Variation in Fluid and Vasopressor Use in Shock With and Without Physiologic Assessment: A Multicenter Observational Study.

OBJECTIVES: To characterize the association between the use of physiologic assessment (central venous pressure, pulmonary artery occlusion pressure, stroke volume variation, pulse pressure variation, passive leg raise test, and critical care ultrasound) with fluid and vasopressor administration 24 hours after shock onset and with in-hospital mortality. DESIGN: Multicenter prospective cohort study between September 2017 and February 2018. SETTINGS: Thirty-four hospitals in the United States and Jordan. PATIENTS: Consecutive adult patients requiring admission to the ICU with systolic blood pressure less than or equal to 90 mm Hg, mean arterial blood pressure less than or equal to 65 mm Hg, or need for vasopressor. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: Of 1,639 patients enrolled, 39% had physiologic assessments. Use of physiologic assessment was not associated with cumulative fluid administered within 24 hours of shock onset, after accounting for baseline characteristics, etiology and location of shock, ICU types, Acute Physiology and Chronic Health Evaluation III, and hospital (beta coefficient, 0.04; 95% CI, -0.07 to 0.15). In multivariate analysis, the use of physiologic assessment was associated with a higher likelihood of vasopressor use (adjusted odds ratio, 1.98; 95% CI, 1.45-2.71) and higher 24-hour cumulative vasopressor dosing as norepinephrine equivalent (beta coefficient, 0.37; 95% CI, 0.19-0.55). The use of vasopressor was associated with increased odds of in-hospital mortality (adjusted odds ratio, 1.88; 95% CI, 1.27-2.78). In-hospital mortality was not associated with the use of physiologic assessment (adjusted odds ratio, 0.86; 95% CI, 0.63-1.18). CONCLUSIONS: The use of physiologic assessment in the 24 hours after shock onset is associated with increased use of vasopressor but not with fluid administration.

Mapping geographical inequalities in oral rehydration therapy coverage in low-income and middle-income countries, 2000-17.

BACKGROUND: Oral rehydration solution (ORS) is a form of oral rehydration therapy (ORT) for diarrhoea that has the potential to drastically reduce child mortality; yet, according to UNICEF estimates, less than half of children younger than 5 years with diarrhoea in low-income and middle-income countries (LMICs) received ORS in 2016. A variety of recommended home fluids (RHF) exist as alternative forms of ORT; however, it is unclear whether RHF prevent child mortality. Previous studies have shown considerable variation between countries in ORS and RHF use, but subnational variation is unknown. This study aims to produce high-resolution geospatial estimates of relative and absolute coverage of ORS, RHF, and ORT (use of either ORS or RHF) in LMICs. METHODS: We used a Bayesian geostatistical model including 15 spatial covariates and data from 385 household surveys across 94 LMICs to estimate annual proportions of children younger than 5 years of age with diarrhoea who received ORS or RHF (or both) on continuous continent-wide surfaces in 2000-17, and aggregated results to policy-relevant administrative units. Additionally, we analysed geographical inequality in coverage across administrative units and estimated the number of diarrhoeal deaths averted by increased coverage over the study period. Uncertainty in the mean coverage estimates was calculated by taking 250 draws from the posterior joint distribution of the model and creating uncertainty intervals (UIs) with the 2·5th and 97·5th percentiles of those 250 draws. FINDINGS: While ORS use among children with diarrhoea increased in some countries from 2000 to 2017, coverage remained below 50% in the majority (62·6%; 12 417 of 19 823) of second administrative-level units and an estimated 6 519 000 children (95% UI 5 254 000-7 733 000) with diarrhoea were not treated with any form of ORT in 2017. Increases in ORS use corresponded with declines in RHF in many locations, resulting in relatively constant overall ORT coverage from 2000 to 2017. Although ORS was uniformly distributed subnationally in some countries, within-country geographical inequalities persisted in others; 11 countries had at least a 50% difference in one of their units compared with the country mean. Increases in ORS use over time were correlated with declines in RHF use and in diarrhoeal mortality in many locations, and an estimated 52 230 diarrhoeal deaths (36 910-68 860) were averted by scaling up of ORS coverage between 2000 and 2017. Finally, we identified key subnational areas in Colombia, Nigeria, and Sudan as examples of where diarrhoeal mortality remains higher than average, while ORS coverage remains lower than average. INTERPRETATION: To our knowledge, this study is the first to produce and map subnational estimates of ORS, RHF, and ORT coverage and attributable child diarrhoeal deaths across LMICs from 2000 to 2017, allowing for tracking progress over time. Our novel results, combined with detailed subnational estimates of diarrhoeal morbidity and mortality, can support subnational needs assessments aimed at furthering policy makers' understanding of within-country disparities. Over 50 years after the discovery that led to this simple, cheap, and life-saving therapy, large gains in reducing mortality could still be made by reducing geographical inequalities in ORS coverage. FUNDING: Bill & Melinda Gates Foundation.

