Abstract/Text
Although often used interchangeably, dehydration and volume depletion are not synonyms. Dehydration refers to loss of total-body water, producing hypertonicity, which now is the preferred term in lieu of dehydration, whereas volume depletion refers to a deficit in extracellular fluid volume. In particular, hypertonicity implies intracellular volume contraction, whereas volume depletion implies blood volume contraction. Using a case of hyperglycemic hypertonic nonketosis as an example, we examine the changing composition of body fluid spaces to explore the distinction between dehydration and hypertonicity from volume depletion.
Copyright © 2011 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.
David R Thomas, Todd R Cote, Larry Lawhorne, Steven A Levenson, Laurence Z Rubenstein, David A Smith, Richard G Stefanacci, Eric G Tangalos, John E Morley, Dehydration Council
Understanding clinical dehydration and its treatment.
J Am Med Dir Assoc. 2008 Jun;9(5):292-301. doi: 10.1016/j.jamda.2008.03.006.
Abstract/Text
Dehydration in clinical practice, as opposed to a physiological definition, refers to the loss of body water, with or without salt, at a rate greater than the body can replace it. We argue that the clinical definition for dehydration, ie, loss of total body water, addresses the medical needs of the patient most effectively. There are 2 types of dehydration, namely water loss dehydration (hyperosmolar, due either to increased sodium or glucose) and salt and water loss dehydration (hyponatremia). The diagnosis requires an appraisal of the patient and laboratory testing, clinical assessment, and knowledge of the patient's history. Long-term care facilities are reluctant to have practitioners make a diagnosis, in part because dehydration is a sentinel event thought to reflect poor care. Facilities should have an interdisciplinary educational focus on the prevention of dehydration in view of the poor outcomes associated with its development. We also argue that dehydration is rarely due to neglect from formal or informal caregivers, but rather results from a combination of physiological and disease processes. With the availability of recombinant hyaluronidase, subcutaneous infusion of fluids (hypodermoclysis) provides a better opportunity to treat mild to moderate dehydration in the nursing home and at home.
Abstract/Text
The treatment of dehydration in older adults admitted from residential care to an acute hospital setting may lead to haemodynamic stability. There is however an increased risk for short or long term alterations in physiological, cognitive and psychological status and ultimately, decreased quality of life. Such acute care admissions could be decreased where preventative strategies tailored to address individual risk factors are combined with more frequent assessment of the degree of hydration. The questionable reliability of assessment criteria in older adults increases the need to use multiple signs and symptoms in the identification and differentiation of early and late stages of dehydration. This article reviews various risk factors, explores the reliability of clinical signs and symptoms and reinforces the need to use multiple patient assessment cues if nurses are to differentiate between, and accurately respond to, the various causes of dehydration. Specific strategies to maintain hydration in older adults are also identified.
Abstract/Text
Dehydration is the most common fluid and electrolyte problem among the elderly. The usual causes of water loss are frequently absent in dehydrated elderly patients. Age-related changes in total body water, thirst perception, renal concentrating ability, and vasopressin effectiveness probably predispose to dehydration. Dehydration related to infection, high-protein tube feedings, cerebral vascular accidents, and medication-related hypodypsia are particularly relevant for elderly patients. Appropriate treatment depends on accurately assessing the water deficit and slowly correcting that deficit.
Abstract/Text
OBJECTIVE: To review, systematically, the physical diagnosis of hypovolemia in adults.
METHODS: We searched MEDLINE (January 1966-November 1997), personal files, and bibliographies of textbooks on physical diagnosis and identified 10 studies investigating postural vital signs or the capillary refill time of healthy volunteers, some of whom underwent phlebotomy of up to 1150 mL of blood, and 4 studies of patients presenting to emergency departments with suspected hypovolemia, usually due to vomiting, diarrhea, or decreased oral intake.
RESULTS: When clinicians evaluate adults with suspected blood loss, the most helpful physical findings are either severe postural dizziness (preventing measurement of upright vital signs) or a postural pulse increment of 30 beats/min or more. The presence of either finding has a sensitivity for moderate blood loss of only 22% (95% confidence interval [CI], 6%-48%) but a much greater sensitivity for large blood loss of 97% (95% CI, 91%-100%); the corresponding specificity is 98% (95% CI, 97%-99%). Supine hypotension and tachycardia are frequently absent, even after up to 1150 mL of blood loss (sensitivity, 33%; 95% CI, 21%-47%, for supine hypotension). The finding of mild postural dizziness has no proven value. In patients with vomiting, diarrhea, or decreased oral intake, the presence of a dry axilla supports the diagnosis of hypovolemia (positive likelihood ratio, 2.8; 95% CI, 1.4-5.4), and moist mucous membranes and a tongue without furrows argue against it (negative likelihood ratio, 0.3; 95% CI, 0.1-0.6 for both findings). In adults, the capillary refill time and poor skin turgor have no proven diagnostic value.
CONCLUSIONS: A large postural pulse change (> or =30 beats/min) or severe postural dizziness is required to clinically diagnose hypovolemia due to blood loss, although these findings are often absent after moderate amounts of blood loss. In patients with vomiting, diarrhea, or decreased oral intake, few findings have proven utility, and clinicians should measure serum electrolytes, serum blood urea nitrogen, and creatinine levels when diagnostic certainty is required.
Abstract/Text
STUDY OBJECTIVE: To determine which of the signs and symptoms of dehydration obtainable from patient history and physical examination in the emergency department are most useful in assessing the severity of dehydration in elderly patients.
DESIGN: Prospective, correlational study.
SETTING: Two university teaching hospitals. Patients: Fifty-five patients aged 60 or older presenting to the emergency department with suspected dehydration were studied.
MEASUREMENTS AND MAIN RESULTS: In the emergency department, patients were evaluated by a standardized history and physical examination that included assessment of 38 signs and symptoms commonly attributed to dehydration. The relationships between the presence and intensity of these putative dehydration indicators and an independent rating of dehydration severity based on a comprehensive review of the medical record were evaluated. Also evaluated were the relationships between these dehydration indicators and patient age. Indicators that correlated best with dehydration severity but were unrelated to patient age included: tongue dryness (P less than 0.001), longitudinal tongue furrows (P less than 0.001), dryness of the mucous membranes of the mouth (P less than 0.001), upper body muscle weakness (P less than 0.001), confusion (P less than 0.001), speech difficulty (P less than 0.01), and sunkenness of eyes (P less than 0.01). Other indicators had only weak associations with dehydration severity or were also related to age. Patient thirst was unrelated to dehydration severity.
CONCLUSIONS: A set of signs and symptoms related to dehydration severity in elderly patients has been identified. These indicators may be more useful for evaluation of dehydration severity in the emergency department than other commonly used indicators.
