[Effect of fluid resuscitation with crystalloid combined with plasma on the prognosis of septic patients with hypoalbuminemia].

OBJECTIVE: To evaluate the difference in efficacy of two fluid resuscitation regimens, crystalloid alone versus crystalloid combined with plasma infusion, on the prognosis of septic patients with hypoalbuminemia. METHODS: A retrospective study was conducted. Septic patients with hypoalbuminemia admitted to the department of critical care medicine of Dongtai People's Hospital from January 2017 to December 2022 were selected as study subjects. Patients were divided into single group (crystalloid alone) and combined group (crystalloid combined with plasma) according to the fluid resuscitation regimen at the time of admission. General information, as well as coagulation indices before resuscitation (on day 1) and day 3 of resuscitation were collected. The primary study endpoint was 28-day mortality. The single and combined groups were stratified according to albumin level at resuscitation (< 25 g/L, 25-30 g/L, and > 30 g/L) to compare the differences in 28-day mortality among patients with different albumin levels. Kaplan-Meier survival curves of patients' 28-day prognosis were plotted. RESULTS: A total of 164 septic patients with hypoalbuminemia were included, including 60 patients in the single group and 104 patients in the combined group. (1) There were no significantly differences in age, gender, acute physiology and chronic health evaluation II (APACHE II), sequential organ failure assessment (SOFA), as well as pre-resuscitation platelet count (PLT), prothrombin time (PT), activated partial thromboplastin time (APTT), D-dimer, antithrombin- III (AT- III), international normalized ratio (INR), fibrin degradation product (FDP), serum lactic acid (Lac), and albumin level between the two groups, indicating comparability. (2) The levels of PT and AT- III in the combined group improved significantly on day 3 compared to before resuscitation, and the level of AT- III in the combined group improved more significantly on day 3 compared to the single group [(79.80±17.95)% vs. (66.67±18.69)%, P < 0.01]. Lac and albumin levels improved significantly after resuscitation in both the single and combined groups, but there were no significantly differences in the degree of improvement between the two groups. (3) There was no significantly difference in the 28-day mortality between the single group and the combined group [55.0% (33/60) vs. 42.3% (44/104), P > 0.05]. The 28-day mortality of patients with albumin < 25 g/L was significantly higher than that with albumin 25-30 g/L and > 30 g/L [63.1% (41/65) vs. 36.2% (25/69), 36.7% (11/30), both P < 0.05]. (4) Kaplan-Meier survival curve analysis showed that there was no significantly difference in 28-day cumulative survival rate between the single group and the combined group (Log-Rank: χ 2 = 2.067,P = 0.151). The median survival rate of albumin was 27.1 g/L [95% confidence interval (95%CI) was 24.203-29.997] in the single group and 28.7 g/L (95%CI was 26.065-31.335) in the combined group. CONCLUSIONS: Fluid resuscitation with crystalloid combined with plasma improves exogenous coagulation dysfunction in septic patients with hypoalbuminemia, but does not improve 28-day mortality outcome. The higher the initial albumin level in septic patients, the lower the mortality.

Mobile phone call reminders to improve oral rehydration salt and zinc adherence for acute diarrhea in children: a single-center, randomized controlled trial.

