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Febuxostat combined with hydration for the prevention of contrast-induced nephropathy in hyperuricemia patients undergoing percutaneous coronary intervention: A CONSORT-compliant randomized controlled trial.
Ma, G, Li, M, Teng, W, He, Z, Zhai, X, Xia, Z
Medicine. 2022;(4):e28683
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Abstract
BACKGROUND To assess the efficacy of febuxostat combined with hydration on contrast-induced nephropathy (CIN) in coronary heart disease patients with hyperuricemia undergoing percutaneous coronary intervention (PCI). METHODS Patients with hyperuricemia who underwent PCI were randomly assigned to 2 groups. The control group was given hydration only, and the febuxostat group received febuxostat 40 mg daily before administration of contrast agent and hydration. The primary endpoint of the study was the incidence of CIN, defined as an increase in baseline serum creatinine concentration by 25% at 2 days after contrast media administration, and variations in the serum levels of creatinine, neutrophil gelatinase-associated lipocalin, uric acid, and estimated glomerular filtration rate were compared. RESULTS A total of 202 patients with hyperuricemia were randomly assigned to either the febuxostat group (n = 100) or the control group (n = 102). The baseline characteristics of the 2 groups were similar. The incidence of CIN was 6.0% (6/100) in the febuxostat group and 14.71% (15/102) in the control group.The levels of neutrophil gelatinase-associated lipocalin at 6-hour and serum creatinine and uric acid at 48-hour in the febuxostat combined hydration group were lower than those in the control group after surgery, and the level of estimated glomerular filtration rate was higher than that in the control group (all P < .05). Multivariate logistic regression analysis revealed that febuxostat was an independent predictor of CIN. CONCLUSION Our study demonstrated that prophylactic treatment with febuxostat combined with hydration can reduce the incidence of CIN in patients with coronary heart disease and hyperuricemia after PCI.
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The effect of type of fluid on disease severity in acute pancreatitis treatment.
Kayhan, S, Selcan Akyol, B, Ergul, M, Baysan, C
European review for medical and pharmacological sciences. 2021;(23):7460-7467
Abstract
OBJECTIVE In this study, we aimed to investigate the effect of type of fluid (Normal Saline solution: NSS or Lactated Ringer's solution: LRS) to be selected in fluid replacement in acute pancreatitis (AP) treatment on disease severity. SUBJECTS AND METHODS This study is a prospective, single-center study. Patients diagnosed with acute pancreatitis in emergency service were included in the study and randomized to receive LRS or NSS. The severity of AP was determined regarding Revised Atlanta Classification. C-reactive protein (CRP) levels and serum pH and bicarbonate (HCO3) levels were measured to evaluate the systemic inflammatory response and to detect changes in acid-base balance, respectively. RESULTS Sixty-five and seventy-seven patients receiving NSS and LRS, respectively, were analyzed. Eighty-nine (67.4%) and 43 (32.6%) patients were with mild and moderate AP, respectively; however, there was no patient with severe AP. The frequency of moderate AP was significantly lower in the LRS group than the NSS group in terms of the severity of AP (p=0.011). Subjects that were randomized to receive LRS had lower CRP levels when compared to the participants in the NSS treatment arm 48 hours after resuscitation (p=0.010). In addition to these results, serum pH and HCO3 level in patients resuscitated with NSS reduced in comparison to LRS (p<0.001). CONCLUSIONS Resuscitation with LRS is associated with decreased severity of AP in patients with AP. It may derive from how it causes lower CRP levels.
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Fluid balance and outcome in critically ill patients with traumatic brain injury (CENTER-TBI and OzENTER-TBI): a prospective, multicentre, comparative effectiveness study.