Abstract/Text
Due to an absence of published primary data, this study explores dehydration prevalence and the change in physiological parameters frequently used to assess dehydration (fluid deficit) in older hospitalized people, as no standard measurement method exists. This observational longitudinal cohort study recruited 43 people aged 60 years or over, voluntarily admitted to a tertiary teaching hospital's Geriatric and Rehabilitation Unit (GARU). Over 40 clinical, hematological and urinary biochemical parameters employed by medical officers during dehydration assessment, identified through literature, interviews and focus group were investigated. Short-term weight changes, intra- and inter-rater repeatability of dehydration assessments were completed to assess validation and precision of the clinician's clinical dehydration assessment. Systolic blood pressure drop on standing, sternal skin turgor, tongue dryness and body mass index (BMI) were associated with hydration status; demonstrated clinically meaningful differences between groups. BMI negatively confounded the association between dehydration and systolic blood pressure drop on standing. Physical, rather than biochemical, parameters more often identified mild dehydration. The findings challenge common expectations of hematological and physiological measurement changes occurring in older people clinically assessed as dehydrated and emphasize the need to adjust for potential confounders during exploration of the associations of clinical parameters with dehydration status.
Abstract/Text
STUDY OBJECTIVES: To evaluate whether the capillary refill test can correctly differentiate between hypovolemic and euvolemic emergency department patients.
DESIGN: A prospective, nonrandomized, nonblinded time series.
SETTING: The orthostatic and hypotensive patients were seen in a university hospital ED with 44,000 visits per year. Blood donors were studied in the hospital's blood donor center.
TYPE OF PARTICIPANTS: Thirty-two adult ED patients who presented with a history suggestive of hypovolemia and either abnormal orthostatic vital signs (19) or frank hypotension (13), and 47 volunteer blood donors who ranged in age from 19 to 83 participated.
INTERVENTIONS: Capillary refill was measured before rehydration in the ED subjects and, in the donor group, before and after a 450-mL blood donation.
MEASUREMENTS: Sensitivity, specificity, accuracy, and positive and negative predictive values were calculated. Analyses were stratified by age, sex, and study group.
MAIN RESULTS: For the blood donor group, mean capillary refill time before donation was 1.4 seconds and after donation was 1.1 seconds. Mean capillary refill time for the orthostatic group was 1.9 seconds and for the hypotensive group was 2.8 seconds. When scored with age-sex specific upper limits of normal, the sensitivity of capillary refill in identifying hypovolemic patients was 6% for the 450-mL blood loss group, 26% for the orthostatic group, and 46% for the hypotensive group. The accuracy of capillary refill in a patient with a 50% prior probability of hypovolemia is 64%. Orthostatic vital signs were found to be more sensitive and specific than capillary refill in detecting the 450-mL blood loss.
CONCLUSION: Capillary refill does not appear to be a useful test for detecting mild-to-moderate hypovolemia in adults.
Abstract/Text
The most useful individual signs for identifying dehydration in children are prolonged capillary refill time, abnormal skin turgor, and abnormal respiratory pattern. However, clinical dehydration scales based on a combination of physical examination findings are better predictors than individual signs. Oral rehydration therapy is the preferred treatment of mild to moderate dehydration caused by diarrhea in children. Appropriate oral rehydration therapy is as effective as intravenous fluid in managing fluid and electrolyte losses and has many advantages. Goals of oral rehydration therapy are restoration of circulating blood volume, restoration of interstitial fluid volume, and maintenance of rehydration. When rehydration is achieved, a normal age-appropriate diet should be initiated.
Abstract/Text
BACKGROUND: In patients with congestive heart failure, evaluation of right atrial pressure (RAP) provides useful therapeutic, functional and prognostic information. The aim of this study was to investigate whether a combination of inferior vena cava variables measured by Doppler echocardiography could provide a reliable non-invasive estimate of RAP.
METHODS: One hundred consecutive patients with severe congestive heart failure (ejection fraction 24 +/- 6%) due to dilated cardiomyopathy were evaluated by simultaneous Doppler echocardiography and hemodynamic studies. RAP, end-expiratory (IVCDmax) and end-inspiratory (IVCDmin) diameters of the inferior vena cava, its collapse index [CIIVC = (IVCDmax - IVCDmin/IVCDmax)*100] and systolic fraction of forward inferior vena cava flow were measured and correlated by both single and multilinear regression analysis. The accuracy of generated equations was tested in a separate testing group of 61 patients at baseline and a subgroup of 20 patients after loading manipulations, prospectively studied in the same methodological setting.
RESULTS: All Doppler echocardiographic variables were correlated with RAP. The IVCDmin showed the strongest correlation (r = 0.84, p < 0.0001). Stepwise regression analysis identified two equations for predicting RAP: 1) RAP = (6.4*IVCDmin + 0.04*CIIVC - 2) (r = 0.82, p < 0.0001, SEE 1.7 mmHg) in all patients, and 2) RAP = (4.9*IVCDmin + 0.01*CIIVC - 0.2) (r = 0.92, p < 0.0001, SEE 1.2 mmHg) in patients without tricuspid regurgitation. In the testing group estimated and measured RAP was strongly correlated at baseline (r = 0.95, SEE 1.3 mmHg, p < 0.00001) and after loading manipulations (r = 0.96, SEE 1.2 mmHg, p < 0.00001). The agreement between invasive and non-invasive measurements of RAP in identifying patients with normal (< or = 5 mmHg), moderately increased (< 5 RAP < 10 mmHg) and markedly increased (> or = 10 mmHg) RAP was 81 or 93% using equation 1 or 2, respectively.
CONCLUSIONS: Our results provide evidence that in patients with congestive heart failure indices derived from Doppler measurements of the inferior vena cava can be used to produce an accurate, strong and non-invasive estimate of RAP. This is another example of the usefulness of Doppler echocardiography in evaluating hemodynamic profile and its changes in patients with congestive heart failure. Echocardiographic assessment of the inferior vena cava should be included in the evaluation of patients with congestive heart failure.
Abstract/Text
This article describes a simple, new technique using ultrasound (US) to estimate central venous pressure (CVP). The sonographic patterns of the internal jugular vein (IJV) with a low, normal, and elevated CVP are also described. Although bedside visual inspection of the height of the jugular veins as an estimate of CVP has been an integral part of the physical examination, its major limitation has been that the jugular veins are not always observable. In obese patients, a layer of fat often obscures the jugular pulsations. US has proven to be a powerful tool to noninvasively visualize neck veins in the emergency department. Bedside US of the IJV, performed by emergency physicians, provides immediate, important information that cannot be obtained without invasive catheters.
Abstract/Text
STUDY OBJECTIVE: Accurate physical examination of patients with dyspnea is important. Jugular venous distention, however, can be difficult to assess in patients. The purpose of this case series is to serve as a pilot study of how ultrasonographic examination of the internal jugular vein compares with other measures of dyspnea.
METHODS: This was a case series of 8 patients presenting with dyspnea without jugular venous distention on physical examination. Each patient underwent ultrasonographic examination of the internal jugular vein and inferior vena cava by an emergency physician sonographer blinded to all other clinical information after initial evaluation by another emergency physician for dyspnea. Results of ultrasonographic examination of the internal jugular vein and inferior vena cava were subsequently compared with initial emergency physician physical examination findings, initial chest radiography interpreted by radiologists, initial B-type natriuretic peptide levels, and final hospital discharge diagnosis.