BACKGROUND: Low-osmolarity oral rehydration salt (ORS) and zinc therapy effectively manage diarrhea in children under five years of age, offering both short- and long-term benefits. Despite this, caregivers' adherence to ORS and zinc is often unsatisfactory due to factors such as forgetfulness, resolution of symptoms, and underestimation of the disease's severity. This study assessed the effect of mobile call reminders on ORS and zinc tablet adherence among children with acute diarrhea in a secondary-level health facility in Kwara State, Nigeria. METHODS: Using an open-label, randomized controlled trial design, this study compared caregiver-child pairs with acute diarrhea aged 6-59 months who received standard instructions (SI) alone (control group) and an intervention group (IG) who received SI plus phone call reminders on days three and seven of zinc sulfate therapy. All participants used a pictorial diary to track loose/watery stools and ORS and zinc tablet treatments for ten days. The primary outcome measures were independent and combined adherence to ORS and zinc therapy. The secondary outcomes were independent and combined adherence scores, defined as the percentage of times the ORS was given post-diarrhea and the percentage of prescribed zinc tablets administered out of ten. RESULTS: A total of 364/400 mother-child pairs completed the study. The percentage of mothers with full adherence in the intervention group was 82.5% for ORS, 72.1% for zinc, and 58.5% for combined use, compared to 78.8%, 60.8%, and 43.6%, respectively, in the control group. The odds of full adherence to ORS and zinc were 1.6 and 1.7 times higher among intervention mothers [ORS: OR = 1.561, 95% CI = 0.939-2.598, P = 0.085; zinc: OR = 1.671, 95% CI = 1.076-2.593, P = 0.022], and 1.8 times higher for combined use according to WHO guidelines [OR = 1.818, 95% CI = 1.200-2.754, P = 0.005]. The mean adherence scores for the intervention group were higher than those for the control group by 4.1% (95% CI = 0.60-7.60) for ORS, 7.3% (95% CI = 3.74-10.86) for zinc, and 5.7% (95% CI = 3.23-8.17) for the combined treatment. CONCLUSION: Phone reminders can effectively improve consistency of home treatment administered by caregivers for children under five years old. TRIAL REGISTRATION: The study was registered retrospectively (17/3/2023) with the Pan African Clinical Trial Registry (PACTR202301560735856).

Fluid bolus increases plasma hyaluronan concentration compared to follow-up strategy without a bolus in oliguric intensive care unit patients.

Fluid therapy is a fundamental part of supportive therapy in critical care. However, it is also a suspected risk for endothelial glycocalyx degradation which is associated with poor clinical outcomes. This secondary analysis of RESPONSE randomized trial compares the effect of follow-up strategy (FU) on endothelial biomarkers to that of 500 ml crystalloid fluid bolus (FB) in oliguric, hemodynamically optimized intensive care unit (ICU) patients. 130 adult subjects were enrolled in two Finnish ICUs from January 2017 to November 2020. Blood and urine samples of 63 patients in FU group and 67 patients in FB group were collected before and after the intervention and analyzed using enzyme-linked immunosorbent assays. Single fluid bolus, given after median of 3887 ml (interquartile range 2842; 5359 ml) resuscitation fluids in the preceding 24 h, increased plasma hyaluronan concentration compared to the follow-up strategy (difference in medians 29.2 ng/ml with 95% CI [14.5ng/ml; 55.5ng/ml], P < 0.001). No treatment effect was detected in the plasma levels of syndecan-1, , angiopoietin-2, angiopoietin receptors Tie2 and Tie1, or in soluble thrombomodulin in the adjusted median regression analysis. The increase in hyaluronan was independent of its simultaneous renal clearance but correlated moderately with the increase in endothelium-specific Tie1. The follow-up strategy did not show consistent endothelium-sparing effect but protected against hyaluronan increase. The mechanisms and consequences of hyaluronan fluctuations need further clarification. Trial registration: clinicaltrials.gov, NCT02860572. Registered 1 August 2016, https://www.clinicaltrials.gov/study/NCT02860572?term=NCT02860572&rank=1.

Evaluation of the effect of fluid management on intracranial pressure in patients undergoing laparoscopic gynaecological surgery based on the ratio of the optic nerve sheath diameter to the eyeball transverse diameter as measured by ultrasound: a randomised controlled trial.

BACKGROUND: During gynecological laparoscopic surgery, pneumoperitoneum and the Trendelenburg position (TP) can lead to increased intracranial pressure (ICP). However, it remains unclear whether perioperative fluid therapy impacts ICP. The purpose of this research was to evaluate the impact of restrictive fluid (RF) therapy versus conventional fluid (CF) therapy on ICP in gynecological laparoscopic surgery patients by measuring the ratio of the optic nerve sheath diameter (ONSD) to the eyeball transverse diameter (ETD) using ultrasound. METHODS: Sixty-four patients who were scheduled for laparoscopic gynecological surgery were randomly assigned to the CF group or the RF group. The main outcomes were differences in the ONSD/ETD ratios between the groups at predetermined time points. The secondary outcomes were intraoperative circulatory parameters (including mean arterial pressure, heart rate, and urine volume changes) and postoperative recovery indicators (including extubation time, length of post-anaesthesia care unit stay, postoperative complications, and length of hospital stay). RESULTS: There were no statistically significant differences in the ONSD/ETD ratio and the ONSD over time between the two groups (all p > 0.05). From T2 to T4, the ONSD/ETD ratio and the ONSD in both groups were higher than T1 (all p < 0.001). From T1 to T2, the ONSD/ETD ratio in both groups increased by 14.3%. However, the extubation time in the RF group was shorter than in the CF group [median difference (95% CI) -11(-21 to -2) min, p = 0.027]. There were no differences in the other secondary outcomes. CONCLUSION: In patients undergoing laparoscopic gynecological surgery, RF did not significantly lower the ONSD/ETD ratio but did shorten the tracheal extubation time, when compared to CF. TRIAL REGISTRATION: ChiCTR2300079284. Registered on December 29, 2023.

