Volume Of Fluid Resuscitation Research Articles

Different Depths May Not Determine the Fluid Resuscitation Volume in Early-stage Management of Severe Burns: A Model-comparison Retrospective Analysis of Fluid Volume Determining Factors.

Large-volume fluid resuscitation remains irreplaceable in the early-stage management of severe burns. We aimed to explore the relationship between fluid volume and other indicators. Data of severe burn patients with successful resuscitation in the early stage was collected. Correlation and linear regression analyses were performed. Multiple linear regression models, related goodness-of-fit assessment (adjusted R-square and Akaike Information Criterion), scatter plots, and paired t-test for two models, and a likelihood ratio test were performed. 96 patients were included. The median of total burn area (TBA) was 70%TBSA, with full thickness burn area (FTBA)/TBA of 0.4, a resuscitation volume of 1.93 mL/kg/%TBSA. Among volume-correlated indicators, two linear regression models were established (Model 1: TBA × weight and tracheotomy; and Model 2: FTBA × weight, partial thickness burn area (PTBA) × weight, and tracheotomy). For these models, close values of Akaike Information Criterion, adjusted R-squares, outliers of the prediction range, and the result of paired t-test, all suggest similarity between two models estimations, while the likelihood ratio test for coefficients of FTBA × weight and PTBA × weight showed a statistical difference. Inhalational injury and decompression surgery only correlated with volume, while Tracheotomy, TBA × weight, FTBA × weight, and PTBA × weight correlated with and were accepted in linear models of volume. Although FTBA and PTBA differed statistically, there may be no need to distinguish them when estimating the resuscitation volume requirements in this patient set. Further study about different depths fluid should be conducted.

Fluid resuscitation based on pulse contour cardiac output monitoring is associated with improved prognosis in adult severe burn patients: a retrospective cohort study.

A monitoring method is needed to further guide fluid resuscitation in severe burn injury. This study was performed to investigate the effects of pulse contour cardiac output (PCCO) monitoring on the prognosis of adult severe burns patients. We conducted a retrospective study enrolling patients from January 2015 to December 2020, who were divided into a control group receiving conventional monitoring and a study group receiving PCCO monitoring. The primary outcomes were 28-day mortality and total mortality, and the secondary outcomes included burn-related complications and the length of hospital stay and ICU stay. Multivariable logistic regression analysis and linear regression analysis were performed to determine the risk factors of burns-related complications and length of hospital stay in enrolled patients. A total of 109 patients in the control group and 82 patients in the study group were enrolled. While the area of full thickness burn was much higher in the control group than in the study group (P=0.021), no significant difference was found in other characteristics between the two groups. During fluid resuscitation, the fluid volume ratio of the study group was significantly different from that of the control group, and both in the first 24 hours and the second 24 hours, the resuscitation fluid volume ratio and colloid volume ratio was significantly higher in the control group than in the study group (all P<0.001). Eight patients died during treatment, and there were more patients experiencing AKI and ARDS in the control group than in the study group (P=0.029 and 0.016). The lengths of hospital stay and ICU stay in the study group was much shorter than in the control group (P<0.001 and 0.005). In addition, TBSA was an important risk factor for both AKI and ARDS, and the existence of inhalation injury and older age increased the incidence of ARDS. Higher TBSA, inhalation injury, and burn-related complications were related to longer hospital stay in enrolled patients. Fluid resuscitation according to PCCO monitoring can effectively reduce the volume of colloid and overall fluid volume and reduce the incidence of burns-related complications and shorten the length of hospital stay.

THE USE OF 5% IV ALBUMIN IN PATIENTS WITH SHOCK: DOES IT DECREASE VASOPRESSOR REQUIREMENT?