RESULTS: Ultrasonographic examination of the internal jugular vein compared more favorably with B-type natriuretic peptide levels and chest radiographic findings than ultrasonographic examination of the inferior vena cava in these patients with dyspnea but not jugular venous distention on physical examination. It was able to identify every patient diagnosed with cardiogenic pulmonary edema on hospital discharge.
CONCLUSION: Ultrasonographic examination of the internal jugular vein appears to be helpful in patients who present with dyspnea but do not have evidence of jugular venous distention on physical examination.
Abstract/Text
PURPOSE: The fluid volume status of a patient is difficult to assess clinically. The aim of this study was to compare the ultrasound estimation of the height of the right internal jugular vein (CVP(IJV)) with direct estimation of central venous pressure (CVP) (CVP(CVC)).
MATERIALS AND METHODS: A portable ultrasound machine defined the "top" of the right internal jugular vein in 44 patients from a single tertiary hospital. The vertical height from this point to the sternal angle was used to estimate CVP(IJV). A central venous catheter was then inserted and direct measurement of CVP was made with a pressure transducer. A normal CVP was defined as 3 to 6 mm Hg.
RESULTS: For overloaded patients, CVP(IJV) correlated well with CVP(CVC), P = .004, sensitivity of 64.3%, specificity of 81.3%, and positive predictive value of 85.7%. The area under the curve for the receiver operating characteristic curve was 0.73 (95% confidence interval, 0.59-0.86). For undervolumed patients, the correlation remained statistically significant, P < .001, sensitivity of 88.9%, specificity of 77.1%, and negative predictive value of 96.4%. The area under the curve was 0.83 (95% confidence interval, 0.70-0.96).
CONCLUSION: Ultrasound estimation of CVP using a portable ultrasound machine and the internal jugular vein is simple, noninvasive, and accurate.
Crown Copyright © 2012. Published by Elsevier Inc. All rights reserved.
Abstract/Text
BACKGROUND: Bedside ultrasound examination could be used to assess jugular venous pressure (JVP), and thus central venous pressure (CVP), more reliably than clinical examination.
METHODS: The study was a prospective, blinded evaluation comparing physical examination of external jugular venous pressure (JVPEXT), internal jugular venous pressure (JVPINT), and ultrasound collapse pressure (UCP) with CVP measured using an indwelling catheter. We compared the examination of the external and internal JVP with each other and with the UCP and CVP. JVPEXT, JVPINT, UCP, and CVP were compared graphically using Bland-Altman plots, and correlation coefficients were calculated.
RESULTS: The correlation coefficients comparing CVP to UCP, JVPEXT, and JVPINT were 0.62, 0.57, and 0.50, respectively. When UCP was compared with JVPEXT and JVPINT, correlation coefficients were 0.91 and 0.81, respectively. Last, the correlation coefficient comparing JVPEXT and JVPINT was 0.98. The Bland-Altman graphical comparison of methods technique revealed that CVP was often underestimated by UCP, and clinical examination of JVPEXT and JVPINT. In contrast, there was no systematic bias between UCP and either JVPEXT or JVPINT, nor between JVPEXT and JVPINT.
CONCLUSIONS: Ultrasound examination is capable of measuring accurately the JVP as judged from the internal or external jugular vein. However, like the JVP, ultrasound typically underestimates CVP. A systematic bias between UCP and CVP suggests the presence of a variable degree of venous tone, possibly signaling contraction of jugular venous smooth muscle.
TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT01099241; URL: clinicaltrials.gov.
Abstract/Text
STUDY OBJECTIVES: To define a set of orthostatic vital signs that minimize the frequency of false-positives among healthy individuals while maximizing sensitivity in detecting acute moderate blood loss and to determine the sensitivity and specificity of this optimized tilt test in detecting acute moderate blood loss.
DESIGN AND INTERVENTION: Postural vital signs were recorded in a standardized manner before and after 450-mL phlebotomy. Paired comparisons were done for a variety of criteria for a positive tilt test using receiver-operating characteristic curves. SETTING AND TYPE OF PARTICIPANTS: Three hundred forty-five healthy euvolemic adult volunteer blood donors were tested at three community blood donation centers over a one-year period. Subjects were prospectively divided into group 1 (less than age 65; 301) and group 2 (age 65 or older; 44).
MEASUREMENTS AND MAIN RESULTS: For each combination of pulse and blood pressure in group 1, a change in pulse alone had the same or higher sensitivity with at least the same specificity. Pulse alone was similarly superior in group 2 compared with previously published combinations of pulse and blood pressure. Even the optimized tilt test had limited sensitivity in detecting acute moderate blood loss with high specificity.
CONCLUSION: In applying the tilt test to young adults without cardiovascular disease, pulse measurement usually is all that is necessary.
Maria-Eleni Roumelioti, Todd S Ing, Helbert Rondon-Berrios, Robert H Glew, Zeid J Khitan, Yijuan Sun, Deepak Malhotra, Dominic S Raj, Emmanuel I Agaba, Glen H Murata, Joseph I Shapiro, Antonios H Tzamaloukas
Principles of quantitative water and electrolyte replacement of losses from osmotic diuresis.
Int Urol Nephrol. 2018 Jul;50(7):1263-1270. doi: 10.1007/s11255-018-1822-0. Epub 2018 Mar 6.
Abstract/Text
Osmotic diuresis results from urine loss of large amounts of solutes distributed either in total body water or in the extracellular compartment. Replacement solutions should reflect the volume and monovalent cation (sodium and potassium) content of the fluid lost. Whereas the volume of the solutions used to replace losses that occurred prior to the diagnosis of osmotic diuresis is guided by the clinical picture, the composition of these solutions is predicated on serum sodium concentration and urinary sodium and potassium concentrations at presentation. Water loss is relatively greater than the loss of sodium plus potassium leading to hypernatremia which is seen routinely when the solute responsible for osmotic diuresis (e.g., urea) is distributed in body water. Solutes distributed in the extracellular compartment (e.g., glucose or mannitol) cause, in addition to osmotic diuresis, fluid transfer from the intracellular into the extracellular compartment with concomitant dilution of serum sodium. Serum sodium concentration corrected to euglycemia should be substituted for actual serum sodium concentration when calculating the composition of the replacement solutions in hyperglycemic patients. While the patient is monitored during treatment, the calculation of the volume and composition of the replacement solutions for losses of water, sodium and potassium from ongoing osmotic diuresis should be based directly on measurements of urine volume and urine sodium and potassium concentrations and not by means of any predictive formulas. Monitoring of clinical status, serum sodium, potassium, glucose, other relevant laboratory values, urine volume, and urine sodium and potassium concentrations during treatment of severe osmotic diuresis is of critical importance.
David E Leib, Christopher A Zimmerman, Zachary A Knight
Thirst.
Curr Biol. 2016 Dec 19;26(24):R1260-R1265. doi: 10.1016/j.cub.2016.11.019.
Abstract/Text
Our bodies are mostly water, and this water is constantly being lost through evaporative and other means. Thus the evolution of robust mechanisms for finding and consuming water has been critical for the survival of most animals. In this Primer, we discuss how the brain monitors the water content of the body and then transforms that physical information into the motivation to drink.
