Volume Of Fluid Resuscitation Research Articles

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.

Correlation Between Degrees of Trauma and Volume of Rescission Fluids with Acute Coagulopathy in Multiple Trauma Patients at Prof. Dr. I.G.N.G Ngoerah Denpasar Hospital

Background: Coagulopathy that occurs in trauma is known as Trauma Induced Coagulopathy (TIC). 1 in 7 deaths caused trauma, and 30% of all trauma patients who came to the hospital were in TIC condition. Prof. Dr IGNG Ngoerah Denpasar Hospital reported that coagulopathy occurred in 24 (39.3%) of 61 multiple trauma patients. Objective: Proving the correlation between the degree of trauma and volume of resuscitation fluid with the incidence of acute coagulopathy due to multiple trauma. Method: A retrospective cohort study conducted at Prof. Dr IGNG Ngoerah Denpasar Hospital with secondary data in a medical record from January 2020-December 2021. This study’s data analysis consisted of univariate, bivariate, and multivariate analysis using SPSS IBM version 23. Results: There were 100 subjects where 40 respondents had coagulopathy, the median age was 33.5 years, the male gender was 80%, and the most type of trauma was a head injury. The results of the degrees of trauma with a NISS score (New Injury Severity Score) ≥ 41 increases the incidence of coagulopathy 17.7 times with p<0.001 of resuscitation fluid is more than 2 litres increases the risk of developing coagulopathy 27 times in multiple trauma patients with p<0.001. In addition, class 3-4 bleeding classification ATLS is known to be 17 times at risk of coagulopathy with p<0.001. Conclusion: There is a statistically significant correlation between an increase in the degree of trauma and NISS️≥ 41 and the volume of resuscitation

1194: THE MORTALITY CAUSAL EFFECT OF POSITIVE FLUID BALANCES SEPSIS SUBTYPES

Introduction: Millions of deaths occur each year due to sepsis and many questions regarding best practices remain. Volume of fluid resuscitation is one of these questions. It is thought that certain sepsis subtypes may actually fare worse with positive fluid balances, however, the current recommendation for an initial resuscitation of 30cc/kg of crystalloid fluids remains. Randomized controlled trials are the gold standard for determining causal effect, but are time and cost-intensive. Causal inference using inverse probability of treatment weighting (IPTW) provides a cost-effective alternative. Through causal inference, we will evaluate the mortality effect of positive fluid balances on sepsis subtypes with the hypothesis that pulmonary sepsis would have a worse outcome. Methods: An anonymous, publicly available database was analyzed using preexisting IRB approval. The eICU Collaborative Research Database contains data on over 200000 intensive care unit admissions. The analysis used 138986 patients with 30 initial features. We dropped features with more than 50% missing values. Imputation with Sklearn Iterative Imputator. Data scaled with Sklearn Standard Scaler. Selecting features sequentially with 6 final features was performed using MLxtend. The primary outcome was ICU mortality. Aim was to establish Average Treatment Effect for positive fluid balances in pulmonary sepsis compared with urosepsis. Pulmonary sepsis had 6754 patients compared to 4152 in urosepsis. Using domain knowledge, we built a Directed Acyclic Graph (DAG). We selected Apache IV as the confounder covariate based on our DAG. As effect modifiers, we selected creatinine and age. In both groups, IPTW was performed using IBM DoWhy. Results: Mortality analysis of the pulmonary sepsis group demonstrated an ATE of 0.13 (95% CI [0.08,0.19]). The urosepsis group showed an ATE of 0.06 (95% CI [0.054 -0.067]). Positive fluid balances had an increased causal effect on mortality for the pulmonary sepsis group. Conclusions: Positive fluid balance may be more harmful in certain sepsis subtypes. Pulmonary sepsis has a higher fluid balance-related effect on mortality than urosepsis, as determined by causal inference techniques. We hope that this analysis will lead to a further evaluation of fluids’ varying effects on sepsis subtypes.

