Epidemiology of intravenous fluid use for headache treatment: Findings from the National Hospital Ambulatory Medical Care Survey.

BACKGROUND: Headache is one of the most common reasons for patients to seek care in emergency departments. While the administration of intravenous fluids is frequently recommended for emergency department patients with migraine, the epidemiology of the use of this intervention is unknown. OBJECTIVES: To describe the epidemiology of intravenous fluid use in emergency department patients with headache. METHODS: This retrospective study utilized the 2011 US National Hospital Ambulatory Medical Survey, a multi-stage weighted survey providing nationally representative estimates of ED visits. Patients with chief complaints of non-traumatic headache or migraine headache were included. We determined the frequency of intravenous fluid administration among patients presenting with headache, and among specific subgroups including those with migraine headache. RESULTS: There were 1251 sample cases representing 5,981,000 visits for a chief complaint of headache. Intravenous fluids were administered at 40% (95% CI 35-44%) of these visits. Among the 222 migraine cases, 47% (95% CI 39-56%) received fluids. Fluids were commonly administered regardless of pain severity, and fluid administration was not significantly associated with pain severity among patients diagnosed with migraine (p=0.39). After adjusting for patient characteristics, ED visit duration remained greater for patients receiving fluids than for those who did not among both patients with a headache complaint and among those with a diagnosis of migraine headache. CONCLUSIONS: Despite a lack of efficacy data, patients treated in United States EDs for headache frequently receive IV fluids. Studies are needed to determine the efficacy of this basic treatment intervention.

Randomized Prospective Clinical Trial Comparing Room Temperature and Warmed Intravenous Fluid Boluses on Pediatric Patients' Comfort.

A common complaint among pediatric patients receiving an intravenous (IV) fluid bolus is that their arm feels cold and uncomfortable. The purpose of this study is to test if administering warmed IV fluids, as compared to room temperature IV fluids, results in increased comfort among pediatric patients seeking care in an emergency department. A blinded randomized controlled trial was conducted and 126 pediatric patients were enrolled. Each patient's overall comfort, arm comfort, and arm temperature were measured prior to IV fluid administration, 15 minutes after the beginning of the infusion, and at the end of the 60-minute infusion. After the first 15 minutes of IV fluid administration, the patients who received warmed IV fluids reported higher comfort than the patients who received room temperature IV fluids, t(118)=2.04, p=0.04. Additionally, patients who received the room temperature IV fluids reported that their arms felt cooler than patients who received the warmed fluids, t(118)=3.25, p=0.0015. Warming IV fluids has the potential to improve the experience of IV bolus administration for pediatric patients.

Fluid administration during routine colonoscopy is not clinically significant: a randomized controlled trial.

BACKGROUND: Retrospective studies have questioned the benefits of intravenous (IV) fluids during routine colonoscopies given they are performed on well patients who experience limited fluid loss, consume clear fluids up until 2 h prior and low IV volumes typically infused. This trial aims to assess the impact of IV fluid on hypotension and electrolyte changes amongst patients undergoing colonoscopy. METHODS: Participants undergoing colonoscopies were randomized (single blinded) to IV fluid or no IV fluid. Primary outcomes were equivalence of intraoperative hypotensive episodes (>20% drop in systolic blood pressure (SBP)) and changes in serum electrolytes post procedure. Secondary outcomes included patient reported outcome measures (PROMs). RESULTS: Of the 470 participants enrolled, 84/235 (35.7%) from the IV fluids group and 88/230 (38.3%) from the no IV fluids group experienced a hypotensive event (difference in prevalence -2.5, 95% CI -11.3, 6.3). Fourteen participants in each group required clinical intervention to provide haemodynamic support (difference in prevalence -0.1, 95% CI -4.4, 4.2). Postoperative electrolytes changes and PROMs were similar for both groups. CONCLUSION: Whilst definitive recommendations for IV fluid use during routine colonoscopy are not possible as this trial was underpowered to show equivalence between the groups for hypotensive events, there was no clinically meaningful difference between the groups. These findings provide important data for meta-synthesis and for planning future work.

