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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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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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Comparison of aggressive versus standard intravenous hydration for clinical improvement among patients with mild acute pancreatitis: A randomized controlled trial.
Angsubhakorn, A, Tipchaichatta, K, Chirapongsathorn, S
Pancreatology : official journal of the International Association of Pancreatology (IAP) ... [et al.]. 2021;(7):1224-1230
Abstract
BACKGROUND Controversy remains regarding fluid management strategy, optimal volume and rate of intravenous fluid in mild acute pancreatitis. We performed a randomized controlled trial to compare clinical improvement and inflammatory markers between aggressive and standard fluid management. METHODS A single center prospective randomized controlled trial was conducted in a tertiary care hospital. We randomized patients with a diagnosis of mild acute pancreatitis using revised Atlanta classification in two groups, the aggressive (20 ml/kg bolus followed by 3 ml/kg/hr) and standard (10 ml/kg bolus followed by 1.5 ml/kg/hr) intravenous hydration with Lactated Ringer's solution. Primary outcome was clinical improvement at 24 and 36 hours. RESULTS The mean age of patients was 46 years and 34 patients (77%) were male. The average volumes of fluid during the first 24 hours in aggressive and standard groups was 4886 ml (71 ml/kg) and 3985 ml (53 ml/kg), respectively; p-value 0.002. Aggressive intravenous hydration did not significantly improve clinical outcome compared with standard intravenous hydration (45.45% vs. 31.82%, respectively; p-value 0.353). However, subgroup analysis between patients with obese and non-obese status, revealed aggressive intravenous hydration significantly improved clinical outcome within the first 24 hours in obese group. CONCLUSION Aggressive intravenous hydration with Lactated Ringer's solution did not improve clinical outcome in mild acute pancreatitis but showed statistically significant improvement only in patients with obese status. Future studies should include a larger sample size to confirm these findings.
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Goal-directed fluid therapy in emergency abdominal surgery: a randomised multicentre trial.
Aaen, AA, Voldby, AW, Storm, N, Kildsig, J, Hansen, EG, Zimmermann-Nielsen, E, Jensen, KM, Tibæk, P, Mortensen, A, Møller, AM, et al
British journal of anaesthesia. 2021;(4):521-531
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BACKGROUND More than 50% of patients have a major complication after emergency gastrointestinal surgery. Intravenous (i.v.) fluid therapy is a life-saving part of treatment, but evidence to guide what i.v. fluid strategy results in the best outcome is lacking. We hypothesised that goal-directed fluid therapy during surgery (GDT group) reduces the risk of major complications or death in patients undergoing major emergency gastrointestinal surgery compared with standard i.v. fluid therapy (STD group). METHODS In a randomised, assessor-blinded, two-arm, multicentre trial, we included 312 adult patients with gastrointestinal obstruction or perforation. Patients in the GDT group received i.v. fluid to near-maximal stroke volume. Patients in the STD group received i.v. fluid following best clinical practice. Postoperative target was 0-2 L fluid balance. The primary outcome was a composite of major complications or death within 90 days. Secondary outcomes were time in intensive care, time on ventilator, time in dialysis, hospital stay, and minor complications. RESULTS In a modified intention-to-treat analysis, we found no difference in the primary outcome between groups: 45 (30%) (GDT group) vs 39 (25%) (STD group) (odds ratio=1.24; 95% confidence interval, 0.75-2.05; P=0.40). Hospital stay was longer in the GDT group: median (inter-quartile range), 7 (4-12) vs 6 days (4-8.5) (P=0.04); no other differences were found. CONCLUSION Compared with pressure-guided i.v. fluid therapy (STD group), flow-guided fluid therapy to near-maximal stroke volume (GDT group) did not improve the outcome after surgery for bowel obstruction or gastrointestinal perforation but may have prolonged hospital stay. CLINICAL TRIAL REGISTRATION EudraCT number 2015-000563-14; the Danish Scientific Ethics Committee and the Danish Data Protection Agency (REG-18-2015).
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Nonaggressive Versus Aggressive Intravenous Fluid Therapy in Acute Pancreatitis With More Than 24 Hours From Disease Onset: A Randomized Controlled Trial.
Cuéllar-Monterrubio, JE, Monreal-Robles, R, González-Moreno, EI, Borjas-Almaguer, OD, Herrera-Elizondo, JL, García-Compean, D, Maldonado-Garza, HJ, González-González, JA
Pancreas. 2020;(4):579-583
Abstract
OBJECTIVE This study aimed to compare a "nonaggressive" hydration versus an "aggressive" hydration using Hartmann's solution in patients with acute pancreatitis (AP) with more than 24 hours from disease onset. METHODS We included 88 patients with AP with more than 24 hours from disease onset, and were randomized into 2 groups. Group I (n = 45) received a nonaggressive hydration (Hartmann's solution at 1.5 mL kg h for the first 24 hours and 30 mL kg during the next 24 hours), and group II (n = 43) received an aggressive hydration (bolus of Hartmann's solution 20 mL kg, followed by an infusion of 3 mL kg h for the first 24 hours and then 30 mL kg for the next 24 hours). RESULTS The mean volume of fluid administered was greater in group II (P < 0.001). We did not find differences when comparing both groups in reference to persistent systemic inflammatory response syndrome (P = 0.528), pancreatic necrosis (P = 0.710), respiratory complications (P = 0.999), acute kidney injury (P = 0.714), or length of hospital stay (P = 0.892). CONCLUSIONS Our study suggests that the clinical evolution of patients with AP with more than 24 hours from disease onset is similar using an aggressive or nonaggressive hydration.