TOPIC: Critical Care TYPE: Original Investigations PURPOSE: Circulatory shock often requires large volume fluid resuscitation as a part of treatment. While crystalloid fluids are more commonly used, many patients in intensive care are unable to receive crystalloid fluids due to conditions such as congestive heart failure and end stage renal disease. Utilizing traditional fluids in such patients often complicates hospital courses. There are many studies regarding the benefits, effects and potential harms of using IV albumin for fluid resuscitation. The 2004 SAFE study suggested some benefit of using IV albumin in sepsis but equivocal to conventional management in morbidity and mortality. The 2014 ALBIOS Study of IV albumin use resulted in 90 day mortality benefit and decreased vasopressor need in severely septic patients. Despite these studies, the use of IV albumin in the critically ill remains controversial with consensus or guidelines being established regarding its use. METHODS: We conducted a retrospective study of 70 critically ill patients admitted to MICU from 7/2019 to 5/2020 to assess the effects of IV albumin. Patients diagnosed with shock who received 5% IV albumin were included. Patients who received 25% IV albumin were excluded. We analyzed cases by type of shock, conditions limiting crystalloid bolus, serum albumin level before IV albumin, MAP pre- and post- albumin infusion, pressor requirement (type/duration), development of ARDS, HD/CRRT requirement, COVID status and mortality. RESULTS: Septic shock patients received IV albumin most, followed by cardiogenic shock. Those unable to receive fluid boluses were due to primarily cardiac etiology, followed by renal & hepatic. Increased MAP was observed after IV albumin infusion in many cases. Serum albumin 2.8 on ICU admission responded better to IV albumin and had lower vasopressor requirements.IV albumin was not related with renal dysfunction and those receiving IV Albumin did not need HD/CRRT. 69.6% did not develop ARDS, 5.8% developed ARDS, 24.6% tested positive for COVID and they were excluded from the ARDS incidence rate. Survival rate was 65.7%, mortality rate 24.3% and 10% went to hospice CONCLUSIONS: The use of 5% IV albumin for volume resuscitation in patients with different forms of shock in ICU showed favorable results, especially in those with serum albumin >2.7-2.8. Our retrospective study showed low incidence of adverse events such as cardiogenic pulmonary edema, ARDS or a need for HD/CRRT, lower vasopressor requirement, in both duration and agents used. Further research should be done in this regard to solidify these findings and to establish clear guidelines/protocols regarding the use of albumin as a resuscitative fluid in the ICU setting. CLINICAL IMPLICATIONS: When treating patients with shock and specially patients with hypoalbuminemia, 5% IV albumin can potentially be used as a means to decrease vasopressor requirements and duration without increasing the risk of pulmonary edema, ARDS and renal dysfunction. Further research should be done in this regard to solidify these findings and to establish clear guidelines/protocols regarding the use of albumin as a resuscitative fluid in the ICU setting. DISCLOSURES: No relevant relationships by Andrew Ajemian, source=Web Response No relevant relationships by Muhammad Umer Altaf, source=Web Response No relevant relationships by Christopher Bowman, source=Web Response No relevant relationships by Gabriel Diaz, source=Web Response No relevant relationships by Jessica Obeahon, source=Web Response No relevant relationships by Travis Yamanaka, source=Web Response

Thermomechanical Combination Injuries: A Rare But Life-Threatening Entity.

Thermomechanical combination injuries (TMCIs) are feared for their demanding preclinical and clinical management and bear the risk of high mortality compared to the single injury of a severe burn or multiple trauma. There remains a significant lack of standardized algorithms for diagnostics and therapy of this rare entity. The objective of the present study was to profile TMCI aiming at standardized procedures. In this study, TMCIs were extracted from our burn database of a level 1 burn and trauma center. From 2004 to 2017, all patients with TMCI were retrospectively analyzed. Further inclusion criteria were multiple trauma accompanied by burn with ≥10% TBSA. Patient and injury characteristics including injury severity score and outcome parameter were analyzed. A total of 45 patients matched the selective inclusion criteria of TMCI, comprising 4% of all burn injuries during the period. The average age was 38 years (range: 14-86), with a mean TBSA of 43% (range: 10-97%). The mean recorded temperature at admission was 34.8°C (range: 29.6-37.1) with 2215 ml volume of resuscitation fluids (range: 500-8000) administered preclinically in total. The mean injury severity score was 16. The overall mortality rate was 22%. TMCIs are rare and life-threatening events that require highly qualified management in combined level 1 trauma and burn centers to address both burn and trauma treatment. The multiple injury pattern is diverse, complicating standardized management in view of burn care-specific measures, as normothermia and restrictive volume management. The present study reveals further profiles and underlines the need for addressing TMCIs in ABLS®, ATLS®, and PHTLS® programs.