Sepsis, the Administration of IV Fluids, and Respiratory Failure: A Retrospective Analysis-SAIFR Study.

BACKGROUND: Although resuscitation with IV fluids is the cornerstone of sepsis management, consensus regarding their association with improvement in clinical outcomes is lacking. RESEARCH QUESTION: Is there a difference in the incidence of respiratory failure in patients with sepsis who received guideline-recommended initial IV fluid bolus of 30 mL/kg or more conservative resuscitation of less than 30 mL/kg? STUDY DESIGN AND METHODS: This was a retrospective analysis of prospectively collected clinical data conducted at an academic medical center in Omaha, Nebraska. We abstracted data from 214 patients with sepsis admitted to a single academic medical center between June 2017 and June 2018. Patients were stratified by receipt of guideline-recommended fluid bolus. The primary outcome was respiratory failure defined as an increase in oxygen flow rate or more intense oxygenation and ventilation support; oxygen requirement and volume were measured at admission, 6 h, 12 h, 24 h, and at discharge. Subgroup analyses were conducted in high-risk patients with congestive heart failure (CHF) as well as those with chronic kidney disease (CKD). RESULTS: A total of 62 patients (29.0%) received appropriate bolus treatment. The overall rate of respiratory failure was not statistically different between patients who received appropriate bolus or did not (40.3% vs 36.8%; P = .634). Likewise, no differences were observed in time to respiratory failure (P = .645) or risk of respiratory failure (adjusted hazard ratio, 1.1 [95% CI, 0.7-1.7]; P = .774). Results were similar within the high-risk CHF and CKD subgroups. INTERPRETATION: In this single-center retrospective study, we found that by broadly defining respiratory failure as an increase in oxygen requirements, a conservative initial IV fluid resuscitation strategy did not correlate with decreased rates of hypoxemic respiratory failure.

How Salty Are Your Fluids? Pediatric Maintenance IV Fluid Prescribing Practices Among Hospitalists.

Objective: The primary goal of this study was to assess current maintenance intravenous fluid (mIVF) prescribing practices of pediatric hospitalists after the release of the American Academy of Pediatrics Clinical Practice Guideline (AAP CPG), specifically assessing the rates of various isotonic vs. hypotonic solutions used in discrete age groups and in common clinical scenarios associated with anti-diuretic hormone (ADH) excess and hyponatremia. We hypothesized that isotonic fluids would be selected in most cases outside of the neonatal period. Methods: A voluntary and anonymous survey was distributed to the LISTSERV® for the AAP Section on Hospital Medicine. Results: There were 402 total responses (10.1% response rate) with the majority of respondents being pediatric hospitalists. Isotonic solutions were preferred by respondents in older children compared to younger age groups, at 87.8% for the 1-18 years age group compared to 66.3% for the 28 days to 1 year age group and 10.6% for the younger than 28 days age group (all p values <0.0001). When presented with disease states associated with ADH excess, isotonic fluids were preferred in higher percentages in all age groups except in children younger than 28 days when 0.45% sodium chloride was preferred; 0.2% sodium chloride was rarely chosen. Conclusions: Overall, based on survey responses, pediatric hospitalists are following the 2018 AAP CPG on mIVF and are more likely to choose isotonic fluids as their primary mIVF in pediatric patients outside of the neonatal period, including in scenarios of excess ADH. Isotonic fluids use seems to be higher with increasing age and hypotonic fluids are more commonly chosen in the neonatal period.

PERioperative Fluid Management in Elective ColecTomy (PERFECT)-a national prospective cohort study.