Copyright © 2016 Elsevier Ltd. All rights reserved.
John A Myburgh, Michael G Mythen
Resuscitation fluids.
N Engl J Med. 2013 Sep 26;369(13):1243-51. doi: 10.1056/NEJMra1208627.
Abstract/Text
Abstract/Text
BACKGROUND: Fractional excretion of sodium (FENa) has been used in the diagnosis of acute renal failure (ARF) to distinguish between the two main causes of ARF, prerenal state and acute tubular necrosis (ATN). However, many patients with prerenal disorders receive diuretics, which decrease sodium reabsorption and thus increase FENa. In contrast, the fractional excretion of urea nitrogen (FEUN) is primarily dependent on passive forces and is therefore less influenced by diuretic therapy.
METHODS: To test the hypothesis that FEUN might be more useful in evaluating ARF, we prospectively compared FEUN with FENa during 102 episodes of ARF due to either prerenal azotemia or ATN.
RESULTS: Patients were divided into three groups: those with prerenal azotemia (N = 50), those with prerenal azotemia treated with diuretics (N = 27), and those with ATN (N = 25). FENa was low only in the patients with untreated plain prerenal azotemia while it was high in both the prerenal with diuretics and the ATN groups. FEUN was essentially identical in the two pre-renal groups (27.9 +/- 2.4% vs. 24.5 +/- 2.3%), and very different from the FEUN found in ATN (58.6 +/- 3.6%, P < 0.0001). While 92% of the patients with prerenal azotemia had a FENa <1%, only 48% of those patients with prerenal and diuretic therapy had such a low FENa. By contrast 89% of this latter group had a FEUN <35%.
CONCLUSIONS: Low FEUN (
Abstract/Text
BACKGROUND: The accuracy of fractional excretion of sodium (FENa) for the diagnosis of transient acute kidney injury (AKI) caused by decreased kidney perfusion is reported to be low in patients administered diuretics.
STUDY DESIGN: This is a prospective study of diagnostic accuracy comparing the performance of fractional excretion of urea (FEur) with that of FENa to distinguish between transient and persistent AKI.
SETTING & PARTICIPANTS: 99 patients hospitalized at a tertiary-care center who developed AKI (>or=30% increase in serum creatinine level from baseline within 1 week).
INDEX TEST: FEur and FENa were calculated for each patient.
REFERENCE TEST & MEASUREMENTS: Patients were classified as having transient or persistent AKI according to the clinical context and whether serum creatinine level returned to baseline within 7 days. Each group also was subdivided according to exposure to diuretics. FEur of 35% or less and FENa of 1% or less were used to define transient AKI. Sensitivity, specificity, and receiver operating characteristic curves were generated for each index test.
RESULTS: Sensitivity and specificity of FEur were 48% and 75% in patients not administered diuretics and 79% and 33% in patients administered diuretics. Sensitivity and specificity of FENa were 78% and 75% in patients not administered diuretics and 58% and 81% in those administered diuretics. Receiver operating characteristic curves did not identify a better diagnostic cutoff value for FEur or FENa.
LIMITATIONS: Small sample size, variable exposure to diuretics, and a high proportion of preexisting chronic kidney disease.
CONCLUSIONS: In patients without diuretic use, FENa is better able to distinguish transient from persistent AKI. In patients administered diuretics, this distinction cannot be made accurately by means of FENa. FEur cannot be used as an alternative tool because it lacks specificity.
Abstract/Text
The fractional excretion of urea (FEU) is a useful index for differentiating the main categories of causes of acute kidney injury, ie, prerenal causes and intrinsic causes. It may be used in preference to the more widely used fractional excretion of sodium (FENa) in situations in which the validity of the latter is limited, such as in patients taking a diuretic.
Abstract/Text
STUDY OBJECTIVE: Among adult emergency department (ED) patients undergoing central venous catheterization, we determine whether a greater than or equal to 50% decrease in inferior vena cava diameter is associated with a central venous pressure of less than 8 mm Hg.
METHODS: Adult patients undergoing central venous catheterization were enrolled in a prospective, observational study. Inferior vena cava inspiratory and expiratory diameters were measured by 2-dimensional bedside ultrasonography. The caval index was calculated as the relative decrease in inferior vena cava diameter during 1 respiratory cycle. The correlation of central venous pressure and caval index was calculated. The sensitivity, specificity, and positive and negative predictive values of a caval index greater than or equal to 50% that was associated with a central venous pressure less than 8 mm Hg were estimated.
RESULTS: Of 73 patients, the median age was 63 years and 60% were women. Mean time and fluid administered from ultrasonographic measurement to central venous pressure determination were 6.5 minutes and 45 mL, respectively. Of the 73 participants, 32% had a central venous pressure less than 8 mm Hg. The correlation between caval index and central venous pressure was -0.74 (95% confidence interval [CI] -0.82 to -0.63). The sensitivity of caval index greater than or equal to 50% to predict a central venous pressure less than 8 mm Hg was 91% (95% CI 71% to 99%), the specificity was 94% (95% CI 84% to 99%), the positive predictive value was 87% (95% CI 66% to 97%), and the negative predictive value was 96% (95% CI 86% to 99%).
CONCLUSION: Bedside ultrasonographic measurement of caval index greater than or equal to 50% is strongly associated with a low central venous pressure. Bedside measurements of caval index could be a useful noninvasive tool to determine central venous pressure during the initial evaluation of the ED patient.
Copyright (c) 2009 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.
Abstract/Text
To evaluate a simple noninvasive means of estimating right atrial (RA) pressure, the respiratory motion of the inferior vena cava (IVC) was analyzed by 2-dimensional echocardiography in 83 patients. Expiratory and inspiratory IVC diameters and percent collapse (caval index) were measured in subcostal views within 2 cm of the right atrium. Parameters were correlated with RA pressure by flotation catheter within 24 hours of the echocardiogram (38 were simultaneous). Correlations between RA pressure (range 0 to 28 mm Hg), expiratory and inspiratory diameters and caval index were 0.48, 0.71 and 0.75, respectively. Of 48 patients with caval indexes less than 50%, 41 (89%) had RA pressure greater than or equal to 10 mm Hg (mean +/- standard deviation, 15 +/- 6), while 30 of 35 patients (86%) with caval indexes greater than or equal to 50% had RA pressure less than 10 mm Hg (mean 6 +/- 5). Sensitivity and specificity for discrimination of RA pressure greater than or equal to or less than 10 mm Hg were maximized at the 50% level of collapse. Thus, IVC respiratory collapse on echocardiography is easily imaged and can be used to estimate RA pressure. A caval index greater than or equal to 50% indicates RA pressure less than 10 mm Hg, and caval indexes less than 50% indicate RA pressure greater than or equal to 10 Hg.
Abstract/Text
CONTEXT: Administration of traditional chloride-liberal intravenous fluids may precipitate acute kidney injury (AKI).
OBJECTIVE: To assess the association of a chloride-restrictive (vs chloride-liberal) intravenous fluid strategy with AKI in critically ill patients.