Wiegers, EJA, Lingsma, HF, Huijben, JA, Cooper, DJ, Citerio, G, Frisvold, S, Helbok, R, Maas, AIR, Menon, DK, Moore, EM, et al
The Lancet. Neurology. 2021;(8):627-638
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Abstract
BACKGROUND Fluid therapy-the administration of fluids to maintain adequate organ tissue perfusion and oxygenation-is essential in patients admitted to the intensive care unit (ICU) with traumatic brain injury. We aimed to quantify the variability in fluid management policies in patients with traumatic brain injury and to study the effect of this variability on patients' outcomes. METHODS We did a prospective, multicentre, comparative effectiveness study of two observational cohorts: CENTER-TBI in Europe and OzENTER-TBI in Australia. Patients from 55 hospitals in 18 countries, aged 16 years or older with traumatic brain injury requiring a head CT, and admitted to the ICU were included in this analysis. We extracted data on demographics, injury, and clinical and treatment characteristics, and calculated the mean daily fluid balance (difference between fluid input and loss) and mean daily fluid input during ICU stay per patient. We analysed the association of fluid balance and input with ICU mortality and functional outcome at 6 months, measured by the Glasgow Outcome Scale Extended (GOSE). Patient-level analyses relied on adjustment for key characteristics per patient, whereas centre-level analyses used the centre as the instrumental variable. FINDINGS 2125 patients enrolled in CENTER-TBI and OzENTER-TBI between Dec 19, 2014, and Dec 17, 2017, were eligible for inclusion in this analysis. The median age was 50 years (IQR 31 to 66) and 1566 (74%) of patients were male. The median of the mean daily fluid input ranged from 1·48 L (IQR 1·12 to 2·09) to 4·23 L (3·78 to 4·94) across centres. The median of the mean daily fluid balance ranged from -0·85 L (IQR -1·51 to -0·49) to 1·13 L (0·99 to 1·37) across centres. In patient-level analyses, a mean positive daily fluid balance was associated with higher ICU mortality (odds ratio [OR] 1·10 [95% CI 1·07 to 1·12] per 0·1 L increase) and worse functional outcome (1·04 [1·02 to 1·05] per 0·1 L increase); higher mean daily fluid input was also associated with higher ICU mortality (1·05 [1·03 to 1·06] per 0·1 L increase) and worse functional outcome (1·04 [1·03 to 1·04] per 1-point decrease of the GOSE per 0·1 L increase). Centre-level analyses showed similar associations of higher fluid balance with ICU mortality (OR 1·17 [95% CI 1·05 to 1·29]) and worse functional outcome (1·07 [1·02 to 1·13]), but higher fluid input was not associated with ICU mortality (OR 0·95 [0·90 to 1·00]) or worse functional outcome (1·01 [0·98 to 1·03]). INTERPRETATION In critically ill patients with traumatic brain injury, there is significant variability in fluid management, with more positive fluid balances being associated with worse outcomes. These results, when added to previous evidence, suggest that aiming for neutral fluid balances, indicating a state of normovolaemia, contributes to improved outcome. FUNDING European Commission 7th Framework program and the Australian Health and Medical Research Council.
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Adjunctive treatments for the management of septic shock - a narrative review of the current evidence.
Donovan, K, Shah, A, Day, J, McKechnie, SR
Anaesthesia. 2021;(9):1245-1258
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Abstract
Septic shock is a leading cause of death and morbidity worldwide. The cornerstones of management include prompt identification of sepsis, early initiation of antibiotic therapy, adequate fluid resuscitation and organ support. Over the past two decades, there have been considerable improvements in our understanding of the pathophysiology of sepsis and the host response, including regulation of inflammation, endothelial disruption and impaired immunity. This has offered opportunities for innovative adjunctive treatments such as vitamin C, corticosteroids and beta-blockers. Some of these approaches have shown promising results in early phase trials in humans, while others, such as corticosteroids, have been tested in large, international, multicentre randomised controlled trials. Contemporary guidelines make a weak recommendation for the use of corticosteroids to reduce mortality in sepsis and septic shock. Vitamin C, despite showing initial promise in observational studies, has so far not been shown to be clinically effective in randomised trials. Beta-blocker therapy may have beneficial cardiac and non-cardiac effects in septic shock, but there is currently insufficient evidence to recommend their use for this condition. The results of ongoing randomised trials are awaited. Crucial to reducing heterogeneity in the trials of new sepsis treatments will be the concept of enrichment, which refers to the purposive selection of patients with clinical and biological characteristics that are likely to be responsive to the intervention being tested.
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Perioperative Goal-Directed Fluid Therapy: A Prime Component of Enhanced Recovery After Surgery.
