Comparison between Crystalloid Versus Colloid in Septic Shock

Background Fluid resuscitation is a critical component to the emergency department (ED) management of patients with sepsis and septic shock. Fluids are administered to patients with sepsis in order to augment cardiac output and improve tissue perfusion and oxygenation. Recent evidence has suggested that the composition of fluids used in sepsis resuscitation may affect patient-centered outcomes. Objective To systematically review the effects of colloids compared with crystalloids in fluid resuscitation for septic shock. Data Sources Medline databases (PubMed, Medscape, ScienceDirect. EMF-Portal) and all materials available in the Internet till 2017. Data Extraction If the studies did not fulfill the inclusion criteria, they were excluded. Study quality assessment included whether ethical approval was gained, eligibility criteria specified, appropriate controls, and adequate information and defined assessment measures. Conclusion In contrast to 0.9% NS, balanced crystalloid solutions contain significantly lower concentrations of chloride. Instead of large amounts of chloride, balanced solutions contain organic anions (i.e., lactate, gluconate, citrate, acetate) which act as physiologic buffers and are rapidly converted to bicarbonate upon administration. In addition, balanced solutions have less of an adverse effect on acid-base equilibrium than 0.9% NS. Balanced solutions also contain varying amounts of cations (i.e., potassium, calcium). Many critically ill patients across the world receive HES solutions for resuscitation. HES solutions are defined by their molecular weight and degree of hydroxyethylation. Recent evidence has demonstrated significant harm with the use of HES solutions. The administration of albumin in the critical patient is not associated to demonstrated adverse effects, though it should be reserved for specific patient groups in which it has been shown to offer benefit.

Fifteen-minute consultation: Emergency management of children presenting with hyperkalaemia

Hyperkalaemia can lead to life-threatening cardiac arrhythmias. A good understanding of the physiological basis of management can help us rationalise treatment and reduce plasma potassium levels efficiently and effectively. Management focuses on avoidance of arrythmias, rapid intracellular movement of potassium and finally reduction of total body potassium. Fluid management in hyperkalaemia should be carefully considered, with balanced solutions providing theoretical benefits compared to 0.9% saline in certain situations.

0.9% Sodium chloride solution versus Plasma-Lyte 148 versus compound sodium lacTate solution in children admitted to PICU—a randomized controlled trial (SPLYT-P): study protocol for an intravenous fluid therapy trial

Background Intravenous fluid therapy represents the most common intervention critically ill patients are exposed to. Hyperchloremia and metabolic acidosis associated with 0.9% sodium chloride have been observed to lead to worse outcomes, including mortality. Balanced solutions, such as Plasma-Lyte 148 and Compound Sodium Lactate, represent potential alternatives but the evidence on optimal fluid choices in critically ill children remains scarce. This study aims to demonstrate whether balanced solutions, when used as intravenous fluid therapy, are able to reduce the incidence of a rise in serum chloride level compared to 0.9% sodium chloride in critically ill children. Methods This is a single-centre, open-label randomized controlled trial with parallel 1:1:1 assignment into three groups: 0.9% sodium chloride, Plasma-Lyte 148, and Compound Sodium Lactate solutions for intravenous fluid therapy. The intervention includes both maintenance and bolus fluid therapy. Children aged < 16 years admitted to intensive care and receiving intravenous fluid therapy during the first 4 h of admission are eligible. The primary outcome measure is a ≥ 5mmol/L increase in serum chloride level within 48 h post-randomization. The enrolment target is 480 patients. The main analyses will be intention-to-treat. Discussion This study tests three types of intravenous fluid therapy in order to compare the risk of hyperchloremia associated with normal saline versus balanced solutions. This pragmatic study is thereby assessing the most common intervention in paediatric critical care. This is a single-centre open-label study with no blinding at the level of delivery of the intervention. Certain paediatric intensive care unit (PICU) patient groups such as those admitted with a cardiac condition or following a traumatic brain injury are excluded from this study. Trial registration The study has received ethical approval (HREC/19/QCHQ/53177: 06/06/2019). It is registered in the Australian New Zealand Clinical Trials Registry (ACTRN12619001244190) from 9th September 2019. Recruitment commenced on 12th November 2019. The primary results manuscript will be published in a peer-reviewed journal.