Oxidized High-Density Lipoprotein Induces Endothelial Fibrosis Promoting Hyperpermeability, Hypotension, and Increased Mortality.

During systemic inflammation, reactive oxygen species (ROS) are generated in the bloodstream, producing large amounts of oxidized HDL (oxHDL). OxHDL loses the vascular protective features of native HDL, acquiring detrimental actions. Systemic inflammation promotes endothelial fibrosis, characterized by adhesion protein downregulation and fibrotic-specific gene upregulation, disrupting endothelial monolayer integrity. Severe systemic inflammatory conditions, as found in critically ill patients in the intensive care unit (ICU), exhibit endothelial hyperpermeability, hypotension, and organ hypoperfusion, promoting organ dysfunction and increased mortality. Because endothelial fibrosis disturbs the endothelium, it is proposed that it is the cellular and molecular origin of endothelial hyperpermeability and the subsequent deleterious consequences. However, whether oxHDL is involved in this process is unknown. The aim of this study was to investigate the fibrotic effect of oxHDL on the endothelium, to elucidate the underlying molecular and cellular mechanism, and to determine its effects on vascular permeability, blood pressure, and mortality. The results showed that oxHDL induces endothelial fibrosis through the LOX-1/NOX-2/ROS/NF-κB pathway, TGF-β secretion, and ALK-5/Smad activation. OxHDL-treated rats showed endothelial hyperpermeability, hypotension, and an enhanced risk of death and mortality, which was prevented using an ALK-5 inhibitor and antioxidant diet consumption. Additionally, the ICU patients showed fibrotic endothelial cells, and the resuscitation fluid volume administered correlated with the plasma oxHDL levels associated with an elevated risk of death and mortality. We conclude that oxHDL generates endothelial fibrosis, impacting blood pressure regulation and survival.

Fluids or vasopressors for the initial resuscitation of septic shock.

Intravenous fluid resuscitation is recommended first-line treatment for sepsis-associated hypotension and/or hypoperfusion. The rationale is to restore circulating volume and optimize cardiac output in the setting of shock. Nonetheless, there is limited high-level evidence to support this practice. Over the past decade emerging evidence of harm associated with large volume fluid resuscitation among patients with septic shock has led to calls for a more conservative approach. Specifically, clinical trials undertaken in Africa have found harm associated with initial fluid resuscitation in the setting of infection and hypoperfusion. While translating these findings to practice in other settings is problematic, there has been a re-appraisal of current practice with some recommending earlier use of vasopressors rather than repeated fluid boluses as an alternative to restore perfusion in septic shock. There is consequently uncertainty and variation in practice. The question of fluids or vasopressors for initial resuscitation in septic shock is the subject of international multicentre clinical trials.

Moderator Effect of Hypoalbuminemia in Volume Resuscitation and Plasma Expansion with Intravenous Albumin Solution.

Intravenous administration of crystalloid or colloid solutions is the most common intervention for correcting hypovolemia in intensive care unit patients. In critical illness, especially sepsis and severe trauma, vascular wall permeability increases, and trans-endothelial escape of serum albumin, the major oncotic plasma constituent, contributes to the development of hypoalbuminemia and edema formation. The volume effects of intravenous human albumin solution exceed those of crystalloid solutions. If hypoalbuminemia is an effect moderator, the crystalloid-to-albumin ratio of fluid resuscitation volumes is not well characterized. Randomized controlled trials have confirmed that intravenous administration of human albumin solutions for volume resuscitation results in a lower net fluid balance compared with crystalloids, and smaller infusion volumes may be sufficient for hemodynamic stabilization when human albumin solutions are used. This narrative review summarizes the current evidence and conclusions drawn regarding the role of hypoalbuminemia in volume resuscitation. In the 'Saline versus Albumin Fluid Evaluation' study using 4% human albumin solution or saline, the saline-to-albumin ratio of study fluids was significantly higher in patients with baseline serum albumin concentrations of 25 g/L or less as compared to patients with baseline serum albumin concentrations of more than 25 g/L. In patients receiving renal replacement therapy, intravenous administration of 20-25% human albumin solution reduces intradialytic hypotension and improves fluid removal better than saline if serum albumin levels are similarly reduced. These data suggest that hypoalbuminemia acts as an effect moderator in volume resuscitation and plasma expansion with albumin solution. The volume effectiveness of intravenous human albumin solution in resuscitation appears to be greater when the serum albumin levels are low. In clinical situations, serum albumin concentrations per se may inform when and how to include intravenous albumin in fluid resuscitation if large amounts of crystalloids are needed, which requires further studies.

