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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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Rehydration during Endurance Exercise: Challenges, Research, Options, Methods.
Armstrong, LE
Nutrients. 2021;(3)
Abstract
During endurance exercise, two problems arise from disturbed fluid-electrolyte balance: dehydration and overhydration. The former involves water and sodium losses in sweat and urine that are incompletely replaced, whereas the latter involves excessive consumption and retention of dilute fluids. When experienced at low levels, both dehydration and overhydration have minor or no performance effects and symptoms of illness, but when experienced at moderate-to-severe levels they degrade exercise performance and/or may lead to hydration-related illnesses including hyponatremia (low serum sodium concentration). Therefore, the present review article presents (a) relevant research observations and consensus statements of professional organizations, (b) 5 rehydration methods in which pre-race planning ranges from no advanced action to determination of sweat rate during a field simulation, and (c) 9 rehydration recommendations that are relevant to endurance activities. With this information, each athlete can select the rehydration method that best allows her/him to achieve a hydration middle ground between dehydration and overhydration, to optimize physical performance, and reduce the risk of illness.
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Lactate versus acetate buffered intravenous crystalloid solutions: a scoping review.
Ellekjaer, KL, Perner, A, Jensen, MM, Møller, MH
British journal of anaesthesia. 2020;(5):693-703
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Abstract
BACKGROUND Buffered crystalloid solutions are increasingly recommended as first-line intravenous resuscitation fluids. However, guidelines do not distinguish between the different types of buffered solutions. The aim of this scoping review was to assess the evidence on the use of lactate- vs acetate-buffered crystalloid solutions and their potential benefits and harms. METHODS We conducted this scoping review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews. We searched PubMed, Embase, Epistemonikos, and the Cochrane Library for studies assessing the effect of lactate- vs acetate-buffered crystalloid solutions on any outcome in adult hospitalised patients. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation approach. RESULTS We included a total of 29 studies, 25 of which were clinical trials and four were observational studies. Most studies were conducted in surgical settings and indications for use were poorly described. The most commonly administered solutions were Ringer's lactate vs Ringer's acetate or Plasma-Lyte™. Outcomes included acid/base and electrolyte status; haemodynamic variables; and markers of renal and liver function, metabolism, and coagulation. Only a few studies reported patient-centred outcomes. Overall, the data provided no firm evidence for benefit or harm of either solution, and the quantity and quality of evidence were low. CONCLUSIONS The quantity and quality of evidence on the use of different buffered crystalloid intravenous solutions were low, data were derived primarily from surgical settings, and patient-important outcomes were rarely reported; thus, the balance between benefits and harms between these solutions is largely unknown.
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The place of hydration using intravenous fluid in patients at risk of developing contrast-associated nephropathy.
Liu, S, Shan, XG, Zhang, XJ
British journal of hospital medicine (London, England : 2005). 2020;(9):1-7
Abstract
There has been a significant rise in the incidence of contrast-associated nephropathy caused by administration of contrast media during cardiac interventions. This is one of the major complications of percutaneous coronary interventions, which may proceed to acute renal failure. Risk factors, including pre-existing renal dysfunction, older age and use of high osmolar contrast media, predispose patients to the development of contrast-associated nephropathy. Different risk-reduction strategies have been used to prevent contrast-associated nephropathy, including use of low osmolar contrast media, N-acetylcysteine, alkalisation of tubular fluid with intravenous sodium bicarbonate, and oral and intravenous hydration with isotonic solution. Hydration using intravenous saline is one of the main treatments used to prevent the development of nephropathy in patients receiving contrast media during cardiac interventions. Prehydration, before administering contrast media, seems to be crucial. The results of studies of the relative efficacy of sodium bicarbonate and/or N-acetylcysteine in reducing the development of contrast-associated nephropathy are not consistent and any beneficial effects may depend on the pre-existing state of the kidney. This review discusses hydration of patients who are at risk of developing contrast-associated nephropathy using intravenous fluid.