BACKGROUND: There is contradictory evidence regarding the merits of restricted versus liberal perioperative intravenous (IV) fluid administration in bowel surgery. This study sought to audit perioperative fluid management in elective colectomy in Ireland and to analyse the impact of such on operative outcomes. METHODS: A national surgical trainee collaborative audit of perioperative fluid management was performed. Data from each site was collected prospectively over a selected 3-week period within a pre-defined 2-month block. Collected variables included demographics, type of operation/anaesthethic, volume/type of fluid administration pre-, intra- and post-operatively, 30-day morbidity and mortality. Primary outcome was fluid balance 24-h post-operatively with further analysis to identify the impact of this on 30-day morbidity. ROC curves were generated to identify the critical volume at which fluid balance was associated with 30-day morbidity. RESULTS: Ninety-four patients were enrolled from 17 hospitals. Mean age was 64 years. A total of 48.9% (N = 46) were managed by ERAS and 51.1% (N = 48) received bowel preparation. Almost 70% of cases (N = 63) were completed by minimally invasive techniques. Significant 30-day morbidity requiring hospital readmission was low [6.4% (n = 6)]. Median fluid balance at 24 h was + 715 ml (IQR 165-1486 ml). On multivariate analysis, high BMI (p = 0.02), indication for surgery (p = 0.02) and critical care admission (p = 0.008) were significantly predictive of 30-day morbidity. Twenty-four hour fluid balance >+ 665 ml was associated with increased risk of 30-day morbidity on univariate but not multivariate analysis, implying association but not causation. CONCLUSION: Overall, perioperative fluid management was within an acceptable range with minimal impact on 30-day morbidity following elective colorectal surgery.

Use of Cold Fluids in Postcardiac Arrest Therapeutic Hypothermia: A Safety Analysis.

Therapeutic hypothermia (TH) has been part of the standard care of postresuscitation patients for more than a decade. Multiple cooling methods are available, including the administration of cold intravenous (IV) fluids. Although this method is widely used, the safety of administration of large volumes of cold IV fluids has not been clearly demonstrated in the literature, and recent evidence points to potential deleterious effects associated with administration of large IV fluid volumes. We conducted a retrospective cohort study among patients who have been treated with TH after cardiac arrest between November 2011 and November 2013 at a tertiary care hospital in Sherbrooke, Quebec, Canada. The primary outcome was the effect of IV fluid quantity on the 28-day survival rate. We reviewed 29 cases, with a total 28-day surviving rate of 51.7%. After adjusting for confounding variables, 28-day surviving rate was not significantly associated with the amount of fluids administrated (odds ratio = 1.034; confidence interval 95% [0.741-1.464]; p = 0.85). The amount of fluids did not influence the variation of the pulmonary component of the sequential organ failure assessment score between days 1 and 3 (ρ = -0.2, p = 0.34). Despite a small sample of patients, cold IV fluids in TH appear safe in the postcardiac arrest population. These findings should be reproduced in a larger, prospective study.

Back to Basics: Unplanned Patient Hypothermia: 1.3 www.aornjournal.org/content/cme.

Unplanned perioperative hypothermia is a common occurrence and can negatively affect a patient's postoperative course. Perioperative nurses are responsible for identifying patients at risk for hypothermia and working with the entire surgical team to prevent this complication from occurring. Multiple interventions can be implemented to address hypothermia, including active or passive warming and warm IV and irrigation fluids. This Back to Basics article addresses patient assessment concerns, identifies a variety of evidence-based interventions that can prevent or mitigate perioperative patient temperature changes, and provides basic steps for perioperative RNs to follow to help prevent perioperative hypothermia in their patients.

A multi-center randomized trial of two different intravenous fluids during labor.

OBJECTIVE: To determine if the intrapartum use of a 5% glucose-containing intravenous solution decreases the chance of a cesarean delivery for women presenting in active labor. METHODS: This was a multi-center, prospective, single (patient) blind, randomized study design implemented at four obstetric residency programs in Pennsylvania. Singleton, term, consenting women presenting in active spontaneous labor with a cervical dilation of <6 cm were randomized to lactated Ringer's with or without 5% glucose (LR versus D5LR) as their maintenance intravenous fluid. The primary outcome was the cesarean birth rate. Secondary outcomes included labor characteristics, as well as maternal or neonatal complications. RESULTS: There were 309 women analyzed. Demographic variables and admitting cervical dilation were similar among study groups. There was no significant difference in the cesarean delivery rate for the D5LR group (23/153 or 15.0%) versus the LR arm (18/156 or 11.5%), [RR (95% CI) of 1.32 (0.75, 2.35), p = 0.34]. There were no differences in augmentation rates or intrapartum complications. CONCLUSIONS: The use of intravenous fluid containing 5% dextrose does not lower the chance of cesarean delivery for women admitted in active labor.