Improving Initial Sepsis Management Through a Nurse-Driven Rapid Response Team Protocol.

Rapid identification and timely management of sepsis improve survival. Therefore, a bundled approach to care is recommended. In an acute care area of the study institution, a 2016 internal evaluation of 27 patients with sepsis showed a median time to first-dose antibiotic administration of 269 minutes, with no patients receiving antibiotics within the 60-minute target time. Additionally, only one-third of patients received appropriate fluid resuscitation (30-mL/kg bolus of intravenous crystalloids). Given poor bundle compliance, a nurse-driven rapid response team protocol for suspected sepsis was implemented. The purpose of this project was to assess the protocol's impact on the timeliness of treatment for sepsis. This retrospective quality improvement evaluation involved patients aged 18 years or older for whom the suspected sepsis protocol was initiated during their acute care area admission. The evaluation focused on improvements in time to intravenous antibiotic administration and volume of fluid resuscitation compared with before protocol implementation. The protocol empowers the rapid response team to initiate sepsis management and includes pertinent laboratory tests, blood cultures, intravenous broad-spectrum antibiotic administration, and a crystalloid bolus (30 mL/kg) if indicated. A total of 32 patients were evaluated. Time to first-dose antibiotic administration was reduced by half (from 269 to 135 minutes). Eighteen patients met criteria for fluid resuscitation, with twice as many receiving appropriate fluid volumes compared with before protocol implementation. Implementation of the suspected sepsis protocol demonstrates the substantial role nurses have in optimizing patient care, especially in the timely treatment of sepsis.

Establishment of SEP-1 national practice guidelines does not impact fluid administration for septic shock patients

BackgroundThe Centers for Medicare and Medicaid Services introduced the Early Management Bundle, Severe Sepsis/Septic Shock (SEP-1) as a national quality measure in October 2015. The purpose of SEP-1 is to facilitate the efficient, effective, and timely delivery of high-quality care to patients presenting along the spectrum of sepsis severity.Objectives: The primary aim of this study was to investigate whether provider practice surrounding emergency department (ED) fluid management of suspected septic shock patients was impacted by SEP-1. MethodsThe study was a retrospective observational analysis of 470,558 patient encounters at an urban academic center over a five-year period. The sample of suspected septic shock patients was defined by the following: blood cultures collected, antibiotics administered, and vasopressors initiated. Participants were divided into two cohorts based on date of presentation (Pre-SEP-1: May 1, 2013, − August 30, 2015, and Post-SEP-1: November 1, 2015, − February 28, 2018). The primary outcome was classified as a dichotomous variable based on whether the total volume of fluids administered equaled or exceeded the calculated weight-based (≥30 cc/kg) goal. Segmented logistic regression analyses were used to assess the immediate impact of SEP-1 as well as to compare the long-term trend of fluid volume administered between Pre-SEP-1 and Post-SEP-1 cohorts. ResultsA total of 413 and 482 septic shock patients were included in the Pre-SEP-1 and Post-SEP-1 cohorts, respectively. There was no statistically significant change in weight-based fluid management between the cohorts. The odds of compliance with the weight-based goal decreased 22% immediately following dissemination of SEP-1, however, this was not statistically significant (log-odds = −0.25, p = 0.41). A positive trend in compliance was observed during both the Pre-SEP-1 and Post-SEP-1 periods with odds ratios increasing 0.005 and 0.018 each month, respectively, however, these findings were not statistically significant (log-odds = 0.005, p = 0.736, and log-odds = 0.018, p = 0.10, respectively). ConclusionsOverall, there were no clinically or statistically meaningful changes in fluid volume resuscitation strategies for suspected septic shock patients following SEP-1. Broad mandates may not be effective tools for promoting practice change in the ED setting. Further research investigating barrier to changes in practice patterns surrounding fluid administration and other SEP-1 bundle elements is warranted.