Electrolyte Analysis and Replacement: Challenging a Paradigm in Surgical Patients.

Postoperative patients are susceptible to alterations in electrolyte homeostasis. Although electrolytes are replaced in critically ill patients, stable asymptomatic non-intensive care unit (ICU) patients often receive treatment of abnormal electrolytes. We hypothesize there is no proven benefit in asymptomatic patients. In 2016, using the electronic medical records and pharmacy database at a university academic medical center, we conducted a retrospective cost analysis of the frequency and cost of electrolyte analysis (basic metabolic panel [BMP], ionized calcium [Ca], magnesium [Mg], and phosphorus [P]) and replacement (potassium chloride [KCl], Mg, oral/iv Ca, oral/iv P) in perioperative patients. Patients without an oral diet order, with creatinine more than 1.4, age less than 16 years, admitted to the ICU, or with length of stay of more than 1 week were excluded. Nursing costs were calculated as a fraction of hourly wages per laboratory order or electrolyte replacement. One hundred thirteen patients met our criteria over 11 months. Mean length of stay was 4 days; mean age was 54 years; and creatinine was 0.67 ± 0.3. Electrolyte analysis laboratory orders (n = 1,045) totaled $6,978, and BMP was most frequently ordered accounting for 36% of laboratory costs. In total, 683 doses of electrolytes cost the pharmacy $1,780. Magnesium was most frequently replaced, followed by KCl, P, and Ca. Nursing cost associated with electrolyte analysis/replacement was $7,782. There is little evidence to support electrolyte analysis and replacement in stable asymptomatic noncritically ill patients, but their prevalence and cost ($146/case) in this study were substantial. Basic metabolic panels, pharmacy charges for potassium, and nursing staff costs accounted for the most significant portion of the total cost. Considering these data, further research should determine whether these practices are warranted.

Restrictive intraoperative fluid management was associated with higher incidence of composite complications compared to less restrictive strategies in open thoracotomy: A retrospective cohort study.

Restrictive fluid management has been recommended for thoracic surgery. However, specific guidelines are lacking, and there is always concern regarding impairment of renal perfusion with a restrictive policy. The objective of this study was to find the net intraoperative fluid infusion rate which shows the lowest incidence of composite complications (either pulmonary complications or acute kidney injury) in open thoracotomy. We hypothesized that a certain range of infusion rate would decrease the composite complications within postoperative 30 days. All patients (n = 1,031) who underwent open thoracotomy at a tertiary care university hospital were included in this retrospective study. The time frame of fluid monitoring was from the start of operation to postoperative 24 hours. The cutoff value of the intraoperative net fluid amount was 4-5 ml.kg-1.h-1 according to the minimum p-value method, thus, patients were divided into Low (≤3 ml.kg-1.h-1), Cutoff (4-5 ml.kg-1.h-1) and High (≥6 ml.kg-1.h-1) groups. The Cutoff group showed the lowest composite complication rate (19%, 12%, and 13% in the Low, Cutoff, and High groups, respectively, P = 0.0283; Low vs. Cutoff, P = 0.0324, Bonferroni correction). Acute respiratory distress syndrome occurred least frequently in the Cutoff group (7%, 3%, and 6% for the Low, Cutoff, and High groups, respectively, P = 0.0467; Low vs. Cutoff, P = 0.0432, Bonferroni correction). In multivariable analysis, intraoperative net fluid infusion rate was associated with composite complications, and the Cutoff group decreased risk (odds ratio 0.54, 95% confidence interval: 0.35-0.81, P = 0.0035). In conclusion, maintaining intraoperative net fluid infusion at 4-5 ml.kg-1.h-1 was associated with better results in open thoracotomy, in terms of composite complications, compared to more restrictive fluid management.

Variation in contrast-associated acute kidney injury prophylaxis for percutaneous coronary intervention: insights from the Veterans Affairs Clinical Assessment, Reporting, and Tracking (CART) program.