Effect of temperature on rehydration and fracture resistance of reattached tooth fragments after crown fracture: An in vitro study.

BACKGROUND: Uncomplicated crown fractures of maxillary anterior teeth are common dental injuries, and the bonding of fractured fragments is recommended for management. Rehydration of fragments improves bonding and fracture resistance. Therefore, the aim of this study was to compare the fracture resistance of the reattached tooth fragment of the incisor crown after rehydration using either a steamer or a humidifier. MATERIALS AND METHODS: Bovine teeth were used as a model. Fractured fragments were divided into three groups: Group I (no rehydration), Group II (rehydration by humidifier), and Group III (rehydration by steamer). Fragments were reattached using a standard bonding protocol. Fracture resistance was tested using a universal testing machine. Statistical analysis was performed using analysis of variance and Chi-square tests. RESULTS: The force required to fracture the reattached fragments was significantly higher in Group II (humidifier) compared to Group I (no rehydration) (P = 0.005). Group III (steamer) had a force value similar to Group I, indicating no significant improvement in fracture resistance with steamer rehydration. The temperature inside the steam-based chamber reached an average of 95.7°C with 95% humidity, whereas the conventional humidification chamber had an average temperature of 39.2°C and 84% humidity. CONCLUSION: Within the limitations of the present study, the rehydration protocol using a steam-based chamber was found to have a significantly lower force required to fracture the reattached fragments as compared to humidifier-based chamber. This was not significantly different from the fragments which were reattached without rehydration.

Impact of staged goal-directed fluid therapy on postoperative pulmonary complications in patients undergoing McKeown esophagectomy: a randomized controlled trial.

BACKGROUND: Our aim was to evaluate the influence of staged goal directed therapy (GDT) on postoperative pulmonary complications (PPCs), intraoperative hemodynamics and oxygenation in patients undergoing Mckeown esophagectomy. METHODS: Patients were randomly divided into three groups, staged GDT group (group A, n = 56): stroke volume variation (SVV) was set at 8-10% during the one lung ventilation (OLV) stage and 8-12% during the two lung ventilation (TLV) stage, GDT group (group B, n = 56): received GDT with a target SVV of 8-12% During the entire surgical procedure, and control group (group C, n = 56): conventional fluid therapy was administered by mean arterial pressure (MAP), central venous pressure (CVP), and urine volume. The primary outcome was the incidence of postoperative pulmonary complications within Postoperative days (POD) 7. The secondary outcomes were postoperative lung ultrasound (LUS) B-lines artefacts (BLA) scoring, incidence of other complications, the length of hospital stay, intraoperative hemodynamic and oxygenation indicators included mean arterial pressure (MAP), heart rate (HR), cardiac index (CI), cardiac output (CO), oxygenation index (OI), respiratory indices (RI), alveolar-arterial oxygen difference (Aa-DO2). RESULTS: Patients in group A and group B had a lower incidence of PPCs (7/56 vs. 17/56 and 9/56 vs. 17/56, p < 0.05), and a fewer B-lines score on postoperative ultrasound (4.61 ± 0.51 vs. 6.15 ± 0.74 and 4.75 ± 0.62 vs. 6.15 ± 0.74, p < 0.05) compared to group C. The CI, CO, MAP, and OI were higher in group A compared to group B and group C in the stage of thoracic operation. During the abdominal operation stage, patients in group A and group B had a better hemodynamic and oxygenation indicators than group C. CONCLUSIONS: In comparison to conventional fluid therapy, intraoperative staged GDT can significantly reduce the incidence of postoperative pulmonary complications in patients undergoing McKeown esophagectomy, facilitating patient recovery. Compared to GDT, it can improve intraoperative oxygenation and stabilize intraoperative hemodynamics in patients. TRIAL REGISTRATION: This study was registered in the Chinese Clinical Trial Registry on 24/11/2021 (ChiCTR2100053598).