McLain, N, Parks, S, Collins, MJ
AANA journal. 2021;(4):351-357
Abstract
Perioperative goal-directed fluid therapy (GDFT) is a prime component of the Enhanced Recovery After Surgery (ERAS) protocol. Multiple studies have demonstrated a relationship between GDFT and positive patient outcomes, including shorter hospital stays, decreased ileus formation, reduced gastrointestinal-related issues, decreased nausea, and hemodynamic stability. Electrolyte disturbances following a positive fluid balance may occur, and GDFT is aimed at euvolemia to avoid a hypervolemic state. Carbohydrate loading, early discontinuation of postoperative intravenous fluids, and use of isoosmotic solutions all are components of GDFT. Lactated Ringer's solution is the fluid recommended for nonrenal patients and patients with hepatic compromise. The negative consequences associated with hypervolemia deem it pertinent to devise an individualized GDFT plan in the ERAS protocol.
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Preoperative carbohydrate loading and intraoperative goal-directed fluid therapy for elderly patients undergoing open gastrointestinal surgery: a prospective randomized controlled trial.
Liu, X, Zhang, P, Liu, MX, Ma, JL, Wei, XC, Fan, D
BMC anesthesiology. 2021;(1):157
Abstract
BACKGROUND The effect of a combination of a goal-directed fluid protocol and preoperative carbohydrate loading on postoperative complications in elderly patients still remains unknown. Therefore, we designed this trial to evaluate the relative impact of preoperative carbohydrate loading and intraoperative goal-directed fluid therapy versus conventional fluid therapy (CFT) on clinical outcomes in elderly patients following gastrointestinal surgery. METHODS This prospective randomized controlled trial with 120 patients over 65 years undergoing gastrointestinal surgery were randomized into a CFT group (n = 60) with traditional methods of fasting and water-deprivation, and a GDFT group (n = 60) with carbohydrate (200 ml) loading 2 h before surgery. The CFT group underwent routine monitoring during surgery, however, the GDFT group was conducted by a Vigileo/FloTrac monitor with cardiac index (CI), stroke volume variation (SVV), and mean arterial pressure (MAP). For all patients, demographic data, intraoperative parameters and postoperative outcomes were recorded. RESULTS Patients in the GDFT group received significantly less crystalloids fluid (1111 ± 442.9 ml vs 1411 ± 412.6 ml; p < 0.001) and produced significantly less urine output (200 ml [150-300] vs 400 ml [290-500]; p < 0.001) as compared to the CFT group. Moreover, GDFT was associated with a shorter average time to first flatus (56 ± 14.1 h vs 64 ± 22.3 h; p = 0.002) and oral intake (72 ± 16.9 h vs 85 ± 26.8 h; p = 0.011), as well as a reduction in the rate of postoperative complications (15 (25.0%) vs 29 (48.3%) patients; p = 0.013). However, postoperative hospitalization or hospitalization expenses were similar between groups (p > 0.05). CONCLUSIONS Focused on elderly patients undergoing open gastrointestinal surgery, we found perioperative fluid optimisation may be associated with improvement of bowel function and a lower incidence of postoperative complications. TRIAL REGISTRATION ChiCTR, ChiCTR1800018227 . Registered 6 September 2018 - Retrospectively registered.
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The impact of fluid resuscitation via colon on patients with severe acute pancreatitis.
Ni, T, Chen, Y, Zhao, B, Ma, L, Yao, Y, Chen, E, Zhou, W, Mao, E
Scientific reports. 2021;(1):12488
Abstract
Severe acute pancreatitis (SAP) is a life-threatening disease. Fluid Resuscitation Via Colon (FRVC) may be a complementary therapy for early controlled fluid resuscitation. But its clinical application has not been reported. This study aims to explore the impact of FRVC on SAP. All SAP patients with the first onset within 72 h admitted to the hospital were included from January 2014 to December 2018 through electronic databases of Ruijin hospital and were divided into FRVC group (n = 103) and non-FRVC group (n = 78). The clinical differences before and after the therapy between the two groups were analyzed. Of the 181 patients included in the analysis, the FRVC group received more fluid volume and reached the endpoint of blood volume expansion ahead of the non-FRVC group. After the early fluid resuscitation, the inflammation indicators in the FRVC group were lower. The rate of mechanical ventilation and the incidence of hypernatremia also decreased significantly. Using pure water for FRVC was more helpful to reduce hypernatremia. However, Kaplan-Meier 90-day survival between the two groups showed no difference. These results suggest that the combination of FRVC might benefit SAP patients in the early stage of fluid resuscitation, but there is no difference between the prognosis of SAP patients and that of conventional fluid resuscitation. Further prospective study is needed to evaluate the effect of FRVC on SAP patients.