BACKGROUND: Contrast-Associated Acute Kidney Injury (CA-AKI) is a serious complication associated with percutaneous coronary intervention (PCI). Patients with chronic kidney disease (CKD) have an elevated risk for developing this complication. Although CA-AKI prophylactic measures are available, the supporting literature is variable and inconsistent for periprocedural hydration and N-acetylcysteine (NAC), but is stronger for contrast minimization. METHODS: We assessed the prevalence and variability of CA-AKI prophylaxis among CKD patients undergoing PCI between October 2007 and September 2015 in any cardiac catheterization laboratory in the VA Healthcare System. Prophylaxis included periprocedural hydration with normal saline or sodium bicarbonate, NAC, and contrast minimization (contrast volume to glomerular filtration rate ratio ≤ 3). Multivariable hierarchical logistic regression models quantified site-specific prophylaxis variability. As secondary analyses, we also assessed CA-AKI prophylaxis measures in all PCI patients regardless of kidney function, periprocedural hydration in patients with comorbid CHF, and temporal trends in CA-AKI prophylaxis. RESULTS: From 2007 to 2015, 15,729 patients with CKD underwent PCI. 6928 (44.0%) received periprocedural hydration (practice-level median rate 45.3%, interquartile range (IQR) 35.5-56.7), 5107 (32.5%) received NAC (practice-level median rate 28.3%, IQR 22.8-36.9), and 4656 (36.0%) received contrast minimization (practice-level median rate 34.5, IQR 22.6-53.9). After adjustment for patient characteristics, there was significant site variability with a median odds ratio (MOR) of 1.80 (CI 1.56-2.08) for periprocedural hydration, 1.95 (CI 1.66-2.29) for periprocedural hydration or NAC, and 2.68 (CI 2.23-3.15) for contrast minimization. These trends were similar among all patients (with and without CKD) undergoing PCI. Among patients with comorbid CHF (n = 5893), 2629 (44.6%) received periprocedural hydration, and overall had less variability in hydration (MOR of 1.56 (CI 1.38-1.76)) compared to patients without comorbid CHF (1.89 (CI 1.65-2.18)). Temporal trend analysis showed a significant and clinically relevant decrease in NAC use (64.1% of cases in 2008 (N = 1059), 6.2% of cases in 2015 (N = 128, p = < 0.0001)) and no significant change in contrast-minimization (p = 0.3907). CONCLUSIONS: Among patients with CKD undergoing PCI, there was low utilization and significant site-level variability for periprocedural hydration and NAC independent of patient-specific risk. This low utilization and high variability, however, was also present for contrast minimization, a well-established measure. These findings suggest that a standardized approach to CA-AKI prophylaxis, along with continued development of the evidence base, is needed.

Clinical Impact and Cost Efficacy of Newborn Screening for Congenital Adrenal Hyperplasia.

OBJECTIVES: To evaluate the clinical impact of a congenital adrenal hyperplasia (CAH) newborn screening program and incremental costs relative to benefits in screened vs unscreened infants. We hypothesized that screening would lead to clinical benefits and would be cost effective. STUDY DESIGN: This was an ambispective cohort study at British Columbia Children's Hospital, including infants diagnosed with CAH from 1988-2008 and 2010-2018. Data were collected retrospectively (unscreened cohort) and prospectively (screened cohort). Outcome measures included hospitalization, medical transport, and resuscitation requirements. The economic analysis was performed using a public payer perspective. RESULTS: Forty unscreened and 17 screened infants were diagnosed with CAH (47% vs 53% male). Median days to positive screen was 6 and age at diagnosis was 5 days (range, 0-30 days) and 6 days (range, 0-13 days) in unscreened and screened populations, respectively. In unscreened newborns, 55% required transport to a tertiary care hospital, 85% required hospitalization, and 35% required a fluid bolus compared with 29%, 29%, and 12% in screened infants, respectively. The cost of care was $33 770 per case in unscreened vs $17 726 in screened newborns. In the screened cohort, the incremental cost-effectiveness ratio was $290 in the best case analysis and $4786 in the base case analysis, per hospital day avoided. CONCLUSIONS: Compared with unscreened newborns, those screened for CAH were less likely to require medical transport and had shorter hospital stays. Screening led to a decrease in hospitalization costs. Although screening did not result in cost savings, it was assessed to be cost effective considering the clinical benefits and incremental cost-effectiveness ratio.

[Evaluation of effectiveness of corrective measures arising from incident notifications in a paediatric emergency department]. / Evaluación de la efectividad de acciones correctivas derivadas de la notificación de incidentes en urgencias pediátricas.

OBJECTIVE: To analyse the effectiveness of corrective measures arising from the analysis of safety incident notifications in the Paediatric Emergency Unit. METHODS: A quasi-experimental, prospective, and single-centre study was carried out between 2015 and 2018. In the first phase, incidents notified throughout one year were analysed. Corrective measures were then implemented for 5 specific kinds of incidents. These incidents were finally compared to those notified within 12 months after the implementation of those measures. Results were expressed as relative risk and relative risk reduction. RESULTS: A total of 1587 safety incidents were notified (0.9% of patients treated) between January 2015 and December 2017. After implementation of corrective measures, there was a decrease in all kinds of incidents notifications analysed. The incidents related to patient identification were reduced by 60.9% (RR 0.39, 95% CI; 0.25-0.60), and those regarding communication between professionals were reduced by 74.5% (RR 0.25, 95% CI; 0.12-0.55). Incidents related to sedation and analgesic procedures totally disappeared. No significant reduction was found in incidents concerning the triage system, or in those related to rapid intravenous rehydration procedures. CONCLUSIONS: The implementation of improvement actions arising from the analysis of voluntary notification of incidents is an effective strategy to improve patient effective strategy to improve.