Resuscitation with whole blood or blood components improves survival and lessens the pathophysiological burden of trauma and haemorrhagic shock in a pre-clinical porcine model

PurposeIn military trauma, disaster medicine, and casualties injured in remote locations, times to advanced medical and surgical treatment are often prolonged, potentially reducing survival and increasing morbidity. Since resuscitation with blood/blood components improves survival over short pre-surgical times, this study aimed to evaluate the quality of resuscitation afforded by blood/blood products or crystalloid resuscitation over extended ‘pre-hospital’ timelines in a porcine model of militarily relevant traumatic haemorrhagic shock.MethodsThis study underwent local ethical review and was done under the authority of Animals (Scientific Procedures) Act 1986. Forty-five terminally anaesthetised pigs received a soft tissue injury to the right thigh, haemorrhage (30% blood volume and a Grade IV liver injury) and fluid resuscitation initiated 30 min later [Group 1 (no fluid); 2 (0.9% saline); 3 (1:1 packed red blood cells:plasma); 4 (fresh whole blood); or 5 (plasma)]. Fluid (3 ml/kg bolus) was administered during the resuscitation period (maximum duration 450 min) when the systolic blood pressure fell below 80 mmHg. Surviving animals were culled with an overdose of anaesthetic.ResultsSurvival time was significantly shorter for Group 1 compared to the other groups (P < 0.05). Despite the same triggers for resuscitation when compared to blood/blood components, saline was associated with a shorter survival time (P = 0.145), greater pathophysiological burden and significantly greater resuscitation fluid volume (P < 0.0001).ConclusionWhen times to advanced medical care are prolonged, resuscitation with blood/blood components is recommended over saline due to the superior quality and stability of resuscitation achieved, which are likely to lead to improved patient outcomes.

An analysis of early volume resuscitation and the association with prolonged mechanical ventilation.

Previous studies have found that intravenous fluid administration within the first 24 h may be associated with prolonged mechanical ventilation (PMV). We examined the association between initial 24 h fluids and PMV in combat casualties. This is a secondary analysis of a previously described dataset from the Department of Defense Trauma Registry (DODTR). We included casualties with at least 24 h on the ventilator and no significant traumatic brain injury. The definition of PMV and associations were constructed using univariable and multivariable logistic regression models. We identified 1508 casualties available for analysis for this study - 1275 in the non-PMV cohort (<9 days on ventilator vs. 233 in the PMV cohort (≥9 days on ventilator). Explosives comprised the most common mechanism of injury for both groups (72% vs. 75%) followed by firearms (21% vs. 16%). The composite injury severity score (ISS) was lower in the non-PMV cohort (18 vs. 30, p < .001). There were lower volumes of all resuscitation fluid within the first 24 h in the non-PMV cohort. When adjusting for composite ISS and mechanism of injury in a multivariable logistic regression model with PMV as the outcome, crystalloid volume (unit odds ratio [UOR] 1.07) and colloid volume (UOR 1.03) were both associated with PMV. We found that volume of resuscitation fluids were substantially higher in the PMV cohort. Our findings suggest the need for caution with the routine use of crystalloid and colloid in the first 24 h of resuscitation.

Correlation and Prognostic Assessment of Low T3 Syndrome and Norepinephrine Dosage for Patients with Sepsis: A Retrospective Single-Center (Cohort) Study.