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Role of Hydration in Contrast-Induced Nephropathy in Patients Who Underwent Primary Percutaneous Coronary Intervention.
Wang, Z, Song, Y, A, G, Li, Y
International heart journal. 2019;(5):1077-1082
Abstract
Patients with ST-segment elevation myocardial infarction (STEMI) who are treated by primary percutaneous coronary intervention (PPCI) have an increased risk of developing contrast-induced nephropathy (CIN) when compared with patients undergoing elective percutaneous coronary intervention (PCI). However, CIN prevention measures are less frequently applied in PPCI than in elective PCI. At present, no preventive strategy has been recommended by the current guidelines for patients with STEMI undergoing PPCI.Published research was scanned by formal searches of electronic databases (PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials) from 1966 to July 2018. Internet-based sources of information on the results of clinical trials in cardiology were also searched.A total of three randomized trials involving 924 patients were included in the present meta-analysis, of whom 462 received hydration with isotonic saline (hydration group) and 462 received no hydration (control group). Periprocedural hydration with isotonic saline was associated with a significant decrease in the rate of CIN (16.9% in the hydration group versus 26.4% in the control group; summary risk ratio: 0.64, 95% confidence interval: 0.50-0.82, P = 0.0005). There was no difference in the rate of postprocedural hemodialysis or death between the groups.Intravenous saline hydration during PPCI reduced the risk of CIN without significantly altering the rate of requirement for renal replacement therapy or mortality.
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Empiric therapy for kidney stones.
Goldfarb, DS
Urolithiasis. 2019;(1):107-113
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Abstract
Careful phenotyping of patients to classify those with kidney stones has a long and important history in revealing the chemical basis for stone formation. Advances in our genetic understanding of kidney stones will lead to incredible insights regarding the pathophysiology of this common disorder. At this time, both evaluation of urine chemistry and genotyping of patients are extremely useful in the setting of a university and research-based kidney stone clinic. For much of the world, in a more clinically focused setting, these techniques are neither available nor absolutely necessary. Careful implementation of an empiric prescription based on stone composition would have an important effect to reduce stone recurrence in the world's many stone formers. Increased fluid intake, generic dietary manipulations, and prescription of potassium citrate and thiazides are all appropriate empiric therapies for people with calcium and uric acid kidney stones.
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Normal saline for intravenous fluid therapy in critically ill patients.
Zhou, FH, Liu, C, Mao, Z, Ma, PL
Chinese journal of traumatology = Zhonghua chuang shang za zhi. 2018;(1):11-15
Abstract
The efficacy and safety of normal saline (NS) for fluid therapy in critically ill patients remain controversy. In this review, we summarized the evidence of randomized controlled trials (RCTs) which compared NS with other solutions in critically ill patients. The results showed that when compared with 6% hydroxyethyl starch (HES), NS may reduce the onset of acute kidney injury (AKI). However, there is no significant different in mortality and incidence of AKI when compared with 10% HES, albumin and buffered crystalloid solution. Therefore, it is important to prescribe intravenous fluid for patients according to their individual condition.
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Goal-directed fluid therapy versus conventional fluid therapy in colorectal surgery: A meta analysis of randomized controlled trials.
