prophylactic escharotomy was performed for 35%. Of note, none of the patients were diagnosed with compartment syndrome nor abdominal compartment syndrome and none required abdominal laparotomy. One patient (4%) was diagnosed with acute respiratory distress syndrome. Continuous renal replacement therapy (CRRT) was not utilized for any pediatric patients during or post-resuscitation, compared to 34% of adults resuscitated at the same center. No patients expired in the initial 48 hours post-burn. The overall survival rate for this population was 91.3%, with 87% discharged direct to home. Conclusions Resuscitation volumes for pediatric patients in a large burn center have exceeded historically accepted rates for resuscitation. Despite the divergence from traditional practice, associated complications remain low, and outcomes have been favorable. Applicability of Research to Practice Further research is needed to establish benchmarks for pediatric fluid resuscitation.

550 Retrospective Review of Fluid Resuscitation and Associated Complications for Adults in a Large Burn Center

Abstract Introduction The foundation for burn fluid resuscitation is well established, however an opportunity exists to improve outcomes for patients requiring such intervention. Resuscitation is influenced by a variety of factors, including associated complications. The purpose of this study was to establish a baseline at our center using historical performance and outcomes to drive quality improvement initiatives. Methods This was a retrospective chart review of patients admitted over a five-year period requiring resuscitation. Due to factors, such as early enactment of comfort care, patients who expired &amp;lt; 48 hours of injury were excluded. Results Charts were reviewed for 346 patients with a total body surface area (TBSA) &amp;gt;20%, 297 were adults. Of these, 32 died &amp;lt; 48-hours post-injury and 127 did not undergo fluid resuscitation or complete records were not available. Thus 138 were evaluable. Averages at admission were age 44.9, weight 86.4 kg and TBSA 39%. Most patients were male (71%). Mechanism was predominantly flame (86%), followed by 7% scald, 3% contact, 2% electrical, and 1% chemical. Concomitant inhalation injury was diagnosed for 34%. Average hourly fluid resuscitation volume was 6.5mL/kg/TBSA with a duration of 31.8 hours. Total volume exceeded Parkland formula calculations for 80%. Continuous albumin was administered for 97%, initiated on average at 8 hours post-injury. Boluses of lactated ringer’s and albumin were administered for 43% and 36% of patients, respectively. Urine output averaged 91 mL/hr and we identified a mean low optimal urine output of 43.2 mL/hr and mean high optimal output of 69.1 mL/hr. Associated complications during fluid resuscitation included temperature &amp;lt; 36◦C (58%), vasopressor administration (12%), intra-abdominal pressure &amp;gt;12 (59%) and/or &amp;gt;19 (14%), and peripheral vascular pulses &amp;lt; +1 (70%). Escharotomy was performed for 42%; 32% preventative, 2% required subsequent fasciotomy. Laparotomy/open abdomen was performed for 7.9%. Diagnosed complications were low for compartment syndrome (9.5%), abdominal compartment syndrome (6.5%), and acute respiratory distress syndrome (1.4%). Continuous renal replacement therapy was initiated for 11.5% of patients &amp;lt; 48 hours post-burn and for 22.4% &amp;gt;48 hours; 25% requiring CRRT had a dialysis or renal history. The overall survival rate for this population was 76.1%. Patients were discharged most often to rehab (37%), home (19%), or skilled nursing facility (12%). Conclusions A baseline for resuscitation in our center revealed a rate double historically accepted rates. Despite nonconformity with tradition, complications remain low. Outcomes have been favorable, yet opportunity for improvement endures. Applicability of Research to Practice Further research is needed to evaluate the predictive value of assessment measures to forecast associated complications.