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Avoiding the emergence of contrast-induced acute kidney injury in acute coronary syndrome: routine hydration treatment.
Arslan, S, Yildiz, A, Dalgic, Y, Batit, S, Kilicarslan, O, Ser, OS, Dalgic, SN, Kocas, C, Abaci, O
Coronary artery disease. 2021;(5):397-402
Abstract
BACKGROUND Patients with acute coronary syndrome (ACS) have about a three-fold risk for developing contrast-induced acute kidney injury(CI-AKI). Investigating studies on routine hydration therapy have frequently included patients with stable coronary artery disease and high risk of CI-AKI [estimated glomerular filtration rate (eGFR) < 60 ml/min]. However, data on routine hydration treatment in non-ST segment elevation myocardial infarction (NSTEMI) patients with eGFR ≥60 ml/min are insufficient. We aimed to investigate the association between routine hydration therapy and CI-AKI development in NSTEMI patients at low risk for nephropathy. METHODS AND RESULTS We randomly assigned a total of 401 NSTEMI patients to two groups: the routine hydration group (198 patients) and the nonhydration group (control group) (203 patients). Intravenous hydration with isotonic saline (1 ml/kg/h, 0.9% sodium chloride) was given for 3-12 h before and 24 h after contrast exposure to the hydration group. CI-AKI was defined as the increase in serum creatinine values 0.5 mg/dl or 25% between 48 and 72 h after the invasive procedures. In our study, the incidence of CI-AKI development in the routine hydration group (7.1%) was significantly lower than in the nonhydration group (14.1%) (P: 0.02). This study revealed that older age, amount of contrast media, and routine hydration were independent risk factors for developing CI-AKI (P < 0.01, P: 0.04, P < 0.01, respectively). CONCLUSION We found that preprocedural and postprocedural intravenous hydration therapy reduces the development of CI-AKI in patients with NSTEMI at low risk for CI-AKI. We suggest administering routine hydration therapy in all ACS patients regardless of eGFR values.
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Managing Diabetic Ketoacidosis in Children.
Tzimenatos, L, Nigrovic, LE
Annals of emergency medicine. 2021;(3):340-345
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Effect of Early Balanced Crystalloids Before ICU Admission on Sepsis Outcomes.
Jackson, KE, Wang, L, Casey, JD, Bernard, GR, Self, WH, Rice, TW, Semler, MW, ,
Chest. 2021;(2):585-595
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BACKGROUND Studies suggest that using balanced crystalloids (lactated Ringer's solution or Plasma-Lyte A) rather than saline (0.9% sodium chloride) may improve outcomes for patients with sepsis in the ED and ICU. RESEARCH QUESTION What is the relative impact on sepsis outcomes of fluid composition during early resuscitation in the ED vs after ICU admission? STUDY DESIGN AND METHODS We performed a secondary analysis of the Isotonic Solutions and Major Adverse Renal Events Trial (SMART) data set, examining medical ICU patients with a diagnosis of sepsis (n = 1,641). SMART was a cluster-crossover trial comparing balanced crystalloids vs saline among critically ill adults. During the first 7 months of SMART, fluid choice was controlled only in the ICU ("ICU-only period"). In the final 15 months, fluid choice was coordinated between the ED and ICU ("ED and ICU period"). We performed logistic regression modeling for 30-day in-hospital mortality with an interaction term between randomized group (balanced crystalloids vs saline) and study period (ICU-only period vs ED and ICU period). RESULTS Three hundred and sixty-seven patients with sepsis were enrolled during the ICU-only period and 1,274 were enrolled during the ED and ICU period. Thirty-day in-hospital mortality occurred in 47 of 142 patients (33.1%) in the balanced crystalloid group vs 74 of 225 patients (32.9%) in the saline group during the ICU-only period (OR, 1.14; 95% CI, 0.70-1.88) and in 170 of 682 patients (24.9%) in the balanced crystalloid group vs 181 of 592 patients (30.6%) in the saline group in the ED and ICU period (OR, 0.68; 95% CI, 0.52-0.89) (P value for interaction, .07), consistent with a beneficial effect of balanced crystalloid primarily in the ED and ICU period. INTERPRETATION Among patients with sepsis, the effect of balanced crystalloids vs saline on mortality was greater among patients for whom fluid choice was controlled starting in the ED compared with starting in the ICU.