[Should fluids thickeners still be used for patients with swallowing problerms?] / Si devono ancora usare gli addensanti per i pazienti con problemi di deglutizione?

. Should fluids thickeners still be used for patients with swallowing problems? The use of thickened fluids in patients with dysphagia is widespread and considered an effective strategy for improving swallowing. However, the evidences that support the effectiveness of thickened fluids in reducing aspiration pneumonia and other complications are scarce. Instead, a body of evidences suggests that it is associated to adverse events, including dehydration, malnutrition and reduced health-related quality of life. A recent study on the implementation of this intervention on patients with dementia and dysphagia admitted to hospital shows no differences in mortality between patients exposed or not to a diet with thick liquid, and a higher risk of respiratory complications. Pending studies to clarify which behaviour is best, it is important to try to understand, together with the patient and the clinical specialists, the best strategy tailored on the patient.

Effect of maneuvers, diuresis, and fluid administration on ultrasound-measured liver stiffness after Fontan.

BACKGROUND: To determine the effect of stress maneuvers/interventions on ultrasound liver stiffness measurements (LSMs) in patients with Fontan circulation and healthy controls. METHODS: In this prospective, IRB-approved study of 10 patients after Fontan palliation and 10 healthy controls, ultrasound 2D shear-wave elastography LSMs were acquired at baseline and after maximum inspiration, expiration, standing, handgrip, aerobic exercise, i.v. fluid (500 mL normal saline) administration, and i.v. furosemide (20 mg) administration. Absolute and percent change in LSM were compared between baseline and each maneuver, and then from fluid infusion to after diuresis. RESULTS: Median ages were 25.5 and 26 years in the post-Fontan and control groups (p = 0.796). LSMs after Fontan were higher at baseline (2.6 vs. 1.3 m/s) and with all maneuvers compared to controls (all p < 0.001). Changes in LSM with maneuvers, exercise, fluid, or diuresis were not significant when compared to baseline in post-Fontan patients. LSM in controls increased with inspiration (+0.02 m/s, 1.6%, p = 0.03), standing (+0.07 m/s, 5.5%, p = 0.03), and fluid administration (+0.10 m/s, 7.8%, p = 0.002), and decreased 60 minutes after diuretic administration (-0.05 m/s, -3.9%, p = 0.01) compared to baseline. LSM after diuretic administration significantly decreased when compared to after i.v. fluid administration at 30 minutes (-0.79 m/s, -26.5%, p = 0.004) and 60 minutes (-0.78 m/s, -26.2%, p = 0.017) for patients after Fontan and controls at 15 minutes (-0.12 m/s, -8.70%, p = 0.002), 30 minutes (-0.15 m/s, -10.9%, p = 0.003), and 60 minutes (-0.1 m/s, -10.9%, p = 0.005). CONCLUSIONS: LSM after Fontan is higher with more variability compared to controls. Diuresis is associated with significantly decreased liver stiffness in both patients after Fontan and controls, with the suggestion of a greater effect in Fontan patients.

The Precision Resuscitation With Crystalloids in Sepsis (PRECISE) Trial: A Trial Protocol.