Blood coagulation alterations over the first 10 days after severe burn injury

IntroductionCoagulation disorders occur during the first 48 h after major burn injury, affecting mainly PT/INR and aPTT. Some authors consider them burn specific. The aim was to assess the magnitude of coagulation disorders during the first 10 days after severe burn injury and its eventual association with fluid intakes. MethodsRetrospective study of prospectively collected data including patients with burns ≥ 20%BSA (body surface area) who stayed ≥ 24 h at the burn-intensive care unit (ICU). Predetermined data for the analysis of fluid and blood products administration and laboratory values were extracted from the computerized information system. Descriptive statistics, data as median. Results167 patients included. The volumes of fluid resuscitation decreased over the first 10 days (median 6815 ml on day 1 decreasing to 4190 ml by day 10, p < 0.0001). During the first 48 h, PT was frequently abnormal and strongly related to fluid volumes (R2 = 0.124, p < 0.0001). Perturbations of PT/INR and aPTT improved after 72 h while the thrombocytopenia had a nadir by day 4, persisting in the most severely burned. Overall, only 12 (7.2%) patients presented combined coagulation alterations. ConclusionsThis study shows transient and self-resolutive coagulation disorders related to fluid delivery, apparently without burn specificity. The late thrombocytopenia is a new observation.

Major Burn Injury Successfully Treated With Cultured Epithelial Autografts, a Case Series Presentation: Establishing Standard Clinical Practices.

Cultured epithelial autografts have been an option for coverage of large surface area burns for over two decades. However, there remains extreme variability in clinical practice in wound bed preparation, application of cultured epithelial autografts, and postoperative wound care and rehabilitation practices, demonstrating the need for a standardized and multidisciplinary approach in the treatment of critically injured patients treated with cultured epithelial autografts. The purpose of this case series was to share the development of a clinical practice guideline and competency checklist in our institution where cultured epithelial autograft case volume is low. In this case series, we examined the medical records of three patients treated with cultured epithelial autografts at a single burn center over a period from 2015 to 2018. Operating room times and fluid resuscitation volumes were examined on days when cultured epithelial autograft grafting was performed. In order to facilitate meticulous postoperative wound care in a facility where only one to two cultured epithelial autograft applications are performed per year, a clinical practice guideline and competency checklist were generated and trialed on a series of nurses and rehabilitation therapists for the three applications of cultured epithelial autografts. Among the patients treated with cultured epithelial autografts, the average TBSA burned was 71.6%. Less intraoperative crystalloid administration and faster operative case times were associated with improved cultured epithelial autograft success. The inclusion of the clinical practice guideline and checklist into our practice led to reported improved confidence in patient care, along with the successful outcomes of these cultured epithelial autograft applications.

Percutaneous hepatic melphalan perfusion: Single center experience of procedural characteristics, hemodynamic response, complications, and postoperative recovery.

BackgroundPercutaneous hepatic melphalan perfusion (PHMP) for the selective treatment of hepatic metastases is known to be associated with procedural hypotension and coagulation disorders. Studies on anesthetic management, perioperative course, complications, and postoperative recovery in the intensive care unit (ICU) have not been published.MethodsIn a retrospective observational study, we analyzed consecutive patients who were admitted for PHMP over a 6-year period (2016–2021). Analyses included demographic, treatment, and outcome data with regard to short-term complications until ICU discharge.ResultsFifty-three PHMP procedures of 16 patients were analyzed. In all of the cases, procedure-related hypotension required the median (range) highest noradrenaline infusion rate of 0.5 (0.17–2.1) μg kg min-1 and fluid resuscitation volume of 5 (3–14) liters. Eighty-four PHMP-related complications were observed in 33 cases (62%), of which 9 cases (27%) involved grade III and IV complications. Complications included airway constriction (requiring difficult airway management), vascular catheterization issues (which resulted in the premature termination of PHMP, as well as to the postponement of PHMP and to the performance of endovascular bleeding control after PHMP), and renal failure that required hemodialysis. Discharge from the ICU was possible after one day in most cases (n = 45; 85%); however, in 12 cases (23%), prolonged mechanical ventilation was required. There were no procedure-related fatalities.ConclusionsPHMP is frequently associated with challenging cardiovascular conditions and complications that require profound anesthetic skills. For safety reasons, PHMP should only be performed in specialized centers that provide high-level hospital infrastructures and interdisciplinary expertise.