509 Relationship of Full Thickness Burn And Volume of Initial Fluid Resuscitation After Major Burn Injury

Abstract Introduction Full thickness burn injury affects the host response to burn injury differently that partial thickness burn injury. Current guidelines for initial resuscitation calculate fluid infusion based on Total Body Surface Area (TBSA) affected and patient’s weight. The widely used formula does not offer guidance based on the depth of the injury. We present an investigation into relationship of full thickness burn injury on fluid resuscitation. This study was approved by our Institutional Review Board. Methods We performed a retrospective review of patients’ charts who were admitted after major burn injury of greater than 20% TBSA to a busy regional burn center. We included patients over age of 14 years admitted from year 2014-2019. We excluded patients who did not have complete resuscitation data, allowing 99 patients for analysis. We performed t test to uncover relationship of age, gender, body weight, TBSA and percent of full thickness burn with fluid received during initial resuscitation with significance set at p &amp;lt; 0.05. Results The volume of fluids given during initial resuscitation was significantly affected by gender and full thickness burn injury. Fluids requirement for females was 4.6ml/kg/TBSA vs males was 3.3ml/kg/TBSA (p value 0.04). Fluid requirement for full thickness burn was 8.4ml/kg/TBSA vs 3.7ml/kg/TBSA for all patients (p=0.0004). Initial fluid resuscitation fluids did not have significant relationship with age, body weight or overall TBSA. Conclusions This study demonstrates that full thickness burn injury has a significant impact on initial fluid resuscitation. Further research is needed to elicit the mechanism to explain the higher fluid requirement for full thickness burn injury. Applicability of Research to Practice Our study brings attention to the effect of depth of burn injury on the actual volume of fluids needed during initial resuscitation of burn injury. This study will alert the clinician to take into account both the surface area as well as depth of the burn injury while embarking on fluid resuscitation after a major burn injury.

Pediatric Sepsis: a Summary of Current Definitions and Management Recommendations.

Pediatric sepsis remains an important cause of morbidity and mortality in children. This review will summarize the main aspects of the definition, the current evidence base for interventions discuss some controversial themes and point towards possible areas of improvement. Controversy remains regarding the accurate definition, resuscitation fluid volume and type, choice of vasoactive/inotropic agents, and antibiotic depending upon specific infection risks. Many adjunctive therapies have been suggested with theoretical benefits, although definitive recommendations are not yet supported by data. We describe best practice recommendations based on international guidelines, a review of primary literature, and a discussion of ongoing clinical trials and the nuances of therapeutic choices. Early diagnosis and timely intervention with antibiotics, fluid resuscitation, and vasoactive medications are the most important interventions in sepsis. The implementation of protocols, resource-adjusted sepsis bundles, and advanced technologies will have an impact on reducing sepsis mortality.

Association between the volume of fluid resuscitation and mortality modified by disease severity in patients with sepsis in ICU: a retrospective cohort study

ObjectiveThe important effect modifiers of high disease severity on the relationship between the different volumes of early fluid resuscitation and prognosis in septic patients are unknown. Thus, this study was...

Initial fluid resuscitation guided by the Parkland formula leads to high fluid volumes in the first 72 h, increasing mortality and the risk for kidney injury

BackgroundOur Burn center has used the Parkland formula (4 ml/kg/TBSA%) adjusted by physiological parameters to guide fluid resuscitation in burn patients. Our main objective was to examine fluid resuscitation in patients with major burn injury and its effect on mortality, need for renal replacement therapy (RRT) and the length of stay (LOS) in the Intensive Care Unit (ICU). Further aims were to determine which factors were associated with fluid resuscitation volumes during the first 24 h, and whether these fluid volumes had an association with the volumes infused during the next 48 h. MethodsThis retrospective observational study accrued patients (N = 46) admitted to the Helsinki Burn Center between 2016 and 2018 with burn injuries ≥ 20% TBSA. The national intensive care registry and the electronic patient record system provided data on fluid infusions, urine output, laboratory measurements, presence of inhalation injury, surgical procedures within 72 h from injury, patient demographics, need for renal replacement therapy and mortality. Patients were divided into groups based on infused fluid volumes and univariate regressions were performed to identify factors associated with fluid volumes. Results48% of the patients received fluids more than 6 ml/kg/TBSA% during the first 24 h. 35% of the patients received fluid volumes exceeding the Ivy index (250 ml/kg/d) and was associated with higher TBSA%, SOFA and SAPS scores as well as increased mortality and need for RRT. Higher lactate and lower base excess were associated with higher fluid volumes. Urine output had no association with the resuscitation volumes. Larger resuscitation volumes during the first 24 h were associated with larger fluid volumes given also during the next 48 h. Higher cumulative fluid volume in 0–72 h resulted in increased need of RRT and higher ICU mortality. ConclusionUsing the Parkland formula and adjusting the infusion based on physiological parameters leads to over resuscitation in many of the patients. It seems that the more fluids are given during the initial resuscitation phase, the more fluids are also administered during the subsequent phase. Higher cumulative fluid volumes are associated with RRT requirements and higher mortality. We postulate that starting fluid resuscitation with a lower infusion rate could be beneficial, as it may lead to smaller cumulative fluid volumes during the first 72 h, leading to reduced mortality and kidney injury.