DESIGN, SETTING, AND PATIENTS: Prospective, open-label, sequential period pilot study of 760 patients admitted consecutively to the intensive care unit (ICU) during the control period (February 18 to August 17, 2008) compared with 773 patients admitted consecutively during the intervention period (February 18 to August 17, 2009) at a university-affiliated hospital in Melbourne, Australia.
INTERVENTIONS: During the control period, patients received standard intravenous fluids. After a 6-month phase-out period (August 18, 2008, to February 17, 2009), any use of chloride-rich intravenous fluids (0.9% saline, 4% succinylated gelatin solution, or 4% albumin solution) was restricted to attending specialist approval only during the intervention period; patients instead received a lactated solution (Hartmann solution), a balanced solution (Plasma-Lyte 148), and chloride-poor 20% albumin.
MAIN OUTCOME MEASURES: The primary outcomes included increase from baseline to peak creatinine level in the ICU and incidence of AKI according to the risk, injury, failure, loss, end-stage (RIFLE) classification. Secondary post hoc analysis outcomes included the need for renal replacement therapy (RRT), length of stay in ICU and hospital, and survival. RESULTS Chloride administration decreased by 144 504 mmol (from 694 to 496 mmol/patient) from the control period to the intervention period. Comparing the control period with the intervention period, the mean serum creatinine level increase while in the ICU was 22.6 μmol/L (95% CI, 17.5-27.7 μmol/L) vs 14.8 μmol/L (95% CI, 9.8-19.9 μmol/L) (P = .03), the incidence of injury and failure class of RIFLE-defined AKI was 14% (95% CI, 11%-16%; n = 105) vs 8.4% (95% CI, 6.4%-10%; n = 65) (P <.001), and the use of RRT was 10% (95% CI, 8.1%-12%; n = 78) vs 6.3% (95% CI, 4.6%-8.1%; n = 49) (P = .005). After adjustment for covariates, this association remained for incidence of injury and failure class of RIFLE-defined AKI (odds ratio, 0.52 [95% CI, 0.37-0.75]; P <.001) and use of RRT (odds ratio, 0.52 [95% CI, 0.33-0.81]; P = .004). There were no differences in hospital mortality, hospital or ICU length of stay, or need for RRT after hospital discharge. CONCLUSION The implementation of a chloride-restrictive strategy in a tertiary ICU was associated with a significant decrease in the incidence of AKI and use of RRT.
TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT00885404.
Abstract/Text
BACKGROUND: The objective of this systematic review and meta-analysis was to assess the relationship between the chloride content of intravenous resuscitation fluids and patient outcomes in the perioperative or intensive care setting.
METHODS: Systematic searches were performed of PubMed/MEDLINE, Embase and Cochrane Library (CENTRAL) databases in accordance with PRISMA guidelines. Randomized clinical trials, controlled clinical trials and observational studies were included if they compared outcomes in acutely ill or surgical patients receiving either high-chloride (ion concentration greater than 111 mmol/l up to and including 154 mmol/l) or lower-chloride (concentration 111 mmol/l or less) crystalloids for resuscitation. Endpoints examined were mortality, measures of kidney function, serum chloride, hyperchloraemia/metabolic acidosis, blood transfusion volume, mechanical ventilation time, and length of hospital and intensive care unit stay. Risk ratios (RRs), mean differences (MDs) or standardized mean differences (SMDs) and confidence intervals were calculated using fixed-effect modelling.
RESULTS: The search identified 21 studies involving 6253 patients. High-chloride fluids did not affect mortality but were associated with a significantly higher risk of acute kidney injury (RR 1.64, 95 per cent c.i. 1.27 to 2.13; P < 0.001) and hyperchloraemia/metabolic acidosis (RR 2.87, 1.95 to 4.21; P < 0.001). High-chloride fluids were also associated with greater serum chloride (MD 3.70 (95 per cent c.i. 3.36 to 4.04) mmol/l; P < 0.001), blood transfusion volume (SMD 0.35, 0.07 to 0.63; P = 0.014) and mechanical ventilation time (SMD 0.15, 0.08 to 0.23; P < 0.001). Sensitivity analyses excluding heavily weighted studies resulted in non-statistically significant effects for acute kidney injury and mechanical ventilation time.
CONCLUSION: A weak but significant association between higher chloride content fluids and unfavourable outcomes was found, but mortality was unaffected by chloride content.
© 2014 The Authors. BJS published by John Wiley & Sons Ltd on behalf of BJS Society Ltd.
Abstract/Text
OBJECTIVES: To assess the impact of the percentage of fluid infused as Lactated Ringer (%LR) during the first 2 days of ICU admission in hospital mortality and occurrence of acute kidney injury.
DESIGN: Retrospective cohort.
SETTING: Analysis of a large public database (Multiparameter Intelligent Monitoring in Intensive Care-II).
PATIENTS: Adult patients with at least 2 days of ICU stay, admission creatinine lower than 5 mg/dL, and that received at least 500 mL of fluid in the first 48 hours.
INTERVENTIONS: None.
MEASUREMENT AND MAIN RESULTS: 10,249 patients were included in mortality analysis and 8,085 were included in the acute kidney injury analysis. For acute kidney injury analysis, we excluded patients achieving acute kidney injury criteria in the first 2 days of ICU stay. Acute kidney injury was defined as stage 2/3 Kidney Disease: Improving Global Outcomes creatinine criteria and was assessed from days 3-7. The effects of %LR in both outcomes were assessed through logistic regression controlling for confounders. Principal component analysis was applied to assess the effect of volume of each fluid type on mortality. Higher %LR was associated with lower mortality and less acute kidney injury. %LR effect increased with total volume of fluid infused. For patients in the fourth quartile of fluid volume (> 7 L), the odds ratio for mortality for %LR equal to 75% versus %LR equal to 25% was 0.50 (95% CI, 0.32-0.79; p < 0.001). Principal component analysis suggested that volume of Lactated Ringer and 0.9% saline infused had opposite effects in outcome, favoring Lactated Ringer.
CONCLUSIONS: Higher %LR was associated with reduced hospital mortality and with less acute kidney injury from days 3-7 after ICU admission. The association between %LR and mortality was influenced by the total volume of fluids infused.
Matthew W Semler, Wesley H Self, Jonathan P Wanderer, Jesse M Ehrenfeld, Li Wang, Daniel W Byrne, Joanna L Stollings, Avinash B Kumar, Christopher G Hughes, Antonio Hernandez, Oscar D Guillamondegui, Addison K May, Liza Weavind, Jonathan D Casey, Edward D Siew, Andrew D Shaw, Gordon R Bernard, Todd W Rice, SMART Investigators and the Pragmatic Critical Care Research Group
Balanced Crystalloids versus Saline in Critically Ill Adults.
N Engl J Med. 2018 Mar 1;378(9):829-839. doi: 10.1056/NEJMoa1711584. Epub 2018 Feb 27.
Abstract/Text
BACKGROUND: Both balanced crystalloids and saline are used for intravenous fluid administration in critically ill adults, but it is not known which results in better clinical outcomes.