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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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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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Balanced Crystalloids Versus Saline for Perioperative Intravenous Fluid Administration in Children Undergoing Neurosurgery: A Randomized Clinical Trial.
Lima, MF, Neville, IS, Cavalheiro, S, Bourguignon, DC, Pelosi, P, Malbouisson, LMS
Journal of neurosurgical anesthesiology. 2019;(1):30-35
Abstract
BACKGROUND Balanced crystalloid solutions induce less hyperchloremia than normal saline, but their role as primary fluid replacement for children undergoing surgery is unestablished. We hypothesized that balanced crystalloids induce less chloride and metabolic derangements than 0.9% saline solutions in children undergoing brain tumor resection. METHODS In total, 53 patients (age range, 6 mo to 12 y) were randomized to receive balanced crystalloid (balanced group) or 0.9% saline solution (saline group) during and after (for 24 h) brain tumor resection. Serum electrolyte and arterial blood gas analyses were performed at the beginning of surgery (baseline), after surgery, and at postoperative day 1. The primary trial outcome was the absolute difference in serum chloride concentrations (post-preopΔCl) measured after surgery and at baseline. Secondary outcomes included the post-preopΔ of other electrolytes and base excess (BE); hyperchloremic acidosis incidence; and the brain relaxation score, a 4-point scale evaluated by the surgeon for assessing brain edema. RESULTS Saline infusion increased post-preopΔCl (6 [3.5; 8.5] mmol/L) compared with balanced crystalloid (0 [-1.0; 3.0] mmol/L; P<0.001). Saline use also resulted in increased post-preopΔBE (-4.4 [-5.0; -2.3] vs. -0.4 [-2.7; 1.3] mmol/L; P<0.001) and hyperchloremic acidosis incidence (6/25 [24%] vs. 0; P=0.022) compared with balanced crystalloid. Brain relaxation score was comparable between groups. CONCLUSIONS In children undergoing brain tumor resection, saline infusion increased variation in serum chloride compared with balanced crystalloid. These findings support the use of balanced crystalloid solutions in children undergoing brain tumor resection.
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A prospective, randomized, comparison study on effect of perioperative use of chloride liberal intravenous fluids versus chloride restricted intravenous fluids on postoperative acute kidney injury in patients undergoing off-pump coronary artery bypass grafting surgeries.
Bhaskaran, K, Arumugam, G, Vinay Kumar, PV
Annals of cardiac anaesthesia. 2018;(4):413-418
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CONTEXT AND AIMS Off-pump coronary artery bypass graft (OPCABG) is a form of CABG surgery. It is performed without the use of cardiopulmonary bypass machine as a surgical treatment for coronary heart disease. Acute kidney injury (AKI) is one of the common postoperative complications of OPCABG. Previous studies suggest important differences related to intravenous fluid (IVF) chloride content and renal function. We hypothesize that perioperative use of chloride restricted IVFs may decrease incidence and severity of postoperative AKI in patients undergoing OPCABG. METHODS Six hundred patients were randomly divided into two groups of 300 each. In Group A (n = 300), chloride liberal IVFs, namely, hydroxyethyl starch (130/0.4) in 0.9% normal saline (Voluven), 0.9% normal saline, and Ringer's lactate were used for perioperative fluid management. In Group B (n = 300), chloride-restricted IVFs, namely, hydroxyethyl starch (130/0.4) in balanced colloid solution (Volulyte) and balanced salt crystalloid solution (PlasmaLyte A), were used for perioperative fluid management. Serum creatinine values were taken preoperatively, postoperatively at 24 h and at 48 h. Postoperative AKI was determined by AKI network (AKIN) criteria. RESULTS In Group A, 9.2% patients and in Group B 4.6% patients developed Stage-I AKI determined by AKIN criteria which was statistically significant (P < 0.05). CONCLUSION Perioperative use of chloride restricted IVF was found to decrease incidence of postoperative AKI. The use of chloride liberal IVF was associated with hyperchloremic metabolic acidosis.
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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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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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Ringer's lactate versus normal saline in acute pancreatitis: A systematic review and meta-analysis.
Iqbal, U, Anwar, H, Scribani, M
Journal of digestive diseases. 2018;(6):335-341
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OBJECTIVE Aggressive i.v. hydration with crystalloids is the first step in managing acute pancreatitis (AP) and is associated with improved survival. Guidelines about the choice of crystalloids to use are unclear. This systematic review and meta-analysis was aimed to discern whether the choice of fluids in managing pancreatitis was associated with patients' outcomes. METHODS A comprehensive literature review was conducted by searching the Embase, MEDLINE, PubMed and Google Scholar databases to December 2017 to identify all studies that compared normal saline (NS) with Ringer's lactate (RL) for managing AP. The characteristics of the participants, outcome measurements (including mortality, the development of systemic inflammatory response syndrome [SIRS] on admission and at 24 h, and pancreatic necrosis) were analyzed. RESULTS Five studies (three randomized controlled trials and two retrospective cohort studies) with 428 patients were included in this analysis. Mortality trended lower in the RL group but this was not statistically significant (pooled odds ratio [OR] 0.61, 95% CI 0.28-1.29, P = 0.20). Patients in the RL group had significantly decreased odds of developing SIRS at 24 h (pooled OR 0.38, 95% CI 0.15-0.98, P = 0.05). CONCLUSIONS RL has anti-inflammatory effects and is associated with decreased odds of persistent SIRS at 24 h, which is a marker of severe disease in AP patients. Although mortality trended lower in the RL group this did not achieve statistical significance and hence larger randomized controlled trials are needed to evaluate this association.