Importance: Intravenous fluids are an essential part of treatment in sepsis, but there remains clinical equipoise on which type of crystalloid fluids to use in sepsis. A previously reported sepsis subphenotype (ie, group D) has demonstrated a substantial mortality benefit from balanced crystalloids compared with normal saline. Objective: To test the hypothesis that targeting balanced crystalloids to patients with group D sepsis through an electronic health record (EHR) alert will reduce 30-day inpatient mortality. Design, Setting, and Participants: The Precision Resuscitation With Crystalloids in Sepsis (PRECISE) trial is a parallel-group, multihospital, single-blind, pragmatic randomized clinical trial to be conducted at 6 hospitals in the Emory Healthcare system. Patients with suspicion of group D infection in whom a clinician initiates an order for normal saline in the emergency department (ED) or intensive care unit (ICU) will be randomized to usual care and intervention arms. Intervention: An EHR alert that appears in the ED and ICUs to nudge clinicians to use balanced crystalloids instead of normal saline. Main Outcomes and Measures: The primary outcome is 30-day inpatient mortality. Secondary outcomes are ICU admission, in-hospital mortality, receipt of vasoactive drugs, receipt of new kidney replacement therapy, and receipt of mechanical ventilation (vasoactive drugs, kidney replacement therapy, and mechanical ventilation are counted if they occur after randomization and within the 30-day study period). Intention-to-treat analysis will be conducted. Discussion: The PRECISE trial may be one of the first precision medicine trials of crystalloid fluids in sepsis. Using routine vital signs (temperature, heart rate, respiratory rate, and blood pressure), available even in low-resource settings, a validated machine learning algorithm will prospectively identify and enroll patients with group D sepsis who may have a substantial mortality reduction from used of balanced crystalloids compared with normal saline. Results: On finalizing participant enrollment and analyzing the data, the study's findings will be shared with the public through publication in a peer-reviewed journal. Conclusions: With use of a validated machine learning algorithm, precision resuscitation in sepsis could fundamentally redefine international standards for intravenous fluid resuscitation. Trial Registration: ClinicalTrials.gov Identifier: NCT06253585.

Conservative fluid resuscitation protocol does not reduce the incidence of reoperation for bleeding after emergency CABG.

Reoperation for bleeding (ROB) after emergency coronary artery bypass grafting (eCABG) has been identified as an independent risk factor for mortality. Consecutively, the influence of fluid intake, fluid output, fluid balance, blood loss, and inotropic demand on ROB were analyzed. This retrospective single-center study included 265 patients undergoing eCABG between 2011 and 2020. From 2018, postoperative hemodynamic management was performed with lower volume administration and higher vasoactive support. The primary outcome measure was the incidence of ROB within 48 h according to altered fluid resuscitation strategy. Consecutively, the influence of fluid intake, fluid output, fluid balance, blood loss, and inotropic demand on ROB were analyzed. Incidence of ROB was independent from the volume resuscitation protocol (P = .3). The ROB group had a higher perioperative risk, which was observed in EuroSCORE II. Fluid intake (P = .021), fluid balance (P = .001), and norepinephrine administration (P = .004) were associated with ROB. Fluid output and blood loss were not associated with ROB (P = .22). Post-test probability was low among all variables. Although fluid management might have an impact on specific postoperative complications, different fluid resuscitation protocols did not alter the incidence of ROB after emergency CABG. TRIAL REGISTRATION: www. CLINICALTRIALS: gov registration number NCT04533698; date of registration: August 31, 2020 (retrospectively registered due to nature of the study); URL: https://classic. CLINICALTRIALS: gov/ct2/show/NCT04533698.

[Importance of hydration in people with dysphagia and its consequences]. / Importancia de la hidratación en personas con disfagia y sus consecuencias.

Introduction: Introduction: dysphagia is a difficulty in moving food or drink from the mouth to the stomach, which may consist of a delay or an impossibility of transit or an-error in the direction, with the consequent passage into the airways. Dysphagia increases the risk of malnutrition and dehydration in the patient. However, although dehydration is one of the most common complications of dysphagia and is associated with significant risks, including hospitalization and mortality, it has been little studied in terms of its relationship and associated risk factors. Methods: a review of the scientific literature on the hydration of people with dysphagia and the dangers of inadequate hydration in them was carried out. Results and discussion: the dietary and nutritional approach in patients with dysphagia requires a multidisciplinary and personalized approach and is essential to improve the quality of life of patients with dysphagia. Dehydration is a frequent and serious complication in patients with dysphagia, which can lead to problems such as urinary tract infections, constipation, confusion, and worsening of chronic diseases. Therefore, it is crucial to carefully evaluate and monitor the fluid intake in these patients, and strategies to improve hydration include the use of thickened liquids, stimulating appetite, and adapting the texture and presentation of foods. Conclusión: adequate and protocolized management, from a dietary and nutritional point of view, can have a significant impact on the quality of life of patients, improving their well-being and preventing complications associated with this condition. A comprehensive approach to dysphagia, which includes adequate assessment and management of hydration, is essential to prevent serious complications.