METHODS: In a pragmatic, cluster-randomized, multiple-crossover trial conducted in five intensive care units at an academic center, we assigned 15,802 adults to receive saline (0.9% sodium chloride) or balanced crystalloids (lactated Ringer's solution or Plasma-Lyte A) according to the randomization of the unit to which they were admitted. The primary outcome was a major adverse kidney event within 30 days - a composite of death from any cause, new renal-replacement therapy, or persistent renal dysfunction (defined as an elevation of the creatinine level to ≥200% of baseline) - all censored at hospital discharge or 30 days, whichever occurred first.
RESULTS: Among the 7942 patients in the balanced-crystalloids group, 1139 (14.3%) had a major adverse kidney event, as compared with 1211 of 7860 patients (15.4%) in the saline group (marginal odds ratio, 0.91; 95% confidence interval [CI], 0.84 to 0.99; conditional odds ratio, 0.90; 95% CI, 0.82 to 0.99; P=0.04). In-hospital mortality at 30 days was 10.3% in the balanced-crystalloids group and 11.1% in the saline group (P=0.06). The incidence of new renal-replacement therapy was 2.5% and 2.9%, respectively (P=0.08), and the incidence of persistent renal dysfunction was 6.4% and 6.6%, respectively (P=0.60).
CONCLUSIONS: Among critically ill adults, the use of balanced crystalloids for intravenous fluid administration resulted in a lower rate of the composite outcome of death from any cause, new renal-replacement therapy, or persistent renal dysfunction than the use of saline. (Funded by the Vanderbilt Institute for Clinical and Translational Research and others; SMART-MED and SMART-SURG ClinicalTrials.gov numbers, NCT02444988 and NCT02547779 .).
Wesley H Self, Matthew W Semler, Jonathan P Wanderer, Li Wang, Daniel W Byrne, Sean P Collins, Corey M Slovis, Christopher J Lindsell, Jesse M Ehrenfeld, Edward D Siew, Andrew D Shaw, Gordon R Bernard, Todd W Rice, SALT-ED Investigators
Balanced Crystalloids versus Saline in Noncritically Ill Adults.
N Engl J Med. 2018 Mar 1;378(9):819-828. doi: 10.1056/NEJMoa1711586. Epub 2018 Feb 27.
Abstract/Text
BACKGROUND: Comparative clinical effects of balanced crystalloids and saline are uncertain, particularly in noncritically ill patients cared for outside an intensive care unit (ICU).
METHODS: We conducted a single-center, pragmatic, multiple-crossover trial comparing balanced crystalloids (lactated Ringer's solution or Plasma-Lyte A) with saline among adults who were treated with intravenous crystalloids in the emergency department and were subsequently hospitalized outside an ICU. The type of crystalloid that was administered in the emergency department was assigned to each patient on the basis of calendar month, with the entire emergency department crossing over between balanced crystalloids and saline monthly during the 16-month trial. The primary outcome was hospital-free days (days alive after discharge before day 28). Secondary outcomes included major adverse kidney events within 30 days - a composite of death from any cause, new renal-replacement therapy, or persistent renal dysfunction (defined as an elevation of the creatinine level to ≥200% of baseline) - all censored at hospital discharge or 30 days, whichever occurred first.
RESULTS: A total of 13,347 patients were enrolled, with a median crystalloid volume administered in the emergency department of 1079 ml and 88.3% of the patients exclusively receiving the assigned crystalloid. The number of hospital-free days did not differ between the balanced-crystalloids and saline groups (median, 25 days in each group; adjusted odds ratio with balanced crystalloids, 0.98; 95% confidence interval [CI], 0.92 to 1.04; P=0.41). Balanced crystalloids resulted in a lower incidence of major adverse kidney events within 30 days than saline (4.7% vs. 5.6%; adjusted odds ratio, 0.82; 95% CI, 0.70 to 0.95; P=0.01).
CONCLUSIONS: Among noncritically ill adults treated with intravenous fluids in the emergency department, there was no difference in hospital-free days between treatment with balanced crystalloids and treatment with saline. (Funded by the Vanderbilt Institute for Clinical and Translational Research and others; SALT-ED ClinicalTrials.gov number, NCT02614040 .).
Abstract/Text
OBJECTIVE: To compare the effectiveness and side effects of lactated Ringer's solution (LR) and 0.9% saline (NS) in the treatment of rhabdomyolysis induced by doxylamine intoxication.
METHODS: In this 15-month-long prospective randomised single-blind study, after excluding 8 patients among 97 doxylamine-intoxicated patients, 28 (31%) patients were found to have developed rhabdomyolysis and were randomly allocated to NS group (n = 15) or LR group (n = 13).
RESULTS: After 12 h of aggressive hydration (400 ml/h), urine/serum pH was found to be significantly higher in the LR group, and serum Na+/Cl- levels to be significantly higher in the NS group. There were no significant differences in serum K+ level and in the time taken for creatine kinase normalisation. The amount of sodium bicarbonate administered and the frequency administration of diuretics was significantly higher in the NS group. Unlike the NS group, the LR group needed little supplemental sodium bicarbonate and did not develop metabolic acidosis.
CONCLUSION: LR is more useful than NS in the treatment of rhabdomyolysis induced by doxylamine intoxication.
Abstract/Text
OBJECTIVE: To determine if Ringer's lactate is superior to 0.9% sodium chloride solution for resolution of acidosis in the management of diabetic ketoacidosis (DKA).
DESIGN: Parallel double blind randomized controlled trial.
METHODS: Patients presenting with DKA at Kalafong and Steve Biko Academic hospitals were recruited for inclusion in this study if they were >18 years of age, had a venous pH >6.9 and ≤7.2, a blood glucose of >13 mmol/l and had urine ketones of ≥2+. All patients had to be alert enough to give informed consent and should have received <1 l of resuscitation fluid prior to enrolment.
RESULTS: Fifty-seven patients were randomly allocated, 29 were allocated to receive 0.9% sodium chloride solution and 28 to receive Ringer's lactate (of which 27 were included in the analysis in each group). An adjusted Cox proportional hazards analysis was done to compare the time to normalization of pH between the 0.9% sodium chloride solution and Ringer's lactate groups. The hazard ratio (Ringer's compared with 0.9% sodium chloride solution) for time to venous pH normalization (pH = 7.32) was 1.863 (95% CI 0.937-3.705, P = 0.076). The median time to reach a pH of 7.32 for the 0.9% sodium chloride solution group was 683 min (95% CI 378-988) (IQR: 435-1095 min) and for Ringer's lactate solution 540 min (95% CI 184-896, P = 0.251). The unadjusted time to lower blood glucose to 14 mmol/l was significantly longer in the Ringer's lactate solution group (410 min, IQR: 240-540) than the 0.9% sodium chloride solution group (300 min, IQR: 235-420, P = 0.044). No difference could be demonstrated between the Ringer's lactate and 0.9% sodium chloride solution groups in the time to resolution of DKA (based on the ADA criteria) (unadjusted: P = 0.934, adjusted: P = 0.758)
CONCLUSION: This study failed to indicate benefit from using Ringer's lactate solution compared to 0.9% sodium chloride solution regarding time to normalization of pH in patients with DKA. The time to reach a blood glucose level of 14 mmol/l took significantly longer with the Ringer's lactate solution.