Increasing coverage of pediatric diarrhea treatment in high-burden countries.

BACKGROUND: Diarrhea is the second leading cause of infectious deaths in children under-five globally. Oral rehydration salts (ORS) and zinc could avert an estimated 93% of deaths, but progress to increase coverage of these interventions has been largely stagnant over the past several decades. The Clinton Health Access Initiative (CHAI), along with donors and country governments in India, Kenya, Nigeria, and Uganda, implemented programs to scale-up ORS and zinc coverage from 2012 to 2016. The programs sought to demonstrate that increases in pediatric diarrhea treatment rates are possible at scale in high-burden settings through a holistic approach addressing both supply and demand barriers. We describe the overall program model and the activities undertaken in each country. The overall goal of the paper is to share the program results and lessons learned to inform other countries aiming to scale-up ORS and zinc. METHODS: We used a triangulation approach, using population-based household surveys, public facility audits, and private outlet surveys, to evaluate the program model. We used pre- and post-program population-based household survey data to estimate the changes in coverage of ORS and zinc for treatment of diarrhea cases in children under-five in program areas. We also conducted secondary analysis of Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS) surveys in surrounding regions and compared annual coverage changes in the CHAI-supported program geographies to the surrounding regions. RESULTS: Across CHAI-supported focal geographies, the average ORS coverage across the program areas increased from 35% to 48% and combined ORS and zinc coverage increased from 1% to 24%. ORS coverage increases were statistically significant in the program states in India, from 22% (95% confidence interval CI = 21-23%) to 48% (95% CI = 47-50%) and program states in Nigeria, from 38% (95% CI = 32-40%) to 55% (95% CI = 51-58%). For combined ORS and zinc, coverage increases were statistically significant in all program geographies. Compared to surrounding regions, the estimated annual changes in combined ORS and zinc coverage were greater in program geographies. Using the Lives Saved Tool and based on the coverage changes during the program period, we estimated 76 090 diarrheal deaths were averted in the program geographies. CONCLUSIONS: Increasing ORS and zinc coverage at scale in high-burden countries and states is possible through a comprehensive approach that targets both demand and supply barriers, including pricing, optimal product qualities, provider dispensing practices, stocking rates, and consumer demand.

Program evaluation of an ORS and zinc scale-up program in 8 Nigerian states.

BACKGROUND: In Nigeria, diarrhea is the second leading killer of children under five. Between 2012-2017, the Clinton Health Access Initiative, Inc. (CHAI) and the Government of Nigeria implemented a comprehensive program in eight states aimed at increasing the percentage of children under five with diarrhea who were treated with zinc and oral rehydration solution (ORS). The program addressed demand, supply, and policy barriers to ORS and zinc uptake through interventions in both public and private sectors. The interventions included: (1) policy revision and partner coordination; (2) market shaping to improve availability of affordable, high-quality ORS and zinc; (3) provider training and mentoring; and (4) caregiver demand generation. METHODS: We conducted cross-sectional household surveys in program states at baseline, midline, and endline and constructed logistic regression models with generalized estimating equations to assess changes in ORS and zinc treatment during the program period. RESULTS: In descriptive analysis, we found 38% (95% CI = 34%-42%) received ORS at baseline and 4% (95% CI = 3%-5%) received both ORS and zinc. At endline, we found 55% (95% CI = 51%-58%) received ORS and 30% (95% CI = 27%-33%) received both ORS and zinc. Adjusting for other covariates, the odds of diarrhea being treated with ORS were 1.88 (95% CI = 1.46, 2.43) times greater at endline. The odds of diarrhea being treated with ORS and zinc combined were 15.14 (95% CI = 9.82, 23.34) times greater at endline. When we include the interaction term to investigate whether the odds ratios between the endline and baseline survey were modified by source of care, we found statistically significant results among diarrhea episodes that sought care in the public and private sector. Among cases that sought care in the public sector, the predictive probability of treatment with ORS increased from 57% (95% CI = 50%-65%) to 83% (95% CI = 79%-87%). Among cases that sought care in the private sector, the predictive probability increased from 41% (95% CI = 34%-48%) to 58% (95% CI = 54%-63%). CONCLUSIONS: Use of ORS and combined ORS and zinc for treatment of diarrhea significantly increased in program states during the program period.

Prevalence of oral rehydration therapy use and associated factors among under-five children with diarrhea in Dangure, Benishangul Gumuz Region, Ethiopia/2018.