Introducción: Introducción: la disfagia supone una dificultad en el desplazamiento del alimento o de la bebida desde la boca hasta al estómago, que puede consistir en un retraso o una imposibilidad de tránsito o en un error en la dirección, con el consiguiente paso a la vía aérea. La disfagia aumenta el riesgo de desnutrición y deshidratación en el paciente. Pero aunque la deshidratación es una de las complicaciones más comunes de la disfagia y se asocia con riesgos importantes, incluyendo hospitalización y mortalidad, su relación y los factores de riesgo asociados han sido poco estudiados. Métodos: se llevó a cabo una revisión de la literatura científica sobre la hidratación de las personas con disfagia y los peligros de una inadecuada hidratación en ellas. Resultados y discusión: el abordaje dietético y nutricional en pacientes con disfagia requiere un enfoque multidisciplinar y personalizado y es fundamental para mejorar su calidad de vida. La deshidratación es una complicación frecuente y grave en pacientes con disfagia, que puede llevar a problemas como infecciones urinarias, estreñimiento, confusión y empeoramiento de enfermedades crónicas. Por ello, es crucial evaluar y monitorizar cuidadosamente la ingesta hídrica de estos pacientes y establecer estrategias para mejorar la hidratación, incluyendo el uso de líquidos espesados, la estimulación del apetito y la adaptación de la textura y presentación de los alimentos. Conclusión: un manejo adecuado y protocolizado, desde el punto de vista dietético y nutricional, puede llegar a tener un impacto significativo en la calidad de vida de los pacientes, mejorando su bienestar y previniendo complicaciones asociadas a esta condición. El abordaje integral de la disfagia, que incluye una adecuada evaluación y manejo de la hidratación, es fundamental para prevenir complicaciones graves.

Preload responsiveness-guided fluid removal in mechanically ventilated patients with fluid overload: A comprehensive clinical-physiological study.

This study investigated fluid removal strategies for critically ill patients with fluid overload on mechanical ventilation. Traditionally, a negative fluid balance (FB) is aimed for. However, this approach can have drawbacks. Here, we compared a new approach, namely removing fluids until patients become fluid responsive (FR) to the traditional empiric negative balance approach. Twelve patients were placed in each group (n = 24). FR assessment was performed using passive leg raising (PLR). Both groups maintained stable blood pressure and heart function during fluid management. Notably, the FR group weaned from the ventilator significantly faster than negative FB group (both for a spontaneous breathing trial (14 h vs. 36 h, p = 0.031) and extubation (26 h vs. 57 h, p = 0.007); the difference in total ventilator time wasn't statistically significant (49 h vs. 62 h, p = 0.065). Additionally, FR group avoided metabolic problems like secondary alkalosis and potential hypokalemia seen in the negative FB group. FR-guided fluid-removal in fluid overloaded mechanically ventilated patients was a feasible, safe, and maybe superior strategy in facilitating weaning and disconnection from mechanical ventilation than negative FB-driven fluid removal. FR is a safe endpoint for optimizing cardiac function and preventing adverse consequences during fluid removal.

Effects of long-term dehydration and quick rehydration on the camel kidney: pathological changes and modulation of the expression of solute carrier proteins and aquaporins.