Abstract/Text
STUDY OBJECTIVE: To compare the effect of normal saline (NS), lactated Ringer's, and Plasmalyte on the acid-base status of dehydrated patients in the emergency department (ED).
METHOD: We conducted a prospective, double-blind, randomized trial of consecutive adult patients who presented to the emergency department with moderate-severe dehydration. Patients were randomly allocated to blindly receive normal saline (NS), lactated Ringer's or Plasmalyte at 20 ml/kg/h for 2 hours. Outcome measures of the study were pH and changes in electrolytes, including serum potassium, sodium, chloride and bicarbonate levels at 0, 60, and 120 minutes in venous blood gas samples.
RESULTS: Ninety patients participated in the study and were randomized to NS (30 patients), lactated Ringer's (30 patients) and Plasmalyte (30 patients) groups. Mean age was 48±20 years and 50% (n=45) of the patients were female. All pH values were in the physiological range (7.35-7.45) throughout the study period. In the NS group there was a significant tendency to lower pH values, with pH values of 7.40, 7.37, and 7.36 at 0, 1, and 2 hours respectively. Average bicarbonate levels fell in the NS group (23.1, 22.2, and 21.5 mM/L) and increased in the Plasmalyte group (23.4, 23.9, and 24.4 mM/L) at 0, 1, and 2 hours, respectively. There were no significant changes in potassium, sodium, or chloride levels.
CONCLUSIONS: NS, lactated Ringer's, and Plasmalyte have no significant effect on acid-base status and all can be used safely to treat dehydrated patients in the emergency department. However, NS can effect acidosis which might be significant in patients who have underlying metabolic disturbances; thus, its use should be weighed before fluid administration in the ED.
Abstract/Text
AIM: We hypothesized that normal saline (NS) may have more deleterious effects compared with lactated ringer (LR) in kidney transplant recipients because of the higher risk of acidosis and higher levels of serum potassium. Thus, the aim of this study was to determine the safety of LR if used during a renal transplant.
METHODS: Adults undergoing kidney transplantations were enrolled in a double-blinded randomized prospective clinical trial. They were divided into two groups in order to receive NS and LR infusion as intraoperative IV fluid replacement therapy.
RESULTS: There was a significant difference in the serum potassium level (p = .000) and the PH (p = .007) between the two groups at the end of transplantations. Two patients in the LR group lost their kidneys due to vascular graft thrombosis. In other words, hyperkalemia and acidosis occurred more frequently in the NS group while thrombotic events may be of concern in the LR group.
CONCLUSION: Compared with NS, LR infusion may lead to a lower serum potassium level and a lower risk of acidosis, while there is major concern of the hypercoagulable state in these patients.
Abstract/Text
Background: Administration of saline in renal transplantation is associated with hyperchloraemic metabolic acidosis, but the effect of normal saline (NS) on the risk of hyperkalaemia or postoperative graft function is uncertain.
Methods: We compared NS with Plasma-Lyte 148® (PL) given during surgery and for 48 h after surgery in patients undergoing deceased donor renal transplantation. The primary outcome was hyperkalaemia within 48 h after surgery. Secondary outcomes were need for hyperkalaemia treatment, change in acid-base status, and graft function.
Results: Twenty-five subjects were randomized to NS and 24 to PL. The incidence of hyperkalaemia in the first 48 h after surgery was higher in the NS group; 20 patients (80%) vs 12 patients (50%) in the PL group (risk difference: 0.3; 95% confidence interval: 0.05, 0.55; P=0.037). The mean (sd) peak serum potassium was NS 6.1 (0.8) compared with PL 5.4 (0.9) mmol litre-1 (P=0.009). Sixteen participants (64%) in the NS group required treatment for hyperkalaemia compared with five (21%) in the PL group (P=0.004). Participants receiving NS were more acidaemic [pH 7.32 (0.06) vs 7.39 (0.05), P=0.001] and had higher serum chloride concentrations (107 vs 101 mmol litre-1, P<0.001) at the end of surgery. No differences in the rate of delayed graft function were observed. Subjects receiving PL who did not require dialysis had a greater reduction in creatinine on day 2 (P=0.04).
Conclusions: Compared with PL, participants receiving NS had a greater incidence of hyperkalaemia and hyperchloraemia and were more acidaemic. These biochemical differences were not associated with adverse clinical outcomes.
Clinical trial registration: Australian New Zealand Clinical Trials Registry: ACTRN12612000023853.
© The Author 2017. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved. For Permissions, please email: journals.permissions@oup.com
Abstract/Text
OBJECTIVE: Intravenous fluids are broadly categorized into colloids and crystalloids. The aim of this review is to present under a clinical point of view the characteristics of intravenous fluids that make them more or less appropriate either for maintaining hydration when enteral intake is contraindicated or for treating hypovolemia.
METHODS: We considered randomized trials and meta-analyses as well as narrative reviews evaluating the effects of colloids or crystalloids in patients with hypovolemia or as maintenance fluids published in the PubMed and Cochrane databases.
RESULTS: Clinical studies have not shown a greater clinical benefit of albumin solutions compared with crystalloid solutions. Furthermore, albumin and colloid solutions may impair renal function, while there is no evidence that the administration of colloids reduces the risk of death compared with resuscitation with crystalloids in patients with trauma, burns or following surgery. Among crystalloids, normal saline is associated with the development of hyperchloremia-induced impairment of kidney function and metabolic acidosis. On the other hand, the other commonly used crystalloid solution, the Ringer's Lactate, has certain indications and contraindications. These matters, along with the basic principles of the administration of potassium chloride and bicarbonate, are meticulously discussed in the review.
CONCLUSIONS: Intravenous fluids should be dealt with as drugs, as they have specific clinical indications, contraindications and adverse effects.
Abstract/Text
Many situations in clinical practice involving patients with hypovolemia or acutely ill patients usually require the administration of intravenous fluids. Current evidence shows that the use of crystalloids should be considered, since most colloids and human albumin are usually associated with increased adverse effects and high cost, respectively. Among crystalloids, the use of normal saline is implicated with the development of hyperchloremic metabolic acidosis and renal vasoconstriction. These observations have led many authors to propose balanced solutions, mainly Lactated Ringer's, as the infusate of choice. However, although the restoration of volume status is the primary target in hypovolemic state, the correction of any associated acid-base or electrolyte disorders that frequently coexist is also of vital importance. This review presents specific situations that are common in daily clinical practice and require targeted infusate therapy in patients with reduced volume status. Furthermore, the review presents an algorithm aiming to help clinicians to make the best choice between normal or hypotonic saline and lactated Ringer's infusates. Lactated Ringer's infusate should not be given in patients with severe metabolic alkalosis, lactic acidosis with decreased lactate clearance, or severe hyperkalemia, and in patients with traumatic brain injury or at risk of increased intracranial pressure. The optimal choice of infusate should be guided by the cause of hypovolemia, the cardiovascular state of the patient, the renal function, as well as the serum osmolality and the coexisting acid-base and electrolyte disorders. Clinicians should be aware of any coexisting disorders in patients with hypovolemia and guide their choice of infusate treatment based on the overall picture of their patients.