OBJECTIVES: This study aims to assess the prevalence of oral rehydration therapy use and associated factors among under-five children with diarrhoea in Dangure district, Benishangul Gumuz Region, Ethiopia/2018. RESULT: A total of 615 under-five children who suffered from diarrhoea 2 weeks before the study were included and the response rate was 610 (99%). Among the total children participated in this study 189 (31%) were between 12 and 23 months with mean 23.5 and SD ± 6.9. Five hundred seventeen (84.8%) of mothers had access to oral rehydration therapy and 85% of mother's home had taken less than 1 h distance from the health facility. The prevalence of oral rehydration therapy is 51%. Two hundred sixty-seven (43.8%) mothers mentioned correctly about the importance of oral rehydration therapy which is to replace fluid while other 243 (39.8%) mothers stated that oral rehydration therapy uses to decrease diarrhoea. Mother's educational status, monthly income, knowledge of oral rehydration therapy, previous experience and seeking advice for treatment from health facilities were factors associated with oral rehydration therapy use.

The role of price and convenience in use of oral rehydration salts to treat child diarrhea: A cluster randomized trial in Uganda.

BACKGROUND: Over half a million children die each year of diarrheal illness, although nearly all deaths could be prevented with oral rehydration salts (ORS). The literature on ORS documents both impressive health benefits and persistent underuse. At the same time, little is known about why ORS is underused and what can be done to increase use. We hypothesized that price and inconvenience are important barriers to ORS use and tested whether eliminating financial and access constraints increases ORS coverage. METHODS AND FINDINGS: In July of 2016, we recruited 118 community health workers (CHWs; representing 10,384 households) in Central and Eastern Uganda to participate in the study. Study villages were predominantly peri-urban, and most caretakers had no more than primary school education. In March of 2017, we randomized CHWs to one of four methods of ORS distribution: (1) free delivery of ORS prior to illness (free and convenient); (2) home sales of ORS prior to illness (convenient only); (3) free ORS upon retrieval using voucher (free only); and (4) status quo CHW distribution, where ORS is sold and not delivered (control). CHWs offered zinc supplements in addition to ORS in all treatment arms (free in groups 1 and 3 and for sale in group 2), following international treatment guidelines. We used household surveys to measure ORS (primary outcome) and ORS + zinc use 4 weeks after the interventions began (between April and May 2017). We assessed impact using an intention-to-treat (ITT) framework. During follow-up, we identified 2,363 child cases of diarrhea within 4 weeks of the survey (584 in free and convenient [25.6% of households], 527 in convenient only [26.1% of households], 648 in free only [26.8% of households], and 597 in control [28.5% of households]). The share of cases treated with ORS was 77% (448/584) in the free and convenient group, 64% (340/527) in the convenient only group, 74% (447/648) in the free only group, and 56% (335/597) in the control group. After adjusting for potential confounders, instructing CHWs to provide free and convenient distribution increased ORS coverage by 19 percentage points relative to the control group (95% CI 13-26; P < 0.001), 12 percentage points relative to convenient only (95% CI 6-18; P < 0.001), and 2 percentage points (not significant) relative to free only (95% CI -4 to 8; P = 0.38). Effect sizes were similar, but more pronounced, for the use of both ORS and zinc. Limitations include short follow-up period, self-reported outcomes, and limited generalizability. CONCLUSIONS: Most caretakers of children with diarrhea in low-income countries seek care in the private sector where they are required to pay for ORS. However, our results suggest that price is an important barrier to ORS use and that switching to free distribution by CHWs substantially increases ORS coverage. Switching to free distribution is low-cost, easily scalable, and could substantially reduce child mortality. Convenience was not important in this context. TRIAL REGISTRATION: Trial registry number AEARCTR-0001288.

Effect of enhanced detailing and mass media on community use of oral rehydration salts and zinc during a scale-up program in Gujarat and Uttar Pradesh.

BACKGROUND: The Clinton Health Access Initiative implemented a program from 2012-2016 to increase use of oral rehydration salts (ORS) and zinc to treat diarrhea in children under five in three states in India: Gujarat, Madhya Pradesh, and Uttar Pradesh. The program interventions included detailing and development of a rural supply chain to reach private rural health care providers, training of Accredited Social Health Activists (ASHAs), technical support to the state governments, and a mass media campaign targeted at caregivers. In Gujarat and Uttar Pradesh, some of the program activities, such as detailing and ASHA trainings, were targeted to high-burden focal districts, thus providing an opportunity to study their effect compared to statewide activities that covered all districts, such as the mass media campaign. Our study aimed to estimate the effect of activities on ORS and zinc use. METHODS: Household surveys were conducted at two points during the program and in both focal and non-focal districts. We used a difference-in-difference quasi-experimental approach to estimate the effect of the enhanced activities in focal districts and mass media campaign on the odds of a child being treated with ORS and zinc. FINDINGS: Focal district interventions were associated with a significant increase in the odds of a diarrhea episode receiving ORS in Gujarat and Uttar Pradesh. Living in focal districts increased the odds of receiving ORS in Gujarat and Uttar Pradesh by factors of 3.42 (95% CI = 1.39-8.33) and 2.29 (95% CI = 1.19-4.39), respectively. Focal district interventions were also associated with 15.02 (95% CI = 2.97-75.19) greater odds of receiving both ORS and zinc in Gujarat. In Uttar Pradesh, where the mass media campaign was focused, exposure to the campaign further modified the odds of receiving ORS and combined ORS and zinc by 1.38 (95% CI = 1.04-1.84) and 1.57 (95% CI = 1.01-2.46), respectively. CONCLUSION: Comprehensive public and private provider interventions combined with mass media are effective strategies for increasing ORS and zinc use.