PurposeTo investigate the correlation and prognostic significance of low triiodothyronine (T3) syndrome and norepinephrine dosage in patients with sepsis and septic shock.MethodsThis single-center, retrospective, cohort study enrolled 169 patients with sepsis and septic shock that were admitted to the intensive care unit of First Hospital of Nanchang, Nanchang, China from June 2017 to July 2019. All included patients were followed up for 28 days or died, whichever was earlier. Patients with free T3 (FT3) of <3.1 pmol/L were considered with low T3 syndrome. The correlation and prognostic significance of the FT3 and maximum dosage of norepinephrine (MDN) within 72 h, as well as other clinical indicators, were analyzed by using correlation analysis, principal component analysis, receiver operating characteristic curve, Youden index, and logistic regression.ResultsA total of 138 patients were allocated to the low T3 group. FT3 inversely correlated with the Sequential Organ Failure Assessment (SOFA) score within 24 h, fluid resuscitation volume within 24 h, and lactic acid levels, and positively correlated with the mean arterial pressure. The critical values of age, SOFA, and MDN for predicting the 28-day mortality were 79.5 years, 8.5 points, and 0.61 µg/kg/min, respectively. The mortality of the low T3 and normal T3 groups was similar. Considering the MDN of 0.61 µg/kg/min as the cutoff value, the mortality between the two groups was significantly different.ConclusionAmong patients with sepsis and septic shock, FT3 was inversely correlated with the disease severity. An MDN ≥ 0.61 µg/kg/min within 72 h may be an important prognostic indicator.

Effect of Pulse Indicator Continuous Cardiac Output Monitoring on Septic Shock Patients: A Meta-Analysis.

Background Septic shock (SS) is the most common severe syndrome in the Intensive Care Unit (ICU). Enhancing the monitoring of hemodynamic indexes in SS patients carries huge clinical implications for reducing patient mortality. Recently, pulse indicator continuous cardiac output (PICCO) has been widely used in clinical practice, but its advantages than central venous pressure (CVP) in guiding the treatment of SS patients remains to be refined. Therefore, this study is aimed at assessing the clinical effects of PICCO in the treatment of patients with SS. Methods The authors systematically searched several databases (PubMed, EMBASE, Cochrane Library, and China National Knowledge) between January 2001 and February 2021. When searching for relevant articles, the authors combined the following phrases describing the monitoring group (“pulse indicator continuous cardiac output,” “central venous pressure”) with the disease of interest as well as management (“SS,” “sepsis”). The outcomes were independently assessed by two reviewers who scored the articles for methodological quality using the Cochrane Collaboration's “risk of bias” tool. Forest plots, as well as sensitivity and bias analyses, were carried out for the included articles. The primary outcome measures were length of ICU stay, duration of mechanical ventilation, 28-day mortality, and fluid resuscitation volume. Results Ten studies comprising 350 cases monitored with PICCO and 373 cases monitored with traditional CVP were eventually identified. PICCO-monitored patients were observed to be significantly associated with shorter ICU stay than CVP-monitored patients (MD: −3.04, 95% CI: −4.74 to −1.34, P = 0.0005), shorter time of mechanical ventilation (MD: −1.84, 95% CI: −2.80 to −0.87, P = 0.0002), and lower 28-day mortality (RR: 0.67, 95% CI: 0.48 to 0.94, P = 0.02). The two groups showed no significant difference in subgroup analysis for fluid resuscitation volumes (P > 0.05). Conclusion PICCO monitoring technique can significantly improve the prognosis of SS patients, shorten the time of mechanical ventilation and ICU stay, and reduce the 28-day mortality, which has positive guiding significance for patients with SS. Given the limitations of the quantity and quality of included studies, further research is warranted to verify the conclusions.

