Evaluation of Intensive Care Measures in Children with Severe New Coronavirus Infection in Pediatric Intensive Care Units

Currently, the number of publications on specific features of the clinical course and outcomes of new coronavirus infection COVID-19 in children is steadily increasing, but there are practically no works demonstrating the effectiveness of intensive care interventions, which served as the basis for the present analysis.The objective is to assess the effectiveness of primary intensive care interventions in children with a severe course of new coronavirus infection.Subjects and Methods. 94 patients were examined. Evaluation of intensive care measures was carried out upon admission to ICU.Results. It was found that corticosteroids were used only in 55 (58.5%) patients (χ2 = 5.254, p = 0.022, Pearson conjugation criterion = 0.130). A moderate correlation was established between the unjustified prescription of prednisolone and the unfavorable disease outcome (χ2 = 27.98, p < 0.001, Pearson conjugation criterion = 0.296). The moderate strength of the association between the prescription of antibacterial drugs and the disease outcome was noted (χ2 = 34.01, p < 0.001, Pearson conjugation criterion = 0.331). In all lethal cases, there was volume overload due to excessive intravenous fluid administration (χ2 = 5.14, p = 0.024).Conclusion: individual therapeutic strategies do not have a direct significant impact on outcomes of new coronavirus infection in children, however, the delivery of comprehensive intensive care presented in clinical guidelines is associated with the patient's recovery.

Significance of initial hemoglobin levels in severe trauma patients without prehospital fluid administration: a single-center study in Japan

ObjectivesHemoglobin (Hb) levels have been considered to remain stable in the early stages of bleeding due to trauma. However, several studies have reported that rapid compensatory fluid shifts cause Hb dilution earlier than previously thought. These reports are from Western countries where it is standard protocol to administer fluids during an emergency, making it almost impossible to eliminate the effect of prehospital intravenous fluid administration on Hb levels. This study aimed to determine the relationship between Hb levels and severity of injury on arrival at the hospital in severe trauma patients without prehospital intravenous fluid administration.MethodsThis single-center observational retrospective study included patients with Abbreviated Injury Scale scores of 3 or above between 2008 and 2014. In Japan, prehospital life-saving technicians were not allowed to administer intravenous fluids until 2014. We investigated whether the difference between the measured blood Hb level at arrival and the corresponding standard blood Hb level for each age group and sex reported in the national survey was associated with the severity of injury and the need for hemostasis.ResultsIn total, 250 patients were included in this study (median age, 46 years; male patients, 183). The median time from injury to arrival at the hospital was 45 min, and there was no statistical correlation with the initial Hb level on arrival (ρ=0.092, p=0.14). When the study subjects were stratified into four groups according to the initial Hb levels, lower Hb levels correlated with higher rates of requirement for hemostatic interventions (p=0.02) and mortality (p=0.02). In addition, lower Hb levels were associated with the need for hemostasis.ConclusionIn severe trauma patients without prehospital intravenous fluid administration, decreased Hb levels on arrival may be associated with the severity of trauma and with the need for hemostasis.Level of evidenceLevel IV.

Paradoxical and Retrograde Air Embolism from Pressurized Peripheral Bolus

Introduction. Cerebral air embolism is a rare, yet serious neurological occurrence with unclear incidence and prevalence. Here, we present a case of fatal cerebral arterial and venous cerebral gas embolism in a patient with infective endocarditis and known large right-to-left shunt and severe tricuspid regurgitation following pressurized fluid bolus administration. Case Presentation. A 32-year-old female was admitted to the medical intensive care unit from a long-term acute care facility with acute on chronic respiratory failure. Her medical history was significant for intravenous heroin and cocaine abuse, methicillin-sensitive Staphylococcus aureus tricuspid valve infective endocarditis on vancomycin, patent foramen ovale, septic pulmonary embolism with cavitation, tracheostomy with chronic ventilator dependence, multifocal cerebral infarction, hepatitis C, nephrolithiasis, anxiety, and depression. After intravenous fluid administration, she became unresponsive with roving gaze, sluggish pupils, and hypotensive requiring vasopressors. CT of the brain showed diffuse arterial and venous cerebral air embolism secondary to accidental air administration from fluid bolus. Magnetic resonance imaging of the brain showed diffuse global anoxic injury and flattening of the globe at the optic nerve insertion. Given poor prognosis, her family chose comfort measures and she died. Conclusions. Fatal cerebral air embolism can occur through peripheral intravenous routes when the lines are inadequately primed and fluids administered with pressure. Caution must be exercised in patients with right-to-left shunting as air may gain access to systemic circulation.