How about "The effect of intraoperative cell salvage on allogeneic blood transfusion for patients with placenta accreta"?: An observational study.

Intraoperative cell salvage (IOCS) for high-risk obstetric hemorrhage is now endorsed by a number of obstetric organizations. Most previous studies have focused on the safety of IOCS from case series and small controlled studies. Here, we describe the effect of IOCS on rates of allogeneic blood transfusion (ABT) under different degrees of bleeding during cesarean section in women with placenta accreta, which has seldom been reported in the literature.We conducted a retrospective analysis on the introduction of routine application of IOCS for the management of hemorrhage during cesarean section in women with placenta accreta. We identified 115 women, with prenatally diagnosed placenta accreta/increta/percreta before this change in practice, who served as controls, and 108 women who had IOCS applied during cesarean section.Compared with the control treatment, IOCS was significantly associated with a lower incidence of ABT (odds ratio, 0.179; 95% confidence interval, 0.098-0.328). Among the women with ≤3000 mL of bleeding, ABT was avoided in 80 (93.0%) of the 86 patients in the IOCS group, while 49 (50.0%) of the 98 controls required ABT. For women with an estimated blood loss >3000 mL, the reinfused IOCS blood may have helped prevent the need for ABT in 6 (28.6%) of the 21 patients, while all of the 17 controls required ABT. Subgroup analysis of coagulation function and the need for coagulation components showed no significant difference between the 2 groups (P > .05). Compared with the control treatment, IOCS was associated with a lower intraoperative volume of crystalloid (P < .01) and colloid infusion (P < .01) and a shorter length of postoperative hospital stay (P < .01) in patients with placenta accreta. In addition, there were no complications or adverse reactions in patients with placenta accreta who underwent IOCS.IOCS helped reduce the need for ABT and fluid transfusion in patients with placenta accreta and may be safe for use in obstetrics.

Assessment of Myocardial Function and Injury by Echocardiography and Cardiac Biomarkers in African Children With Severe Plasmodium falciparum Malaria.

OBJECTIVES: Perturbed hemodynamic function complicates severe malaria. The Fluid Expansion as Supportive Therapy trial demonstrated that fluid resuscitation, involving children with severe malaria, was associated with increased mortality, primarily due to cardiovascular collapse, suggesting that myocardial dysfunction may have a role. The aim of this study was to characterize cardiac function in children with severe malaria. DESIGN: A prospective observational study with clinical, laboratory, and echocardiographic data collected at presentation (T0) and 24 hours (T1) in children with severe malaria. Cardiac index and ejection fraction were calculated at T0 and T1. Cardiac troponin I and brain natriuretic peptide were measured at T0. We compared clinical and echocardiographic variables in children with and without severe malarial anemia (hemoglobin < 5 mg/dL) at T0 and T1. SETTING: Mbale Regional Referral Hospital. PATIENTS: Children 3 months to 12 years old with severe falciparum malaria. INTERVENTIONS: Usual care. MEASUREMENTS AND MAIN RESULTS: We enrolled 104 children, median age 23.3 months, including 61 children with severe malarial anemia. Cardiac troponin I levels were elevated (> 0.1 ng/mL) in n equals to 50, (48%), and median brain natriuretic peptide was within normal range (69.1 pg/mL; interquartile range, 48.4-90.8). At T0, median Cardiac index was significantly higher in the severe malarial anemia versus nonsevere malarial anemia group (6.89 vs 5.28 L/min/m) (p = 0.001), which normalized in both groups at T1 (5.60 vs 5.13 L/min/m) (p = 0.452). Cardiac index negatively correlated with hemoglobin, r equals to -0.380 (p < 0.001). Four patients (3.8%) had evidence of depressed cardiac systolic function (ejection fraction < 45%). Overall, six children died, none developed pulmonary edema, biventricular failure, or required diuretic treatment. CONCLUSIONS: Elevation of cardiac index, due to increased stroke volume, in severe malaria is a physiologic response to circulatory compromise and correlates with anemia. Following whole blood transfusion and antimalarial therapy, cardiac index in severe malarial anemia returns to normal. The majority (> 96%) of children with severe malaria have preserved myocardial systolic function. Although there is evidence for myocardial injury (elevated cardiac troponin I), this does not correlate with cardiac dysfunction.