711 Regional Burn Review: Brooke or Parkland, neither reaches the 85% accuracy mark for burn resuscitation

IntroductionMuch has been written about burn resuscitation and, despite preponderant studies, the topic remains controversial. Over-resuscitation can result in burn wound conversion and other complications. Our team switched from using modified Parkland (PF) to Brooke formula (BF) in January 2020. Secondary to difficult resuscitations, we sought to review our data to identify factors associated with over-resuscitation using either formula. We hypothesized that the Brooke formula under-predicted resuscitation volumes compared to Parkland, particularly in older patients or in more severe burn injuries.MethodsMedical records from patients who were admitted to the burn unit between 1/1/2019 and 8/29/2021 for a burn injury with %TBSA ≥15% were retrospectively reviewed. Exclusion criteria included age < 18 years, weight < 30 kg, patient not requiring resuscitation, or death within 24 h of admission. Demographics, injury information, resuscitation formula used, predicted 24-h resuscitation goal, the volume of resuscitation fluids, and time to reach maintenance were collected. Univariate analysis was performed to compare patients resuscitated using the BF vs. the PF. Multivariate analysis was performed to identify factors associated with over-resuscitation. Over resuscitation was defined as >2.5 mL/kg/%TBSA for BF and >5 mL/Kg/%TBSA for PF. P < 0.05 was considered significant.ResultsSixty-four patients were included; 27 were resuscitated using BF and 37 using PF. Neither age, sex, weight, BMI, or severity of burn injury were significantly different between the groups. Patients required a median of 3.59 mL/Kg/%TBSA for BF and 3.99 mL/kg/%TBSA for PF, p = 0.32. Over-resuscitation was more likely to occur when using BF compared to PF (59.3% vs. 32.4%, p = 0.043). Stepwise multivariate logistic regression showed that over-resuscitation was associated with longer time to reach maintenance (OR = 1.179 [1.042-1.333], p = 0.009) and arrival through ground transportation (OR = 10.523 [1.171-94.597], p = 0.036). Patients who arrived through ground transportation took longer to reach the burn center (3.98 h [2.65-5.15] vs. 2.57 h [1.93-3.2], p = 0.004) and presented with lower %TBSA (20.8 [18-27.9] vs. 31.3[21-55], p = 0.004).ConclusionsTime to reach definitive care was the only independent variable associated with over-resuscitation. While not significant, compared to PF, using BF tended to be associated with over-resuscitation. More studies are warranted to determine if BF continues to underperform and, if so, the populations in which it underperforms will be identified.

513 Fluid Over-Resuscitation in Burn Patients After Initial 24-Hours of Care is Associated with Increased Mortality

IntroductionFluid resuscitation is a cornerstone of modern burn care. Despite the use of well-established formulae to determine the appropriate amount of fluid resuscitation for the first 24 hours of care, there is increasing recognition that patients receive fluids in excess of predicted volumes, a phenomenon termed fluid creep. Underscoring the significance of this phenomenon is the association between large volumes of fluid resuscitation and adverse outcomes. Although research in non-burn ICU patients reveals a clear association between overall fluid intake and increased morbidity, minimal burn-related literature exists regarding fluid patterns after the initial 24-hour period and their impact on outcomes. We hypothesized that increased fluid administration after the standard initial resuscitation period is associated with increased morbidity and mortality.MethodsA retrospective chart review was performed for 113 patients with ≥20% TBSA burns admitted to an American Burn Association-verified burn center between 2010 and 2020. Patients admitted with Stevens-Johnson Syndrome and/or Toxic Epidermal Necrolysis, with length of stay ≤ 72 hours, who required renal replacement therapy (RRT) within 72 hours of admission, and those with withdrawal of care ≤ 7 days of admission were excluded. Univariate and multivariate logistic regression was used to determine the association between the primary outcome of in-hospital mortality and secondary outcomes of increased ventilator days, acute kidney injury, need for RRT, and hospital length of stay, with increasing total and net fluid volumes from days 2 through 7 of treatment. Additionally, the association between first OR day and total fluid volumes in the first week were assessed.ResultsMedian age was 41 years (IQR 23-55) and TBSA was 31% (IQR 24-43). 21 patients (18.6%) died during hospitalization. Increase in net fluid balance from days 2-7 were associated with increased mortality (OR 1.016, 95% CI 1.00 – 1.03, p = 0.013). Increasing total fluid volumes were significantly associated with increased ventilator days (OR 1.027, 95% CI 1.008-1.047, p = 0.006) and acute kidney injury (OR 1.003, 95% CI 1.000-1.006, p = 0.017). Early first OR day was associated with decreased net fluid balance between hospital days 2-7 (OR 0.993, 95% CI 0.989-0.997, p = 0.001).ConclusionsSimilar to studies on other ICU populations, increasing total fluid volumes and net fluid balance is associated with adverse outcomes in critically ill burn patients. Additionally, earlier initial OR is associated with less total fluid volumes and lower net fluid balance in the first week of hospitalization. Further investigation is needed to elucidate optimal markers of resuscitation in burn patients in an effort to decrease adverse fluid administration.