Xu, C, Peng, J, Liu, S, Huang, Y, Guo, X, Xiao, H, Qi, D
International journal of surgery (London, England). 2018;:264-273
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Abstract
OBJECTIVES This meta-analysis was conducted to compare the effects of goal-directed fluid therapy (GDFT) versus conventional fluid therapy (CFT) in colorectal surgery on patients' postoperative outcome and to detect whether the results differ between studies with the Enhanced Recovery After Surgery (ERAS) protocol and those without, between studies using different devices for GDFT, or between different surgical approaches (laparoscopy or laparotomy). METHODS The Cochrane Library, PubMed, Embase, Wanfang Data and ClinicalTrials.com were searched for studies from January,1990 to February, 2018. Randomized controlled trials (RCTs) comparing both two abovementioned fluid therapy protocols in colorectal surgery were included. The primary outcome was 30-day mortality after surgery. Secondary outcomes were length of hospital stay (LOS), complication rate, ICU admission and gastrointestinal indicators. RESULTS Eleven studies were included, including a total of 1281 patients: the GDFT group included 624 patients and the control group included 657 patients. No significant differences were found between groups in 30-day mortality (relative risk, RR 0.86,0.28 to 2.63, P = 0.79), LOS (weighted mean difference, WMD 0.22,-0.1 to 0.55, P = 0.18), and ICU admission (RR 0.42, 0.17 to 1.04, P = 0.06). However, the GDFT group had a lower complication rate (RR 0.84,0.71 to 0.99, P = 0.04). In subgroup analyses, time to first flatus and time to tolerate an oral diet were shorter in GDFT group than the control group in studies who did not use the ERAS protocol. No publication bias was identified according to Begg's test. CONCLUSION Compared with conventional fluid therapy, GDFT may not improve patients' postoperative outcome in colorectal surgery. However, the improvement of gastrointestinal function associated with GDFT over conventional fluid therapy was significant in the surgeries that did not use the ERAS protocol.
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Fluid management concepts for severe neurological illness: an overview.
Heifets, BD, Tanaka, P, Burbridge, MA
Current opinion in anaesthesiology. 2018;(5):526-531
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PURPOSE OF REVIEW The acute care of a patient with severe neurological injury is organized around one relatively straightforward goal: avoid brain ischemia. A coherent strategy for fluid management in these patients has been particularly elusive, and a well considered fluid management strategy is essential for patients with critical neurological illness. RECENT FINDINGS In this review, several gaps in our collective knowledge are summarized, including a rigorous definition of volume status that can be practically measured; an understanding of how electrolyte derangements interact with therapy; a measurable endpoint against which we can titrate our patients' fluid balance; and agreement on the composition of fluid we should give in various clinical contexts. SUMMARY As the possibility grows closer that we can monitor the physiological parameters with direct relevance for neurological outcomes and the various complications associated with neurocritical illness, we may finally move away from static therapy recommendations, and toward individualized, precise therapy. Although we believe therapy should ultimately be individualized rather than standardized, it is clear that the monitoring tools and analytical methods used ought to be standardized to facilitate appropriately powered, prospective clinical outcome trials.
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Hyperglycemic Hyperosmolar State: A Pragmatic Approach to Properly Manage Sodium Derangements.
Baldrighi, M, Sainaghi, PP, Bellan, M, Bartoli, E, Castello, LM
Current diabetes reviews. 2018;(6):534-541
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Abstract
INTRODUCTION Although hypovolemia remains the most relevant problem during acute decompensated diabetes in its clinical manifestations (diabetic ketoacidosis, DKA, and hyperglycemic hyperosmolar state, HHS), the electrolyte derangements caused by the global hydroelectrolytic imbalance usually complicate the clinical picture at presentation and may be worsened by the treatment itself. AIM: This review article is focused on the management of dysnatremias during hyperglycemic hyperosmolar state with the aim of providing clinicians a useful tool to early identify the sodium derangement in order to address properly its treatment. DISCUSSION The plasma sodium concentration is modified by most of the therapeutic measures commonly required in such patients and the physician needs to consider these interactions when treating HHS. Moreover, an improper management of plasma sodium concentration (PNa+) and plasma osmolality during treatment has been associated with two rare potentially life-threatening complications (cerebral edema and osmotic demyelination syndrome). Identifying the correct composition of the fluids that need to be infused to restore volume losses is crucial to prevent complications. CONCLUSION A quantitative approach based on the comparison between the measured PNa+ (PNa+ M) and the PNa+ expected in the presence of an exclusive water shift (PNa+ G) may provide more thorough information about the true hydroelectrolytic status of the patient and may therefore, guide the physician in the initial management of HHS. On the basis of data derived from our previous studies, we propose a 7-step algorithm to compute an accurate estimate of PNa+ G.