Cutaneous Complications Associated With Intraosseous Access Placement.

Intraosseous (IO) access provides a potentially lifesaving means of vascular access in settings of trauma and advanced cardiovascular life support in which patients often require prompt and large volumes of fluid resuscitation, blood products, and medications. An additional benefit of IO access is the rare incidence of complications, with many studies reporting rates of less than 1%. The most commonly cited complications include compartment syndrome, osteomyelitis, traumatic bone fracture, and epiphyseal plate damage. To evaluate the dermatologic sequelae, we performed a retrospective chart review spanning 18 consecutive months to identify patients who underwent IO line placement, either at or en route to a large metropolitan level I trauma center in the Midwestern United States. Our review identified a complication rate of 2.7%, with complications including compartment syndrome, needle breakage, and a previously unreported cutaneous complication of traumatic bullae.

Ileus in Acute Pancreatitis Correlates with Severity of Pancreatitis, Not Volume of Fluid Resuscitation or Opioid Use: Observations from Mid-West Cohort.

The recovery of gastrointestinal functions is an important determinant of course of acute pancreatitis and the timing of hospital discharge. Here, we evaluated association between fluid resuscitation volume and opioid use with clinically significant ileus development in patients with acute pancreatitis. Consecutive adults admitted with acute pancreatitis between January 2014 and December 2019 to our academic and two community hospital were included. The Bedside Index for Severe Acute Pancreatitis (BISAP) and systemic inflammatory response syndrome (SIRS) were used to predict severity of pancreatitis based on their readily availability. Severity of pancreatitis was determined based on the Revised Atlanta classification. Fluid resuscitation volume and opioid use were collected as administered on day 1 and day 2.Clinically significant ileus was determined based on treating physician's assessment. Forty-nine (11%) of 441 unique patients included in the study developed clinically significant ileus. Demographics of patients with or without ileus were similar between the two groups. On univariate analysis, the presence of SIRS syndrome (< 0.001), a > 3 BISAP score (p < 0.001), and severity of pancreatitis (p < 0.001) were associated with ileus, mean fluid resuscitation volume (5.6L vs 5.5L, p = 0.888) and cumulative median morphine-equivalent units (12 vs 12, p = 0.232) on day 1 and day 2 were not. However, ileus development was associated with increased hospital length of stay and admission to intensive care unit. On observations, clinically significant ileus development is associated with severity of acute pancreatitis, not with fluid resuscitation volume or opioid analgesia dose used in current standard of care.

A Preoperative Volume Resuscitation Window Between 1.0 and 2.5 L Is Associated with Decreased Mortality in Hypotensive Patients with a Ruptured Abdominal Aortic Aneurysm

Mortality from ruptured aortic aneurysms (rAAA) remains extremely high and minimally changed over the past 20 years. This is likely impacted by preoperative hemodynamics and fluid resuscitation. We hypothesize that the volume of preoperative intravenous fluid (IVF) resuscitation in patients with rAAA and preoperative hypotension predicts mortality.

What's New in Shock, February 2021?

What's New in Shock, February 2021?

A New Resuscitation Formula Based on Burn Index Provides More Reliable Prediction for Fluid Requirement in Adult Major Burn Patients.