BACKGROUND: Recurrent dehydration causes chronic kidney disease in humans and animal models. The dromedary camel kidney has remarkable capacity to preserve water and solute during long-term dehydration. In this study, we investigated the effects of dehydration and subsequent rehydration in the camel's kidney histology/ultrastructure and changes in aquaporin/solute carrier proteins along with gene expression. RESULTS: In light microscopy, dehydration induced few degenerative and necrotic changes in cells of the cortical tubules with unapparent or little effect on medullary cells. The ultrastructural changes encountered in the cortex were infrequent during dehydration and included nuclear chromatin condensation, cytoplasmic vacuolization, mitochondrial swelling, endoplasmic reticulum/ lysosomal degeneration and sometimes cell death. Some mRNA gene expressions involved in cell stability were upregulated by dehydration. Lesions in endothelial capillaries, glomerular membranes and podocyte tertiary processes in dehydrated camels indicated disruption of glomerular filtration barrier which were mostly corrected by rehydration. The changes in proximal tubules brush borders after dehydration, were accompanied by down regulation of ATP1A1 mRNA involved in Na + /K + pump that were corrected by rehydration. The increased serum Na, osmolality and vasopressin were paralleled by modulation in expression level for corresponding SLC genes with net Na retention in cortex which were corrected by rehydration. Medullary collecting ducts and interstitial connective tissue were mostly unaffected during dehydration. CKD, a chronic nephropathy induced by recurrent dehydration in human and animal models and characterized by interstitial fibrosis and glomerular sclerosis, were not observed in the dehydrated/rehydrated camel kidneys. The initiating factors, endogenous fructose, AVP/AVPR2 and uric acid levels were not much affected. TGF-ß1 protein and TGF-ß1gene expression showed no changes by dehydration in cortex/medulla to mediate fibrosis. KCNN4 gene expression level was hardly detected in the dehydrated camel's kidney; to encode for Ca + + -gated KCa3.1 channel for Ca + + influx to instigate TGF-ß1. Modulation of AQP 1, 2, 3, 4, 9 and SLC protein and/or mRNAs expression levels during dehydration/rehydration was reported. CONCLUSIONS: Long-term dehydration induces reversible or irreversible ultrastructural changes in kidney cortex with minor effects in medulla. Modulation of AQP channels, SLC and their mRNAs expression levels during dehydration/rehydration have a role in water conservation. Cortex and medulla respond differently to dehydration/rehydration.

Myocardial strain is regulated by cardiac preload in the early stage of sepsis.

BACKGROUND: Owing to a lack of data, this study aimed to explore the effect of cardiac preload on myocardial strain in patients with sepsis. METHODS: A total of 70 patients with sepsis in intensive care unit (ICU) of a tertiary teaching hospital in China from January 2018 to July 2019 and underwent transthoracic echocardiography were enrolled. Echocardiographic data were recorded at ICU admission and 24 h later. Patients were assigned to low left ventricular end-diastolic volume index (LVEDVI) and normal LVEDVI groups. We assessed the impact of preload on myocardial strain between the groups and analyzed the correlation of echocardiographic parameters under different preload conditions. RESULTS: Thirty-seven patients (53%) had a low LVEDVI and 33 (47%) a normal LVEDVI. Those in the low LVEDVI group had a faster heart rate (121.7 vs. 95.3, p < 0.001) and required a greater degree of fluid infusion (3.67 L vs. 2.62 L, P = 0.019). The left ventricular global strain (LVGLS) (-8.60% vs. -10.80%, p = 0.001), left ventricular global circumferential strain (LVGCS) (-13.83% vs. -18.26%, p = 0.006), and right ventricular global longitudinal strain (RVGLS) (-6.9% vs. -10.60%, p = 0.001) showed significant improvements in the low LVEDVI group after fluid resuscitation. However, fluid resuscitation resulted in a significantly increased cardiac afterload value (1172.00 vs. 1487.00, p = 0.009) only in the normal LVEDVI group. Multivariate backward linear regression showed that LVEDVI changes were independently associated with myocardial strain-related improvements during fluid resuscitation. The baseline LVEDVI was significantly negatively correlated with the LVGLS and RVGLS (r = -0.44 and - 0.39, respectively) but not LVGCS. LVEDVI increases during fluid resuscitation were associated with improvements in the myocardial strain degree. CONCLUSIONS: Myocardial strain alterations were significantly influenced by the cardiac preload during fluid resuscitation in sepsis.

Prehospital treatment of severely burned patients: a retrospective analysis of patients admitted to the Berlin burn centre.

