A Multicenter, Open-Label, Randomized Controlled Trial of a Conservative Fluid Management Strategy Compared With Usual Care in Participants After Cardiac Surgery: The Fluids After Bypass Study.

OBJECTIVES: There is little evidence to guide fluid administration to patients admitted to the ICU following cardiac surgery. This study aimed to determine if a protocolized strategy known to reduce fluid administration when compared with usual care reduced ICU length of stay following cardiac surgery. DESIGN: Prospective, multicenter, parallel-group, randomized clinical trial. SETTING: Five cardiac surgical centers in New Zealand conducted from November 2016 to December 2018 with final follow-up completed in July 2019. PATIENTS: Seven-hundred fifteen patients undergoing cardiac surgery; 358 intervention and 357 usual care. INTERVENTIONS: Randomization to protocol-guided strategy utilizing stroke volume variation to guide administration of bolus fluid or usual care fluid administration until desedation or up to 24 hours. Primary outcome was length of stay in ICU. Organ dysfunction, mortality, process of care measures, patient-reported quality of life, and disability-free survival were collected up to day 180. MEASUREMENTS AND MAIN RESULTS: Overall 666 of 715 (93.1%) received at least one fluid bolus. Patients in the intervention group received less bolus fluid (median [interquartile range], 1,000 mL [250-2,000 mL] vs 1,500 mL [500-2,500 mL]; p < 0.0001) and had a lower overall fluid balance (median [interquartile range], 319 mL [-284 to 1,274 mL] vs 673 mL [38-1,641 mL]; p < 0.0001) in the intervention period. There was no difference in ICU length of stay between the two groups (27.9 hr [21.8-53.5 hr] vs 25.6 hr [21.9-64.6 hr]; p = 0.95). There were no differences seen in development of organ dysfunction, quality of life, or disability-free survival at any time points. Hospital mortality was higher in the intervention group (4% vs 1.4%; p = 0.04). CONCLUSIONS: A protocol-guided strategy utilizing stroke volume variation to guide administration of bolus fluid when compared with usual care until desedation or up to 24 hours reduced the amount of fluid administered but did not reduce the length of stay in ICU.

Bedside placement of an endobronchial valve to aid invasive ventilation and weaning from extracorporeal membrane oxygenation.

A bronchopleural fistula (BPF) is a life-threatening complication of cardiothoracic surgery and acute illness. There is no consensus on how best to treat a BPF. Recently, endobronchial one-way valves, designed for bronchoscopic lung volume reduction in emphysema, have been used to treat BPFs. We describe the use of an endobronchial oneway valve, placed at the bedside via flexible bronchoscopy, to treat a BPF in a patient with hypoxic respiratory failure, supported by extracorporeal membrane oxygenation (ECMO), secondary to pneumonia. We believe that this is the first published description of this technique being used in a patient needing ECMO support.

The accuracy of multidetector computed tomography in the diagnosis of non-occlusive mesenteric ischaemia in patients after cardiovascular surgery.

OBJECTIVE: To determine the accuracy of multidetector computed tomography (MDCT) in the diagnosis of nonocclusive mesenteric ischaemia (NOMI) among patients after cardiovascular surgery. DESIGN, SETTING AND PARTICIPANTS: A retrospective review of 38 patients in a cardiothoracic intensive care unit who underwent MDCT examination before laparotomy for suspected NOMI between January 2001 and December 2012. INTERVENTION AND MAIN OUTCOME MEASURES: The MDCT studies were examined independently by three radiologists, who were asked to make a determination on the presence or absence of NOMI. The radiological diagnosis was compared against the surgical and/or histological outcome to determine the diagnostic accuracy of MDCT. RESULTS: The sensitivity and specificity of MDCT in the diagnosis of NOMI were 96% and 33%-60%, respectively. The positive and negative likelihood ratios and diagnostic odds ratio were 1.43-2.39, 0.072-0.13 and 11-33.2, respectively. The inter-rater agreement was 68%, with a Fleiss κ of 0.43. CONCLUSIONS: MDCT has high sensitivity but lacks specificity in the diagnosis of NOMI. Its main value is in selection of patients for non-operative management, at least in the short-to-medium term.

Resuscitation for major trauma.

Disability from traumatic injury is on the increase worldwide. Dogma rather than scientific evidence has tended to be responsible for determining the treatment of major trauma victims. Evidence is now beginning to emerge, however, questioning the dogma, and suggesting that different treatment options may yield better outcomes. This review examines the recent literature in resuscitation for major trauma.