Medication and Fluid Management of Pediatric Sepsis and Septic Shock.

Sepsis is a life-threatening response to infection that contributes significantly to neonatal and pediatric morbidity and mortality worldwide. The key tenets of care include early recognition of potential sepsis, rapid intervention with appropriate fluids to restore adequate tissue perfusion, and empiric antibiotics to cover likely pathogens. Vasoactive/inotropic agents are recommended if tissue perfusion and hemodynamics are inadequate following initial fluid resuscitation. Several adjunctive therapies have been suggested with theoretical benefit, though definitive recommendations are not yet supported by research reports. This review focuses on the recommendations for medication and fluid management of pediatric sepsis and septic shock, highlighting issues related to antibiotic choices and antimicrobial stewardship, selection of intravenous fluids for resuscitation, and selection and use of vasoactive/inotropic medications. Controversy remains regarding resuscitation fluid volume and type, antibiotic choices depending upon infectious risks in the patient's community, and adjunctive therapies such as vitamin C, corticosteroids, intravenous immunoglobulin, and methylene blue. We include 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.

Risk factors for mortality from sepsis in an intensive care unit in Ecuador: A prospective study.

To investigate risk factors for mortality from sepsis in an intensive care unit (ICU) in Quito-Ecuador and their association to adherence to Surviving Sepsis Campaign recommendations.Prospective cohort study of patients with severe sepsis/septic shock admitted to the ICU of a public Ecuadorian hospital from March, 2018 to March, 2019. Demographic, clinical, treatment, and outcome data were collected from patients' health records. Patients were divided into 2 groups according to ICU survival or death. Log-binomial regression models were used to identify risk factors for mortality.In total, 154 patients were included. Patients who died in the ICU (n = 42; 27.3%) had higher sequential organ failure assessment score (median 11.5 vs 9; P<.01), more organ dysfunction (median 4 vs 3; P<.0001), and received greater volumes of fluid resuscitation in the first 6 hours (median 800 vs 600 mL; P = .01). Dysfunction of > 2 organs was a risk factor for mortality (relative risks [RR] 3.80, 95% CI 1.33-10.86), while successful early resuscitation (RR 0.32, 95% CI 0.15-0.70), successful empirical antibiotic treatment (RR 0.38, 95%CI 0.18-0.82), and antibiotic de-escalation (RR 0.28, 95%CI 0.13-0.61) were protective factors.Dysfunction of >2 organs was a risk factor for mortality from sepsis while successful early resuscitation and appropriate antibiotic treatment were protective.

Significant variations in preoperative fluid resuscitation volumes delivered to elderly hip fracture patients at six level 1 trauma centers: an observational descriptive study.

Objective:To describe the variations in administration of preoperative (preop) fluids and in the volumes of fluid administered among geriatric hip fracture patients requiring surgical repair.Design:Observational descriptive.Setting:Six Level 1 trauma centers.Patients:A total of 595 patients aged ≥65 with ICD-10 codes indicating hip fracture and surgical repair were identified. Of these, 87.9% (n = 525) received preop fluid. The median volume of preop fluid delivered was 1500 mL (IQR: 1000–2250 mL).Intervention:None.Main Outcome Measures:Receipt of preop fluids; median volume of fluid received.Results:Receipt of preop fluid was significantly different by inter-hospital transfer, facility, BMI, hospital length of stay, and postop fluid volume. Age, sex, time to surgery, time to ambulation, and hospital disposition were not associated with preop fluid. There were significant differences in median preop fluid volumes by facility and postop fluid volume.Conclusion:This descriptive study of current practices among geriatric trauma patients with isolated hip fractures revealed significant differences in the use of preop fluid resuscitation and the resuscitation volumes administered. Treating facility may be the most substantial source of variation highlighting the need for a guideline on fluid resuscitation. These observed variations may be a result of patient characteristics or provider discretion and should be evaluated further.