EP.TH.174The FLIP Study – Fluid Resuscitation in Pancreatitis

Acute pancreatitis is a common condition encountered in emergency general surgical presentations. The severity of this condition can range from mild to severe and potentially life threatening in up to 20% of cases. Intravenous fluids are the cornerstone of management however there is very little guidance and poor quality evidence regarding optimal intravenous fluid administration. Aim to establish current clinical practice regarding the rate of intravenous fluid administration in acute pancreatitis and the effect this has on patient morbidity and mortality. A prospective multi-centre audit of patients presenting with acute pancreatitis in the North East of England (Sixty days recruitment with 30-day follow-up, November 2020 – February 2021). Patients aged 18 years or above with acute pancreatitis will be included. Data will be collected on intravenous fluid administration within 72 hours of admission. The primary outcome measure will be admission to HDU/ITU with secondary end-points including 30-day mortality, length of stay, radiological evidence of necrosis, and evidence of organ failure. Data collection has commenced across nine sites with over 150 patients recruited to date. The results of this study will be prepared in accordance with guidelines set by the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) statement for observational studies. Data will be analysed using SPSS. Statistical significance will be defined as a p value of ≤ 0.05. Data collection will be completed in February 2021. Pending the results of phase one, an RCT will be designed to determine the optimal rate of intravenous fluids for improved patient outcomes.

Sistem Kendali dan Monitoring Cairan Infus pada Proses Tatalaksana Dehidrasi Berbasis IoT

Diarrhea is an endemic disease with Potential Extraordinary Events (PEE), often accompanied by death in Indonesia. Globally, at least diarrheal disease has caused 525,000 deaths in children each year, with the most severe threat being dehydration. It takes a system that can determine the degree of dehydration and manage dehydration quickly and appropriately to reduce the mortality rate. This study created a system to assess the degree of dehydration and perform the dehydration management process automatically. The method of determining the degree of dehydration using heart rate parameters and the process of justification is measured physical condition. In the process of dehydration management, intravenous fluid administration is carried out automatically using servo motors. To improve safety in infusion users, infusion volume, flow obstruction, air bubble, and rising blood detection are also carried out. All results will be processed on the microcontroller and will be sent to the ESP32 via serial communication. The data processing results will be connected using the Internet of Things so medical personnel can monitor via the website. The results showed that the average error of heart rate measurement using the moving average method of 0.41%, and the accuracy value in the infusion control system reached 90%.

Optimizing Fluid Resuscitation and Preventing Fluid Overload in Patients with Septic Shock

Intravenous fluid administration remains an important component in the care of patients with septic shock. A common error in the treatment of septic shock is the use of excessive fluid in an effort to overcome both hypovolemia and vasoplegia. While fluids are necessary to help correct the intravascular depletion, vasopressors should be concomitantly administered to address vasoplegia. Excessive fluid administration is associated with worse outcomes in septic shock, so great care should be taken when deciding how much fluid to give these vulnerable patients. Simple or strict “recipes” which mandate an exact amount of fluid to administer, even when weight based, are not associated with better outcomes and therefore should be avoided. Determining the correct amount of fluid requires the clinician to repeatedly assess and consider multiple variables, including the fluid deficit, organ dysfunction, tolerance of additional fluid, and overall trajectory of the shock state. Dynamic indices, often involving the interaction between the cardiovascular and respiratory systems, appear to be superior to traditional static indices such as central venous pressure for assessing fluid responsiveness. Point-of-care ultrasound offers the bedside clinician a multitude of applications which are useful in determining fluid administration in septic shock. In summary, prevention of fluid overload in septic shock patients is extremely important, and requires the careful attention of the entire critical care team.

