Protocolized reduction of non-resuscitation fluids versus usual care in septic shock patients (REDUSE): a randomized multicentre feasibility trial.

BACKGROUND/PURPOSE: Non-resuscitation fluids constitute the majority of fluid administered for septic shock patients in the intensive care unit (ICU). This multicentre, randomized, feasibility trial was conducted to test the hypothesis that a restrictive protocol targeting non-resuscitation fluids reduces the overall volume administered compared with usual care. METHODS: Adults with septic shock in six Swedish ICUs were randomized within 12 h of ICU admission to receive either protocolized reduction of non-resuscitation fluids or usual care. The primary outcome was the total volume of fluid administered within three days of inclusion. RESULTS: Median (IQR) total volume of fluid in the first three days, was 6008 ml (interquartile range [IQR] 3960-8123) in the restrictive fluid group (n = 44), and 9765 ml (IQR 6804-12,401) in the control group (n = 48); corresponding to a Hodges-Lehmann median difference of 3560 ml [95% confidence interval 1614-5302]; p < 0.001). Outcome data on all-cause mortality, days alive and free of mechanical ventilation and acute kidney injury or ischemic events in the ICU within 90 days of inclusion were recorded in 98/98 (100%), 95/98 (98%) and 95/98 (98%) of participants respectively. Cognition and health-related quality of life at six months were recorded in 39/52 (75%) and 41/52 (79%) of surviving participants, respectively. Ninety out of 134 patients (67%) of eligible patients were randomized, and 15/98 (15%) of the participants experienced at least one protocol violation. CONCLUSION: Protocolized reduction of non-resuscitation fluids in patients with septic shock resulted in a large decrease in fluid administration compared with usual care. A trial using this design to test if reducing non-resuscitation fluids improves outcomes is feasible. TRIAL REGISTRATION: Clinicaltrials.gov, NCT05249088, 18 February 2022. https://clinicaltrials.gov/ct2/show/NCT05249088.

Selective dorsal rhizotomy and postoperative pain management. A worldwide survey.

BACKGROUND: Selective dorsal rhizotomy (SDR) is an operation method that decreases the degree of spasticity with long-lasting beneficial effects for children with spastic diplegia. Children undergoing SDR are postoperatively in severe pain, a pain related to both the extensive surgical exposure with multilevel laminectomy and the nerve root manipulation. Various pain management strategies for children undergoing SDR have been published. The postoperative pain treatment is a vital part of the management. The aim of this study was to estimate the number of centers performing SDR, the frequency of SDR surgery and to investigate pain management of the different centers. METHODS: A questionnaire comprising 7 questions was sent by mail and/or e-mail to a total of 59 potential centers performing SDR, centers that have published material concerning SDR or centers that have been recommended. Forty-seven (80%) centers responded to the questionnaire; 11 of them do not presently perform SDR surgery, and the remaining 36 centers constitute the material of the present study. RESULTS: 23 of the 36 centers use Peacock's operation technique and 8 centers use Park's technique. Continuous intravenous infusion of opioids for postoperative pain treatment is used by 17 (47%) of the centers. Seven (19%) centers use the epidural (ED) approach for treating postoperative pain and 6 (17%) centers use intrathecal (IT) pain treatment. The duration of intravenous ED or IT pain relief ranged from 24 h up to 7 days. To evaluate pain relief, 25 (70%) centers used some form of pain scale. CONCLUSION: The most common operation techniques in use today are described by Peacock or by Park, with an estimated number of procedures of more than 487/year in 36 centers. The majority of the centers seem to have a satisfactory pain management strategy. These centers administer continuous infusions of opioids, with an intravenous, ED or IT approach, and incorporate the use of a pain assessment tool to evaluate pain relief.

Survey of the management of children with minor head injuries in Sweden.

BACKGROUND: This study investigates current management practice of children with MHI in Swedish hospitals to define present need for management guidelines for children. METHODS: A cross-sectional mail survey including 51 hospitals treating children with MHI outlines management routines concerning clinical and radiological examinations, in-hospital observation, discharge criteria and follow-up. RESULTS: Twenty-seven per cent of the hospitals have established written criteria for referral and management of children with MHI. Eighty-eight per cent use the Swedish Reaction Level Scale for assessing the level of consciousness. Eight per cent use the paediatric Glasgow Coma Scale. Routine computerised tomography is performed in 18% of the hospitals, 12% perform skull radiography and/or radiography of the cervical spine as routine. Eighty-four per cent have established criteria for early discharge without hospitalisation. CONCLUSION: The management of children with MHI varies in Swedish hospitals. There is a need for standardised protocols for detection of intracranial complications and guidelines for the management of MHI in children.

Serum S100B levels in patients with epidural haematomas.

Protein S100B is today the most promising biomarker for cerebral injury. A welcomed area for the use of such a marker is in the early stages of head trauma and diagnosis of brain injury, in particular epidural haematomas. We report five consecutive cases of epidural haematoma where serum samples for S100B were drawn at admission. Three of the patients showed low levels of S100B (< or =0.2 microg/l). One patient with a large epidural haematoma with radiological signs of cerebral herniation displayed normal levels (0.14 microg/l) of S100B 3.5 h after the initial head trauma. Normal S100B levels in serum do not predict normal intracranial findings. S100B may be unreliable as a marker for epidural haematomas after closed head injury.

Serial S100B levels before, during and after cerebral herniation.

Protein S100B has been shown to increase in serum and cerebrospinal fluid (CSF) in various neurological diseases. However, the levels of S100B in conjunction with cerebral herniation have not been studied and the significance of extracerebral S100B has become an important issue. We report on a multi-trauma patient in whom cerebral herniation occurred 2 days after admission. Following this, organ-harvesting procedures were performed for transplantation. We measured serial serum S100B during both the ongoing herniation and the following extracerebral surgery. We found that S100B levels seemed to peak immediately prior to cerebral herniation and then decreased shortly thereafter and concluded that the source of the measured serum S100B in this patient was of predominately cerebral origin. In conjunction with the organ harvesting procedure S100B levels increased, indicating that extracerebral sources of the protein also exist.