Enhanced Recovery Implementation in Major Gynecologic Surgeries: Effect of Care Standardization.

OBJECTIVE: To examine implementing an enhanced recovery after surgery (ERAS) protocol for women undergoing major gynecologic surgery at an academic institution and compare surgical outcomes before and after implementation. METHODS: Two ERAS protocols were developed: a full pathway using regional anesthesia for open procedures and a light pathway without regional anesthesia for vaginal and minimally invasive procedures. Enhanced recovery after surgery pathways included extensive preoperative counseling, carbohydrate loading and oral fluids before surgery, multimodal analgesia with avoidance of intravenous opioids, intraoperative goal-directed fluid resuscitation, and immediate postoperative feeding and ambulation. A before-and-after study design was used to compare clinical outcomes, costs, and patient satisfaction. Complications and risk-adjusted length of stay were drawn from the American College of Surgeons' National Surgical Quality Improvement Program database. RESULTS: On the ERAS full protocol, 136 patients were compared with 211 historical controls and the median length of stay was reduced (2.0 compared with 3.0 days; P=.007) despite an increase in National Surgical Quality Improvement Program-predicted length of stay (2.5 compared with 2.0 days; P=.009). Reductions were seen in median intraoperative morphine equivalents (0.3 compared with 12.7 mg; P<.001), intraoperative (285 compared with 1,250 mL; P<.001) and total intravenous fluids (-917.5 compared with 1,410 mL; P<.001), immediate postoperative pain scores (3.7 compared with 5.0; P<.001), and total complications (21.3% compared with 40.2%; P=.004). On the ERAS light protocol, 249 patients were compared with 324 historical controls and demonstrated decreased intraoperative and postoperative morphine equivalents (0.0 compared with 13.0 mg; P<.001 and 15.0 compared with 23.6 mg; P<.001) and decreased intraoperative and overall net intravenous fluids (P<.001). Patient satisfaction scores showed a marked and significant improvement on focus questions regarding pain control, nurses keeping patients informed, and staff teamwork; 30-day total hospital costs were significantly decreased in both ERAS groups. CONCLUSION: Implementation of ERAS protocols in gynecologic surgery was associated with a substantial decrease in intravenous fluids and morphine administration coupled with reduction in length of stay for open procedures combined with improved patient satisfaction and decreased hospital costs.

Bottleneck analysis and strategic planning using Tanahashi model for childhood diarrhea management in Gujarat, Western India.

In spite of continued efforts, India is still lagging behind in achieving its MDG goals. The objectives of this study were to identify stake-holders who have a role to play in childhood diarrhea management, to identify gaps in childhood diarrhea management and to propose strategic options for relieving these gaps. Bottleneck analysis exercise was carried out based on the Tanahashi model in six High Priority Districts (HPDs) of Gujarat in period between July-November 2013. The major bottlenecks identified for Childhood Diarrhea management were poor demand generation, unsafe drinking water, poor access to improved sanitation facility and lack of equitable distribution and replenishment mechanisms for Oral Rehydration Solution (ORS) packets and Zinc tablets till the front-line worker level. The main strategic options that were suggested for relieving these bottlenecks were Zinc-ORS roll out in scale-up districts, develop Information Education Communication/Behaviour Change Communication (IEC/BCC) plan for childhood diarrhea management at state/district level, use of Drug Logistics Information Management System (DLIMS) software for supply chain management of Zinc-ORS, strengthening of chlorination activity at household level, monitoring implementation of Nirmal Bharat Abhiyaan (NBA) for constructing improved sanitation facilities at household level and to develop an IEC/BCC plan for hygiene promotion and usage of sanitary latrines. Use of Zinc tablets need to be intensified through an effective scale-up. Adequate demand generation activity is needed. There is need to address safe drinking water and improved sanitation measures at household levels. Multi-sectoral engagements and ownership of Zinc-ORS program is the need of the hour.

Crystalloid administration among patients undergoing liver surgery: Defining patient- and provider-level variation.