The Third Military Medical University (TMMU) formula is widely used in fluid resuscitation in China. However, the actual volume needs usually exceed the prediction provided by the TMMU formula in major burn patients with a high proportion of full-thickness burn wounds. This retrospective study included 149 adult major burn patients (≥40% TBSA) who were admitted to the Burn Department, Southwest Hospital from 2014 to 2020 and received appropriate fluid resuscitation by the TMMU protocol. The actual volume infused in the first 48 hours postburn was compared to the estimation by the TMMU formula. A new fluid volume prediction formula was developed by multivariate linear regression analysis. The mean fluid requirements were 2.35 ml/kg/% TBSA and 1.75 ml/kg/% TBSA in the first and second 24 hours postburn, respectively. The TMMU formula underestimated the fluid requirement, and its prediction accuracy was 54.1% and 25.8% for the first and second 24 hours, respectively. The proportion of full-thickness burn wound was found to be associated with the fluid requirements postburn. A revised multifactorial formula consisting of the burn index, body weight, and inhalation injury was developed. Using the revised formula, the prediction reliability of resuscitation fluid volume improved to 65.3% and 61.1% in the first and second 24 hours, respectively. The TMMU formula showed low accuracy in predicting fluid requirements among major burn patients. A revised formula based on burn index was developed to provide better guidance for initiative fluid resuscitation for major burns by the TMMU protocol.

Kawasaki Disease Shock Syndrome Versus Septic Shock: Early Differentiating Features Despite Overlapping Clinical Profiles

To compare the clinical features and resuscitative measures of children with Kawasaki disease shock syndrome vs septic shock. In this retrospective case-control study, children with Kawasaki disease shock syndrome admitted to the intensive care unit from 2007 to 2017 were identified and compared with age-matched controls with septic shock. We studied 9 children with Kawasaki disease shock syndrome and 18 children with septic shock. Clinical characteristics were abstracted and between-group differences were compared. Compared with septic shock controls, children with Kawasaki disease shock syndrome were less likely to have an underlying comorbid illness (1/9 [11%] vs 11/18 [61%]; P=.02) and were more likely to have at least 1 of the 5 classic diagnostic signs of Kawasaki disease at presentation (9/9 [100%] vs 0/18 [0%]; P<.001), a longer duration of illness before admission (9days [IQR, 7-14days] vs 3days [IQR, 1-5days]; P=.004), and a lower platelet count at presentation (140 [IQR 73, 167]) vs 258 [IQR, 137-334]; P=.02). Among patients who underwent echocardiography, abnormalities such as ventricular dysfunction, valvulitis, and coronary artery dilation were more common in the Kawasakidisease shock syndrome cohort (5/9 [56%] vs 0/7 [0%]; P=.03). There were no differences in volume of fluid resuscitation, vasoactive-inotropic scores, duration of inotropic therapy, or biochemical markers of illness severity (other than platelet count) between the matched groups. A longer duration of illness before admission, lack of any significant underlying medical comorbidities, a lower platelet count, echocardiographic abnormalities, and the presence of classic diagnostic signs of Kawasaki disease at presentation may be useful early features to differentiate Kawasaki disease shock syndrome from septic shock.

Inferior vena cava diameter combined with lung ultrasound B-line score to guide fluid resuscitation in patients with septic shock

