Choice of Intravenous Crystalloid Fluid and Mortality in Critically Ill Adult Patients.

OBJECTIVES: Intravenous balanced crystalloid fluid therapy may improve mortality and other outcomes in critically ill adult patients, but data are conflicting. We conducted a meta-analysis and literature review to evaluate the impact of intravenous balanced crystalloid, as compared with normal saline, fluid therapy on outcomes in critically ill adult patients. METHODS: We searched PubMed, Scopus, MEDLINE, and the Cochrane Register of Clinical Trials for relevant studies. Randomized controlled trials comparing the effects of balanced intravenous crystalloids with normal saline on intensive care unit (ICU) or hospital mortality were included. Pooled risk ratios (RRs) were calculated using a fixed effects model. Heterogeneity was calculated using the I2 statistic. The risk of bias was assessed using the Cochrane tool. RESULTS: Seven randomized controlled trials with 20,171 patients (10,179 participants received balanced crystalloids and 9992 participants received normal saline) were included. For hospital mortality, the pooled RR (95% confidence interval [CI]) was 0.92 (0.85-1.00). For ICU mortality, the pooled RR (95% CI) was 0.91 (0.82-1.00). For major adverse kidney events at 30 days, pooled RR (95% CI) was 0.95 (0.88-1.01). For stage ≥2 acute kidney injury, the pooled RR (95% CI) was 0.94 (0.86-1.02). For receipt of new renal replacement therapy, the pooled RR (95% CI) was 0.91 (0.77-1.07). None of these findings reached statistical significance. CONCLUSIONS: Intravenous balanced crystalloid use, compared with normal saline, does not result in a statistically significant reduction in hospital or ICU mortality, major adverse kidney events at 30 days, stage ≥2 acute kidney injury, or receipt of new renal replacement therapy in critically ill adult patients.

A remarkable case of rhabdomyolysis associated with ingestion of energy drink 'neon volt'.

Rhabdomyolysis is defined as a syndrome characterized by muscle necrosis and the release of intracellular muscle constituents into the circulation. We present a case of a 35-year-old male who exercised for 2 h after ingesting energy drink and subsequently presented with rhabdomyolysis. After excluding common and uncommon causes of rhabdomyolysis, we reached the conclusion that the likely cause was the ingestion of energy drink 'NEON VOLT' in a setting of mild dehydration. Increasing physical activity and intense exercise is becoming a trend in many countries, due to its many health-related benefits such as prevention of obesity. This renewed focus toward optimal fitness has spawned many supplements that aid in improvement of the performance, muscle growth, and recovery. Energy drinks predominantly contain caffeine that is often combined with other supplements to form what manufacturers have termed an 'energy blend'. Studies have shown that excessive caffeine intake from energy drinks can cause arrhythmias, hypertension, dehydration, sleeplessness, nervousness, and in rare instances, rhabdomyolysis. As per Drug Abuse Warning Network report, there is a sharp increase in the number of emergency department visits involving energy drinks from 1,128 visits in 2005 to 16,053 and 13,114 visits in 2008 and 2009, respectively. Due to emergence of energy drink abuse as a national health problem, Food and Drug Administration has launched a dietary supplement adverse event reporting system for surveillance of any adverse events linked to these agents.

Left Atrial to Esophageal Fistula: A Case Report and Literature Review.

BACKGROUND Left atrial to esophageal fistula (LAEF) is a rare fatal complication of radiofrequency ablation (RFA) for atrial fibrillation and is associated with high mortality. Clinical features can be nonspecific and include fever, dysphagia, upper gastrointestinal (GI) bleeding, sepsis, and embolic stroke a after recent history of RFA for atrial fibrillation. CASE REPORT  A 57-year-old Caucasian male was brought to the emergency department (ED) by his family because of an altered mental status. He had undergone a radiofrequency ablation for paroxysmal atrial fibrillation three weeks earlier. Several hours after admission to the ED, the patient transiently became unresponsive and had a right sided hemiplegia. A brain MRI revealed multiple cerebral infarcts. On the following day, the patient had an episode of melena, and an esophagogastroduodenoscopy (EGD) was performed which did not reveal any source of bleeding. While the patient was being monitored in the intensive care unit (ICU), he had an episode of hematemesis and went into cardiac arrest from which he was successfully resuscitated and transferred to another facility. He had another EGD, which uncovered a flap of mucosa covering the lower third of his esophagus and a 1 cm fistulous opening was seen with fresh blood oozing out of it. The patient had another cardiac arrest during the endoscopy and died despite all measures. CONCLUSIONS We present this case to stress the importance of early diagnosis of LAEF. LAEF can be fatal if diagnosis is delayed or missed. Early surgical intervention can reduce LAEF morbidity and mortality. Newer diagnostic modalities such as endoscopic ultrasound (EUS) can be helpful in cases where conventional imaging is unclear.