Ensayo clínico aleatorizado sobre la administración de una solución de mantenimiento intravenosa hipotónica comparada contra una isotónica en pacientes pediátricos críticos / Hypotonic versus isotonic maintenance fluids in critically ill pediatric patients: a randomized control trial

Introducción. Las soluciones hipotónicas se han vinculado a la producción de hiponatremia iatrogénica. Objetivos. Evaluar las variaciones en el sodio sérico (NaS) tras la administración de una solución de mantenimiento intravenosa isotónica (NaCl al 0,9% en dextrosa al 5%) en comparación con una solución de mantenimiento hipotónica (NaCl al 0,45% en dextrosa al 5%). Material y métodos. Ensayo clínico aleatorizado, doble ciego y controlado. Se enrolaron pacientes pediátricos con una estadía esperada en la unidad de cuidados intensivos mayor de 24 horas, NaS normal y líquidos intravenosos > 80% de los líquidos totales de mantenimiento. La concentración sérica de Na se midió antes de colocar la solución de mantenimiento y al reducir la administración de ésta a < 80% del total del aporte. Resultados. Se incorporaron 63 pacientes, que fueron asignados en forma aleatoria a recibir una solución de mantenimiento hipotónica (n= 32) o isotónica (n= 31). Las características basales fueron similares en ambos grupos. No hubo diferencias con respecto a la cantidad de solución administrada (grupo hipotónico 865 ± 853 ml; grupo isotónico 778 ± 649 ml, p= 0,654) o el tiempo de infusión (grupo hipotónico: 24 ± 10,8 horas; grupo isotónico: 27,6 ± 12,8 horas, p= 0,231). Se encontró una diferencia en el NaS luego de la administración de las soluciones de mantenimiento (grupo hipotónico: 137,8 ± 4,3 mmol/L; grupo isotónico: 140,0 ± 4,1 mmol/L, p=0,04). Ninguna de las dos soluciones de mantenimiento aumentó el riesgo de hiponatremia (Na < 135 mmol/L) o de hipernatremia (Na > 145 mmol/L). Conclusiones. Ambas soluciones de mantenimiento, en 24 horas de infusión, no aumentaron el riesgo de producir hiponatremia iatrogénica.

Introduction: Hypotonic fluids have been associated with the development of iatrogenic hyponatremia. Objectives. To assess variations in serum sodium (sNa) following the intravenous administration of isotonic maintenance fluids (0.9% NaCl/5% dextrose) compared to hypotonic maintenance fluids (0.45% NaCl/5% dextrose). Material and Methods. Randomized, controlled, double-blind clinical trial. Pediatric patients with an expected length of stay in the intensive care unit of more than 24 hours were enrolled, with normal serum Na, and IV fluids >80% of total maintenance fluids. Serum Na level was measured before administering maintenance fluids and when reducing the administration to <80% of total fluids. Results. The study included 63 patients who were randomly assigned to receive hypotonic (n= 32) or isotonic (n= 31) maintenance fluids. Baseline characteristics were similar inboth groups. There were no differences in terms of volume of fluid administered (hypotonic group: 865 ± 853 mL; isotonic group: 778 ± 649 mL; p=0.654) or infusion duration (hypotonic group: 24 ± 10.8 hours; isotonic group: 27.6 ± 12.8 hours; p= 0.231). A difference was found in the serum Na following the administration of maintenance fluids (hypotonic group: 137.8 ± 4.3 mmol/L; isotonic group: 140.0 ±4.1 mmol/L, p= 0.04). None of these two maintenance fluids increased the risk of hyponatremia (Na <135 mmol/L) or hypernatremia (Na >145 mmol/L). Conclusions. Neither hypotonic nor isotonic maintenance fluids increased the risk of developing iatrogenic hyponatremia with the 24 hour infusion.