To compare the effect of goal-directed fluid resuscitation and bedside ultrasound-guided fluid resuscitation in patients with septic shock, and to evaluate the application value of bedside ultrasound in fluid resuscitation of patients with septic shock. Forty patients with septic shock admitted to department of critical care medicine of Affiliated Hospital of Nanjing University of Chinese Medicine from June 2018 to October 2019 were enrolled, and they were divided into early goal-directed therapy (EGDT) group and ultrasound group according to random number table, with 20 patients in each group. Bacterial cultures were routinely performed, and all patients received conventional treatments, such as anti-infection, nutritional support and organ support. All patients were given initial fluid resuscitation (30 mL/kg). The patients in the EGDT group continued to be given fluid resuscitation according to the guidelines (EGDT 6-hour target) after the initial fluid resuscitation. The patients in the ultrasound group were given follow-up fluid resuscitation based on bedside ultrasound inferior vena cava diameter and lung ultrasound B-line score after initial fluid resuscitation. The general data, main laboratory indexes and efficacy indexes of the two groups were compared, including 6-hour blood pressure achieved rate [mean arterial pressure (MAP) ≥ 65 mmHg (1 mmHg = 0.133 kPa) was defined as blood pressure reaching standard], 24-hour resuscitation fluid volume, 24-hour norepinephrine (NE) consumption, 24-hour oxygenation index (PaO2/FiO2) and 24-hour clearance of lactic acid (LCR) were compared between the two groups. The survival curve of intensive care unit (ICU) was drawn by Kaplan-Meier analysis. There was no significant difference in the gender, age, heart rate (HR), respiratory rate (RR), systolic blood pressure (SBP), underlying diseases, sequential organ failure assessment (SOFA) score, PaO2/FiO2, blood lactic acid (Lac), D-dimer, cardiac troponin I (cTnI), brain natriuretic peptide (BNP), total bilirubin (TBil) and serum creatinine (SCr) baselines at admission between the two groups. There was also no significant difference in the 6-hour target blood pressure achieved rate [65.0% (13/20) vs. 70.0% (14/20)], 24-hour total NE dosage [mg: 20.0 (10.0, 66.5) vs. 30.0 (10.5, 85.0)], 24-hour PaO2/FiO2 (mmHg: 274.6±123.8 vs. 243.1±124.0) or 24-hour LCR [9.1% (-34.5%, 58.0%) vs. 44.0% (-24.1%, 81.3%)] between the EGDT group and ultrasound group (all P > 0.05), but the 24-hour total fluid infusion in the ultrasound group was significantly less than that in the EGDT group (mL: 2 783.1±704.2 vs. 3 692.0±1 433.1, P < 0.05). The Kaplan-Meier survival curve showed that the cumulative survival rate of ICU between the two groups was not statistically significant (Log-Rank test: χ2 = 0.088, P = 0.767). Bedside ultrasound protocol combined inferior vena cava diameter with lung ultrasound B-line score can be used to guide fluid resuscitation in patients with septic shock, the total fluid infusion is decreased and the risk of oxygenation deterioration is reduced.

Is the Parkland formula still the best method for determining the fluid resuscitation volume in adults for the first 24 hours after injury? — A retrospective analysis of burn patients in Germany

BackgroundR Rapid fluid resuscitation is a crucial therapy during the treatment of patients with extensive burns. In 1968, the Parkland Formula was introduced for the calculation of the estimated volume of the resuscitation fluid. Since then, different methods for the calculation of fluid resuscitation volume have been developed. We aimed to evaluate if the Parkland formula is still the most effective method for fluid resuscitation volume calculation in burn patients. MethodsIn the period between January 2015 and January 2019, data from 569 patients over 16 years old with burns of more than 20% total body surface area (TBSA) and at least 15% TBSA full thickness burns were entered in the German burn registry. The patients were divided into 5 groups (0, +1, −1, +2, −2) according to the volume of the resuscitation fluid they received. Group 0 patients received the amount of fluid calculated according to the Parkland formula (n = 83). The 4 other groups received reduced (-1, -2) or increased (+1, +2) fluid volumes in comparison to the value obtained by the Parkland formula. ResultsPatients in Group 0 presented a significantly lower mortality in the first week (4.5%) compared to groups –2 (16.7%) and group +2 (19.5%) (p = 0.021). Furthermore, the mean number of operations in group +2 (5.81) was higher than in group −2 (3.81). Surviving patients from group +2 presented a longer hospital stay (68.1 days) compared to the other groups. Additionally, the logistic regression analysis showed a higher survival of patients in groups −2 and −1 (regression coefficients −0.11 and −0.086; Odds Ratio 0.896 and 0.918; 95% Confidence Interval (CI) 0,411–1.951 and 0.42–2.004). ConclusionIn this retrospective study, register based analysis a restrictive fluid regime was associated with a higher survival compared to the liberal Parkland guided fluid regime.

Hidden sources of fluids, sodium and potassium in stabilised Swedish ICU patients: A multicentre retrospective observational study.