Assisted Fluid Management Software Guidance for Intraoperative Fluid Administration

Background Excessive or inadequate fluid administration causes complications, but despite this, fluid administration during noncardiac surgery is highly variable. Goal-directed management helps optimize the amount and timing of fluid administration; however, implementation is difficult because algorithms are complex. The authors therefore tested the performance of the Acumen Assisted Fluid Management software (Edwards Lifesciences, USA), which is designed to guide optimal intravenous fluid administration during surgery. Methods In this multicenter, prospective, single-arm cohort evaluation, the authors enrolled 330 adults scheduled for moderate- to high-risk noncardiac surgery that required arterial catheter insertion and mechanical ventilation. Clinicians chose a fluid strategy based on a desired 10%, 15%, or 20% increase in stroke volume (SV) in response to a fluid bolus. Dedicated fluid management software prompted “test” or “recommended” boluses, and clinicians were free to initiate a “user” bolus of 100 to 500 ml of crystalloid or colloid. Clinicians were free to accept or decline the software prompts. The authors primarily compared the fraction of software-recommended boluses that produced suitable increases in SV to a 30% reference rate. On an exploratory basis, we compared responses to software-recommended and clinician-initiated boluses. Results Four hundred twenty-four of 479 (89%) software-recommended fluid boluses and 508 of 592 (86%) clinician-initiated fluid boluses were analyzed per protocol. Of those, 66% (95% CI, 62 to 70%) of delivered fluid boluses recommended by the software resulted in desired increases in SV, compared with the 30% reference rate, whereas only 41% (95% CI, 38 to 44%) of clinician-initiated boluses did (P &lt; 0.0001). The mean ± SD increase in SV after boluses recommended by the software was 14.2 ± 13.9% versus 8.3 ± 12.1% (P &lt; 0.0001) for those initiated by clinicians. Conclusions Fluid boluses recommended by the software resulted in desired SV increases more often, and with greater absolute SV increase, than clinician-initiated boluses. Automated assessment of fluid responsiveness may help clinicians optimize intraoperative fluid management during noncardiac surgery. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

Intravenous Fluid Administration and the Coagulation System

Intravenous fluid administration in veterinary patients can alter coagulation function by several mechanisms. Both crystalloid and colloid fluids cause hemodilution, reducing platelet count and plasma coagulation protein concentrations. Hemodilution is associated with a hypercoagulable effect at low dilutions and a hypocoagulable effect at higher dilutions. Composition of crystalloid fluids likely has a minor effect, primarily dependent on fluid ion composition. Hypertonic crystalloids may also cause hypocoagulability. Colloids, both synthetic and natural, can cause hypocoagulability by several mechanisms beyond the effects of hemodilution. These include impaired platelet function, decreased plasma coagulation factor activity, impaired fibrin formation and crosslinking, and accelerated fibrinolysis. The vast majority of the veterinary literature investigates the hypocoagulable effects of hydroxyethyl starch–containing fluids using in vitro, experimental, and clinical studies. However, results are inconsistent, likely due to the varying doses and physicochemical properties of the specific fluid products across studies. In addition, some evidence exists for hypocoagulable effects of gelatin and albumin solutions. There is also evidence that these colloids increase the risk of clinical bleeding in people. Limitations of the veterinary evidence for the hypocoagulable effects of colloid fluids include a predominance of in vitro studies and in vivo studies using healthy subjects, which exclude the interaction of the effects of illness. Therefore, clinical relevance of these effects, especially for low-molecular-weight hydroxyethyl starch, is unknown. Firm recommendations about the most appropriate fluid to use in clinical scenarios cannot be made, although it is prudent to limit the dose of synthetic colloid in at-risk patients. Clinicians should closely monitor relevant coagulation assays and for evidence of hemorrhage in at-risk patients receiving any type of fluid therapy, especially in large volumes.