Association Between Unbalanced Solutions and Acute Kidney Injury During Fluid Resuscitation in Children With Sepsis

Objective: To evaluate the outcomes of patients with sepsis-associated organ dysfunction and septic shock who receive fluid resuscitation with balanced and unbalanced solutions in a middle-income country. Design: An observational, analytical cohort study with propensity score matching (PSM) in children admitted to a pediatric intensive care unit (PICU). Patients from one month to 17 years old who required fluid boluses due to hemodynamic instability were included. The primary outcome was the presence of acute kidney injury and the secondary outcomes were the need to begin continuous renal replacement therapy (CRRT), metabolic acidosis, PICU length of stay and mortality. Measurements and Main Results: Out of the 1,074 admissions to the PICU during the study period, 99 patients had sepsis-associated organ dysfunction and septic shock. Propensity score matching was performed including each patient´s baseline characteristics. The median age was 9.9 months (IQR 4.9-22.2) with 55.5% of the patients being male. Acute kidney injury was seen less frequently in children who received a balanced solution than in those who received an unbalanced solution (20.3% vs 25.7% P = 0.006 ORa, 0.75; 95% CI, 0.65-0.87), adjusted for disease severity. In addition, the group that received balanced solutions had less need for CRRT (3.3 % vs 6.5%; P = 0.02 ORa 0.48; 95% CI, 0.36-0.64) and a shorter PICU stay (6 days IQR 4.4-20.2 vs 10.2 days IQR 4.7-26; P < 0.001) than the group with unbalanced solutions. We found no difference in the frequency of metabolic acidosis ( P = 0.37), hyperchloremia ( P = 0.11) and mortality ( P = 0.25) between the 2 groups. Conclusion: In children with sepsis-associated organ dysfunction and septic shock, the use of unbalanced solutions for fluid resuscitation is associated with a higher frequency of acute kidney injury, a greater need for continuous renal support and a longer PICU stay compared to the use of balanced solutions, in a middle-income country.

0.9% Sodium chloride solution versus Plasma-Lyte 148 versus compound sodium lacTate Solution in children admitted to PICU – a randomised controlled trial – SPLYT-P: study protocol for an intravenous fluid therapy trial

Background: Intravenous fluid therapy represents the most common intervention critically ill patients are exposed to. Hyperchloremia and metabolic acidosis associated with 0.9% sodium chloride have been observed to lead to worse outcomes, including mortality. Balanced solutions, such as PlasmaLyte-148 and Compound Sodium Lactate, represent potential alternatives but the evidence on optimal fluid choices in critically ill children remains scarce. The aim of this study is to demonstrate whether balanced solutions, when used as the intravenous fluid therapy, are able to reduce the incidence of a rise in serum chloride level compared to 0.9% sodium chloride in critically ill children.Methods: This is a single centre, open label randomised controlled trial with parallel 1:1:1 assignment into three groups: 0.9% sodium chloride, Plasma-Lyte 148, and Compound Sodium Lactate solutions for intravenous fluid therapy. The intervention includes both maintenance and bolus fluid therapy. Children age <16 years admitted to intensive care and receiving intravenous fluid therapy during the first four hours of admission are eligible. The primary outcome measure is a ³5mmol/L increase in serum chloride level within 48 hours post randomisation. The enrolment target is 480 patients. The main analyses will be intention-to-treat.Discussion: This study tests three types of intravenous fluid therapy in order to compare the risk of hyperchloremia associated with normal saline versus balanced solutions. The pragmatic study is thereby assessing the most common intervention in paediatric critical care. This is a single centre open label study with no blinding at the level of delivery of intervention. Certain Paediatric Intensive Care Unit (PICU) patient groups such as patients admitted with a cardiac condition or following traumatic brain injury are excluded from this study. Trial registration: The study has received ethical approval (HREC/19/QCHQ/53177: 06/06/2019). It is registered in the Australian New Zealand Clinical Trials Registry (ACTRN12619001244190) from 9th September 2019. Recruitment commenced on 12th November 2019. The primary results manuscript will be published in a peer reviewed journal.

Dividing Splittable Goods Evenly and With Limited Fragmentation

A splittable good provided in n pieces shall be divided as evenly as possible among m agents, where every agent can take shares from at most F pieces. We call F the fragmentation and mainly restrict attention to the cases $$F=1$$F=1 and $$F=2$$F=2. For $$F=1$$F=1, the max–min and min–max problems are solvable in linear time. The case $$F=2$$F=2 has neat formulations and structural characterizations in terms of weighted graphs. First we focus on perfectly balanced solutions. While the problem is strongly NP-hard in general, it can be solved in linear time if $$m\ge n-1$$m≥n-1, and a solution always exists in this case, in contrast to $$F=1$$F=1. Moreover, the problem is fixed-parameter tractable in the parameter $$2m-n$$2m-n. (Note that this parameter measures the number of agents above the trivial threshold $$m=n/2$$m=n/2.) The structural results suggest another related problem where unsplittable items shall be assigned to subsets so as to balance the average sizes (rather than the total sizes) in these subsets. We give an approximation-preserving reduction from our original splitting problem with fragmentation $$F=2$$F=2 to this averaging problem, and some approximation results in cases when m is close to either n or n / 2.