Fluid overload in ICU patients is associated with increased morbidity and mortality. Although studies report on optimisation of resuscitation fluids given to ICU patients, increasing evidence suggests that maintenance fluids and fluids used to administer drugs are important sources of fluid overload. We aimed to evaluate the volume of maintenance fluids and electrolytes on overall fluid balance and their relation to mortality in stabilised ICU patients. Multicentre retrospective observational study. Six mixed surgical and medical ICUs in Sweden. A total of 241 adult patients who spent at least 7 days in the ICU during 2018. The primary endpoint was the volume of maintenance, resuscitation and drug diluent fluids administered on days 3 to 7 in the ICU. Secondary endpoints were to compare dispensed amounts of maintenance fluids and electrolytes with predicted requirements. We also investigated the effects of administered fluids and electrolytes on patient outcomes. During ICU days 3 to 7, 56.4% of the total fluids given were maintenance fluids, nutritional fluids or both, 25.4% were drug fluids and 18.1% were resuscitation fluids. Patients received fluids 1.29 (95% confidence interval 1.07 to 1.56) times their estimated fluid needs. Despite this, 93% of the cohort was treated with diuretics or renal replacement therapy. Patients were given 2.17 (1.57 to 2.96) times their theoretical sodium needs and 1.22 (0.75 to 1.77) times their potassium needs. The median [IQR] volume of fluid loss during the 5-day study period was 3742 [3156 to 4479] ml day-1, with urine output the main source of fluid loss. Death at 90 days was not associated with fluid or electrolyte balance in this cohort. Maintenance and drug fluids far exceeded resuscitative fluids in ICU patients beyond the resuscitative phase. This excess fluid intake, in conjunction with high urinary output and treatment for fluid offload in almost all patients, suggests that a large volume of the maintenance fluids given was unnecessary. ClinicalTrials.org NCT03972475.

S0128 Clinically Significant Ileus in Patients With Acute Pancreatitis Is Associated With Severity of Pancreatitis, Not Volume of Fluid Resuscitation

INTRODUCTION: Aggressive fluid resuscitation has been the standard of care for acute pancreatitis but a tailored approach appears to have best outcomes. Liberal perioperative fluid administration is an independent risk factor for the development of ileus and delayed recovery of gastrointestinal functions after abdominal surgeries. The recovery of gastrointestinal functions is an important determinant of course of acute pancreatitis and the timing of hospital discharge. Here, we evaluated association between fluid resuscitation volume and clinically significant ileus development in patients with acute pancreatitis. METHODS: Consecutive adults admitted with acute pancreatitis between Jan 2014 and Dec 2019 to our academic and two community hospital were included. The Bedside Index for Severe Acute Pancreatitis (BISAP) and systemic inflammatory response syndrome (SIRS) were used to predict severity of pancreatitis based on their readily availability and ease in use. Severity of pancreatitis was determined based on the Revised Atlanta classification. Fluid resuscitation volume was collected as administered in time 0 to 24 hours, 0 to 48 hours and 0 to 72 hours. Clinically significant ileus was determined based on treating physician’s assessment with radiological diagnosis. RESULTS: A total of 441 unique patients were included in the study. Among them, 49 (11%) patients developed clinically significant ileus. Demographics of patients with or without ileus are summarized in Table 1 and were similar between the two groups. On univariate analysis, the presence of SIRS syndrome (<0.001), and higher BISAP scores (P < 0.001) were associated with ileus but pancreatitis etiology and fluid resuscitation volume were not (see table 2). However, Ileus development was associated with increased length of hospital stay and admission to intensive care unit. CONCLUSION: Our data showed that ileus development is associated with severity of acute pancreatitis, not with fluid resuscitation volume or patient demographic.Table 1.: Demographic characteristics.Table 2.: Clinical and laboratory characteristics.