Flow rates of double-lumen over-the-wire catheters for high-volume fluid resuscitation in large animal species.

To evaluate the maximum in vitro flow rate of 6 types of polyurethane over-the-wire double lumen catheters using both ports, for high volume fluid resuscitation in large animal species. University teaching hospital. Prospective in vitro experimental study. The flow rate of both ports of 6 polyurethane double lumen over-the-wire catheters (11 and 13-Fr, 15 and 20cm long, elliptical and tapered tip designs) and 2 types of infusion (with or without pressure bags) were tested on a factorial scheme (6×2) in triplicate, using commercial isotonic crystalloid (0.9% NaCl) and synthetic colloid (6% Hydroxyethyl starch, 130/0.4). Flow rates were influenced by catheter diameter, length, tip design and presence or absence of pressure bags (P<0.05). Mean flow rates during non-pressurized 0.9% NaCl infusion ranged from 584mL/min (35 L/h; 11-Fr x 15cm x tapered tip catheter) to 905mL/min (54 L/h; 13-Fr x 15cm x elliptical tip catheter). Mean flow rates during non-pressurized synthetic colloid infusion varied from 404mL/min (24 L/h; 11-Fr x 15cm x tapered tip catheter) to 724mL/min (43 L/h; 13-Fr x 15cm x elliptical tip catheter). Mean flow rates during pressurized infusion were 1.72 and 2.02 times greater than those obtained by gravity alone for 0.9% NaCl and synthetic colloid, respectively (P<0.05). Highest in vitro flow rates were achieved when larger diameter, shorter and elliptical tip catheters were used during 0.9% NaCl infusion. Catheter diameter, tip design but not length influenced the flow rate during synthetic colloid infusion. The use of pressure bags significantly increased the flow rate of all catheters, for both solutions.

Fluid resuscitation of at least 30 mL/kg was not associated with decreased mortality in patients with infection, signs of hypoperfusion, and a do-not-intubate order.

AimAdministration of at least 30 mL/kg of fluid as fluid resuscitation is recommended for patients with sepsis and signs of hypoperfusion. However, it is not clear whether this is appropriate for patients with a do‐not‐intubate (DNI) order. This study evaluated the association between volume of fluid resuscitation and outcomes in patients with infection, signs of hypoperfusion, and a DNI order in an emergency department.MethodsThis was a single‐center retrospective cohort study. We classified the infected patients with signs of hypoperfusion and a DNI order seen in our emergency department between April 1, 2015 and November 31, 2020 into the standard fluid resuscitation group (≥30 mL/kg) and the restricted fluid resuscitation group (<30 mL/kg). We compared with in‐hospital mortality and the rate of discharge to home in two groups.ResultsOf 367 patients, 149 received standard fluid resuscitation and 218 received restricted fluid resuscitation. In‐hospital mortality was similar in each group (40/149 and 62/218, respectively). Standard fluid resuscitation was not associated with in‐hospital mortality (adjusted odds ratio [aOR], 1.05; 95% confidence interval [CI], 0.62–1.77, P = 0.86), but was associated with a significantly lower rate of discharge to home (aOR, 0.55; 95% CI, 0.30–0.98, P = 0.043). There was no significant difference in respiratory rate or need for oxygen therapy post‐resuscitation between the two groups.ConclusionThis study suggests that fluid resuscitation may be not beneficial for infected patients with signs of hypoperfusion and a DNI order. Further studies should be conducted on the options for resuscitation management for these patients.