BACKGROUND: Fluid administration among patients undergoing liver resection is a key aspect of perioperative care. We sought to examine practice patterns of crystalloid administration, as well as potential factors associated with receipt of crystalloid fluids. METHOD: Patients who underwent liver resection between 2010 and 2014 were identified. Data on clinicopathologic variables, operative details, and perioperative fluid administration were collected and analyzed using univariable and multivariable analyses; variation in practice of crystalloid administration was presented as coefficient of variation (COV). RESULTS: Among 487 patients, median crystalloid administered at the time of surgery was 4,000 mL. After adjusting for body size and operative duration, median corrected crystalloid was 30.0 mL kg(-1) m(2) h(-1), corresponding with a COV of 35%. Patients who received <30 mL kg(-1) m(2) h(-1) crystalloids were more likely to be younger (58 vs 60 years), white (79% vs 74%), and have a higher body mass index (BMI; 28.2 vs 25.4 kg/m(2); all P < .001). On multivariable analysis, increasing Charlson comorbidity index, BMI, estimated blood loss, and each additional hour of surgery were all associated with increased crystalloid administration (all P < .05). Corrected crystalloid administration varied among providers with a corrected COV ranging from 14% to 61%. When overall variation in crystalloid administration was assessed, 80% of the variation occurred at the patient level, and 20% occurred at the provider level (surgeon, 3% vs anesthesiologist, 17%). CONCLUSION: There was wide variability in crystalloid administration among patients undergoing liver resection. Although the majority of variation was attributable to patient factors, a large amount of residual variation was attributable to provider-level differences.

Fluid prescription practices of anesthesiologists managing patients undergoing elective colonoscopy: an observational study.

BACKGROUND: Routine fluid prescription is common practice amongst anesthesiologists caring for patients undergoing colonoscopy. However there is limited information about routine procedural fluid prescription practices of anesthesiologists in this setting. Routine fluid administration may also have important pharmaco-economic implications for the health care budget. Therefore we performed a prospective observational study assessing the fluid prescription practices of anesthesiologists caring for patients undergoing elective colonoscopy. METHODS: With Institutional Review Board approval, adult patients receiving procedural fluid intervention during elective colonoscopy were included. DATA COLLECTED: size of intravenous cannula inserted, volumes of fluid administered, adverse events, procedure duration, and pharmaco-economic costs associated with fluid prescription. Anesthesiologists and gastroenterologists were blinded to the study. RESULTS: We collected data on 289 patients who received fluid prescription by their attending anesthesiologist. Median patient age: 48 yrs (range 18-83), gender: 174 (60%) female; median duration of procedure: 24 minutes (range 12-48). Cannula size: 181 (63%) patients received a 22G cannula or smaller. Median volume of fluid administered during the colonoscopy was 325 ml (range 0 to 1000 ml). Median duration of the procedure: 25 minutes (range 12 to 48 minutes). Median volume of fluid administered in the post anaesthesia recovery unit: 450 ml (range 0 to 1000 ml). Fifteen patients (5%) became hypotensive during the procedure and two patients (<1%) developed hypotension in the PACU. There was no difference in the median fluid requirements between patients with hypotension and those without. Fluid volumes were strongly associated with increasing cannula diameter (p = 0.0001), however there was no association between fluid volumes administered and vasopressor use, peri-procedural adverse events, or procedure duration. At our institution fluid therapy currently cost about AUD$4.90 per patient: 1 L crystalloid $1.18 and fluid delivery set $3.77 Our institution performs over 9000 endoscopic procedures annually with fluid therapy costing about $45,000/year. CONCLUSIONS: Routine fluid prescription by anesthesiologists managing patients undergoing colonoscopy was ineffective with low actual fluid volumes delivered during the procedure. There was no association between volumes of fluid delivered and procedural hypotension, adverse events, or procedure duration. Anesthesiologists should question the clinical and pharmaco-economic value of routine fluid administration for patients undergoing elective endoscopy.

Assessment of the household availability of oral rehydration salt in rural Botswana.

INTRODUCTION: Diarrhea contributed for 17.6% of under-five deaths in Botswana. Oral rehydration salt (ORS) therapy has been the cornerstone in the control of morbidity and mortality secondary to diarrheal diseases. The study was aimed at assessing the household availability of ORS following the nationwide campaign of availing ORS at household level. METHODS: A cross sectional community based study was conducted in August 2012. EPI random walk method was used to identify households. Data was collected using interviewers' administered structured questionnaire. SPSS software was used in data entry and analysis. RESULTS: Oral Rehydration Salt (ORS) was available in 50.8% of the households with under-five children. Information on ORS is well disseminated whereas only three-fourth of informed participants had adequate knowledge of ORS preparation. The sources of information were predominantly the Child Welfare Clinic (88.8%). Being grandmother as a care taker was a negative predictor of household availability of ORS (AOR 0.25, 95% CI 0.09-0.69) while respondents who are knowledgeable about ORS preparation were more likely to have ORS available at home (AOR 1.92, 95% CI 1.10-3.34). CONCLUSION: The campaign has brought a significant coverage in terms of availability of ORS. The health education and community sensitization efforts need to go beyond health facilities via other means like the media and community based approaches. Approaches aimed at improving the knowledge of care takers on the importance of ORS, its preparation, correct use and restocking are of paramount importance. Availing community based outlet for ORS is an alternative to enhance accessibility.