Andrew Rhodes, Laura E Evans, Waleed Alhazzani, Mitchell M Levy, Massimo Antonelli, Ricard Ferrer, Anand Kumar, Jonathan E Sevransky, Charles L Sprung, Mark E Nunnally, Bram Rochwerg, Gordon D Rubenfeld, Derek C Angus, Djillali Annane, Richard J Beale, Geoffrey J Bellinghan, Gordon R Bernard, Jean-Daniel Chiche, Craig Coopersmith, Daniel P De Backer, Craig J French, Seitaro Fujishima, Herwig Gerlach, Jorge Luis Hidalgo, Steven M Hollenberg, Alan E Jones, Dilip R Karnad, Ruth M Kleinpell, Younsuck Koh, Thiago Costa Lisboa, Flavia R Machado, John J Marini, John C Marshall, John E Mazuski, Lauralyn A McIntyre, Anthony S McLean, Sangeeta Mehta, Rui P Moreno, John Myburgh, Paolo Navalesi, Osamu Nishida, Tiffany M Osborn, Anders Perner, Colleen M Plunkett, Marco Ranieri, Christa A Schorr, Maureen A Seckel, Christopher W Seymour, Lisa Shieh, Khalid A Shukri, Steven Q Simpson, Mervyn Singer, B Taylor Thompson, Sean R Townsend, Thomas Van der Poll, Jean-Louis Vincent, W Joost Wiersinga, Janice L Zimmerman, R Phillip Dellinger
Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016.
Crit Care Med. 2017 Mar;45(3):486-552. doi: 10.1097/CCM.0000000000002255.
Abstract/Text
OBJECTIVE: To provide an update to "Surviving Sepsis Campaign Guidelines for Management of Sepsis and Septic Shock: 2012."
DESIGN: A consensus committee of 55 international experts representing 25 international organizations was convened. Nominal groups were assembled at key international meetings (for those committee members attending the conference). A formal conflict-of-interest (COI) policy was developed at the onset of the process and enforced throughout. A stand-alone meeting was held for all panel members in December 2015. Teleconferences and electronic-based discussion among subgroups and among the entire committee served as an integral part of the development.
METHODS: The panel consisted of five sections: hemodynamics, infection, adjunctive therapies, metabolic, and ventilation. Population, intervention, comparison, and outcomes (PICO) questions were reviewed and updated as needed, and evidence profiles were generated. Each subgroup generated a list of questions, searched for best available evidence, and then followed the principles of the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system to assess the quality of evidence from high to very low, and to formulate recommendations as strong or weak, or best practice statement when applicable.
RESULTS: The Surviving Sepsis Guideline panel provided 93 statements on early management and resuscitation of patients with sepsis or septic shock. Overall, 32 were strong recommendations, 39 were weak recommendations, and 18 were best-practice statements. No recommendation was provided for four questions.
CONCLUSIONS: Substantial agreement exists among a large cohort of international experts regarding many strong recommendations for the best care of patients with sepsis. Although a significant number of aspects of care have relatively weak support, evidence-based recommendations regarding the acute management of sepsis and septic shock are the foundation of improved outcomes for these critically ill patients with high mortality.
Abstract/Text
OBJECTIVES: This study was designed to determine the relevance of a proposed classification for advanced heart failure (HF). Profiles based on clinical assessment of congestion and perfusion at the time of hospitalization were compared with subsequent outcomes.
BACKGROUND: Optimal design of therapy and trials for advanced HF remains limited by the lack of simple clinical profiles to characterize patients.
METHODS: Prospective analysis was performed for 452 patients admitted to the cardiomyopathy service at the Brigham and Women's Hospital with a diagnosis of HF. Patients were classified by clinical assessment into four profiles: profile A, patients with no evidence of congestion or hypoperfusion (dry-warm, n = 123); profile B, congestion with adequate perfusion (wet-warm, n = 222); profile C, congestion and hypoperfusion (wet-cold, n = 91); and profile L, hypoperfusion without congestion (dry-cold, n = 16). Other standard predictors of outcome were included and patients were followed for the end points of death (n = 117) and death or urgent transplantation (n = 137) at one year.
RESULTS: Survival analysis showed that clinical profiles predict outcomes in HF. Profiles B and C increase the risk of death plus urgent transplantation by univariate (hazard ratio [HR] 1.83, p = 0.02) and multivariate analyses (HR 2.48, p = 0.003). Moreover, clinical profiles add prognostic information even when limited to patients with New York Heart Association (NYHA) class III/IV symptoms (profile B: HR 2.23, p = 0.026; profile C: HR 2.73, p = 0.009).
CONCLUSIONS: Simple clinical assessment can be used to define profiles in patients admitted with HF. These profiles predict outcomes and may be used to guide therapy and identify populations for future investigation.
Abstract/Text
Hyponatraemia is the commonest electrolyte abnormality in hospitalized patients. If the plasma sodium concentration (P(Na)) declines to approximately 120 mM in <48 h, brain cell swelling might result in herniation, with devastating consequences. The volume and/or the composition of fluids used for intravenous therapy often contribute to the development of acute hyponatraemia. Our hypothesis is that the traditional calculation of the daily loss of insensible water overestimates this parameter, leading to an excessive daily recommended requirement for water. We offer suggestions to minimize the risk of iatrogenic hyponatraemia.
Abstract/Text
Hyponatremia is a common clinical problem in hospitalized patients and nursing home residents. It also may occur in healthy athletes after endurance exercise. The majority of patients with hyponatremia are asymptomatic and do not require immediate correction of hyponatremia. Symptomatic hyponatremia is a medical emergency requiring rapid correction to prevent the worsening of brain edema. How fast we should increase the serum sodium levels depends on the onset of hyponatremia and still remains controversial. If the serum sodium levels are corrected too rapidly, patients may develop central pontine myelinolysis, but if they are corrected too slowly, patients may die of brain herniation. We review the epidemiology and mechanisms of hyponatremia, the sensitivity of women to hyponatremic injury, the adaptation and maladaptation of brain cells to hyponatremia and its correction, and the practical ways of managing hyponatremia. Because the majority of hyponatremia is caused by the non-osmotic release of vasopressin, the recent approval of the vasopressin receptor antagonist conivaptan for euvolemic hyponatremia may simplify hyponatremia management. However, physicians should be aware of the risk of rapid correction of hyponatremia, hypotension, and excessive fluid intake.
Abstract/Text
Edematous patients with renal sodium and water retention, particularly cardiac failure and cirrhosis, have been suggested to have a decreased "effective blood volume." This enigmatic and undefined term was coined because edematous patients were found to have increased, rather than the earlier proposed decreased, blood volumes. This article discusses the advances that have occurred in understanding the pathophysiology of edema as occurs in conditions such as cardiac failure, cirrhosis, and pregnancy. The regulatory mechanisms that lead to increased sodium and water retention by the normal kidney are related to arterial underfilling, as a result of a decrease in cardiac output, arterial vasodilation, or both.