BACKGROUND: Prehospital management of severely burned patients is extremely challenging. It should include adequate analgesia, decision-making on the necessity of prehospital endotracheal intubation and the administration of crystalloid fluids. Guidelines recommend immediate transport to specialised burn centres when certain criteria are met. To date, there is still insufficient knowledge on the characteristics of prehospital emergency treatment. We sought to investigate the current practice and its potential effects on patient outcome. METHODS: We conducted a single centre, retrospective cohort analysis of severely burned patients (total burned surface area > 20%), admitted to the Berlin burn centre between 2014 and 2019. The relevant data was extracted from Emergency Medical Service reports and digital patient charts for exploratory data analysis. Primary outcome was 28-day-mortality. RESULTS: Ninety patients (male/female 60/30, with a median age of 52 years [interquartile range, IQR 37-63], median total burned surface area 36% [IQR 25-51] and median body mass index 26.56 kg/m2 [IQR 22.86-30.86] were included. The median time from trauma to ED arrival was 1 h 45 min; within this time, on average 1961 ml of crystalloid fluid (0.48 ml/kg/%TBSA, IQR 0.32-0.86) was administered. Most patients received opioid-based analgesia. Times from trauma to ED arrival were longer for patients who were intubated. Neither excessive fluid treatment (> 1000 ml/h) nor transport times > 2 h was associated with higher mortality. A total of 31 patients (34,4%) died within the hospital stay. Multivariate regression analysis revealed that non-survival was linked to age > 65 years (odds ratio (OR) 3.5, 95% CI: 1.27-9.66), inhalation injury (OR 3.57, 95% CI: 1.36-9.36), burned surface area > 60% (OR 5.14, 95% CI 1.57-16.84) and prehospital intubation (5.38, 95% CI: 1.92-15.92). CONCLUSION: We showed that severely burned patients frequently received excessive fluid administration prehospitally and that this was not associated with more hemodynamic stability or outcome. In our cohort, patients were frequently intubated prehospitally, which was associated with increased mortality rates. Further research and emergency medical staff training should focus on adequate fluid application and cautious decision-making on the risks and benefits of prehospital intubation. TRIAL REGISTRATION: German Clinical Trial Registry (ID: DRKS00033516).

Assessment of fluid responsiveness using pulse pressure variation, stroke volume variation, plethysmographic variability index, central venous pressure, and inferior vena cava variation in patients undergoing mechanical ventilation: a systematic review and meta-analysis.

IMPORTANCE: Maneuvers assessing fluid responsiveness before an intravascular volume expansion may limit useless fluid administration, which in turn may improve outcomes. OBJECTIVE: To describe maneuvers for assessing fluid responsiveness in mechanically ventilated patients. REGISTRATION: The protocol was registered at PROSPERO: CRD42019146781. INFORMATION SOURCES AND SEARCH: PubMed, EMBASE, CINAHL, SCOPUS, and Web of Science were search from inception to 08/08/2023. STUDY SELECTION AND DATA COLLECTION: Prospective and intervention studies were selected. STATISTICAL ANALYSIS: Data for each maneuver were reported individually and data from the five most employed maneuvers were aggregated. A traditional and a Bayesian meta-analysis approach were performed. RESULTS: A total of 69 studies, encompassing 3185 fluid challenges and 2711 patients were analyzed. The prevalence of fluid responsiveness was 49.9%. Pulse pressure variation (PPV) was studied in 40 studies, mean threshold with 95% confidence intervals (95% CI) = 11.5 (10.5-12.4)%, and area under the receiver operating characteristics curve (AUC) with 95% CI was 0.87 (0.84-0.90). Stroke volume variation (SVV) was studied in 24 studies, mean threshold with 95% CI = 12.1 (10.9-13.3)%, and AUC with 95% CI was 0.87 (0.84-0.91). The plethysmographic variability index (PVI) was studied in 17 studies, mean threshold = 13.8 (12.3-15.3)%, and AUC was 0.88 (0.82-0.94). Central venous pressure (CVP) was studied in 12 studies, mean threshold with 95% CI = 9.0 (7.7-10.1) mmHg, and AUC with 95% CI was 0.77 (0.69-0.87). Inferior vena cava variation (∆IVC) was studied in 8 studies, mean threshold = 15.4 (13.3-17.6)%, and AUC with 95% CI was 0.83 (0.78-0.89). CONCLUSIONS: Fluid responsiveness can be reliably assessed in adult patients under mechanical ventilation. Among the five maneuvers compared in predicting fluid responsiveness, PPV, SVV, and PVI were superior to CVP and ∆IVC. However, there is no data supporting any of the above mentioned as being the best maneuver. Additionally, other well-established tests, such as the passive leg raising test, end-expiratory occlusion test, and tidal volume challenge, are also reliable.