Intravenous fluids in acute pancreatitis: a prospective study

Background: Fluid therapy is the mainstay of treatment in the management of acute pancreatitis. Most guidelines recommend aggressive fluid therapy in the initial 48-72 hours. We aimed to compare the occurrence, persistence or worsening of systemic inflammatory response syndrome (SIRS) and occurrence organ failure in patients with acute pancreatitis receiving normal and high volume fluid therapy in the first 24 hours.Methods: This was a prospective observational study. Consecutive adult patients admitted with acute pancreatitis were included in the study. SIRS was defined according to the criteria. Organ failure and local complications were defined according to Atlanta classification. Patients were divided into two groups according to the rate of fluid administered in the initial 24 hours: Normal volume group which received fluids at a rate &lt;150 ml/hour and high volume group &gt;150 ml/hour.Results: A total 60 patients were included in the study with 30 each in the two groups. Persistence or worsening of SIRS at 48 hours was more in normal volume fluid group compared to the high volume fluid group (p=0.076). Organ failure at 48 hours was more in normal volume fluid group compared to the high volume fluid group (p=0.074). Incidence of local complications equal in both group.Conclusions: Our study did not show any statistically significant difference in outcomes in patients with acute pancreatitis receiving normal or high volume fluids in the initial 24 hours. Further multi-centric randomised control trials are required to analyze the outcomes of high and normal volume fluid resuscitation in acute pancreatitis.

Epidemiology and outcome of patients admitted to intensive care after anaphylaxis in France: a retrospective multicentre study

BackgroundFew data are available on patients who have experienced anaphylaxis and were admitted to ICUs. The purpose of this observational study was to describe the epidemiology and management of these patients. MethodsThis was a multicentre retrospective study carried out in 23 French ICUs between 2012 and 2017. All patients who suffered anaphylaxis and were transferred to an ICU were included. Data were collected using an electronic database after approval by an ethics committee. ResultsA total of 339 patients were included, and 17 (5%) died secondary to anaphylaxis. The main triggers were drugs (77%), contrast media (11%), and food (7%). Epinephrine was administered before ICU admission in 88% of patients with Grade III anaphylaxis and 100% of patients with Grade IV anaphylaxis. Most patients with Grades III and IV anaphylaxes did not receive the recommended dose of i.v. fluid of 30 ml kg−1 within the first 4 h of ICU admission. The time to epinephrine administration was not statistically different between survivors and non-survivors, but non-survivors received a higher dose of epinephrine (median: 5 [3–10] vs 3 [2–7] mg; P<0.0001), which suggests that some forms of anaphylactic shock may be resistant to epinephrine. In multivariate analysis, only lactate concentration at ICU admission was a predictor of death (odds ratio: 1.47 [1.15–1.88]; P=0.002). ConclusionsLactate concentration at ICU admission appeared to be the most reliable criterion for assessing prognosis. Epinephrine is widely used during anaphylaxis, but the volume of fluid resuscitation was consistently lower than recommended. Clinical trial registrationNCT04290507.

Haemostatic changes associated with fluid resuscitation in canine parvoviral enteritis.

The haemostatic status of dogs with canine parvovirus (CPV) enteritis, within 24 h of admission after initial fluid administration, has been described previously, but the haemostatic status at admission and after standard fluid resuscitation, as well as after initial fluid redistribution, has not been investigated previously. The objective of this study was to characterise the haemostatic status at admission and describe the effect of crystalloid fluid resuscitation on haemostatic variables in dogs with CPV enteritis. Twenty-seven client-owned, hospitalised dogs with confirmed natural CPV infection and 15 healthy age-matched controls were included in a prospective, observational clinical study. The volume of resuscitation fluid, haematocrit (HCT), platelet count, thromboelastography (TEG) variables, antithrombin (AT) activity, fibrinogen- and C-reactive protein (CRP) concentrations were measured in all dogs at admission, after fluid resuscitation and, in 10 dogs, after receiving an additional 3 hours of maintenance-rate crystalloid fluids. For the CPV group at admission, the median TEG reaction time (R) and maximum amplitude (MA) or clot strength, as well as the median HCT, fibrinogen and CRP concentrations, were significantly increased compared to the controls. After fluid resuscitation, median R was significantly shorter, MA significantly increased and HCT and AT activity significantly decreased compared to admission values. The haemostatic variables remained unchanged after 3 h of maintenance-rate crystalloid therapy. The increased clot strength present in dogs with CPV enteritis at admission was exacerbated after fluid resuscitation and persisted for hours after large-volume crystalloid fluid administration.