Correlation analysis between lung ultrasound score and cumulative fluid balance and their predictive value of extubation outcome in patients with intro-abdominal infection / 中华急诊医学杂志

Objective:To investigate the correlation between lung ultrasound score at the end of spontaneous breathing trial (SBT) and cumulative fluid balance at 48 h and their predictive value of extubation outcome in patients with intro-abdominal infection (IAI) under mechanical ventilation.Methods:A retrospective study was conducted. Patients with IAI under mechanical ventilation for more than 48 h were collected from three hospitals from October 1, 2017 to September 30, 2018. Routine demographic variables and clinical characteristics were recorded. The patients were divided into the successful extubation group and failed extubation group according to whether they could maintain spontaneous breathing for 48 h after extubation. LUS at the end of SBT (before extubation) and cumulative fluid balance at 48 h were compared between the two groups. LUS and cumulative fluid balance at 48 h were analyzed by bivariate correlation analysis, and their correlations with shallow fast breathing index (RSBI) and precursor protein of BNP (Pro-BNP) were analyzed. The predictive value of LUS at the end of SBT (before extubation) and cumulative fluid balance for extubation failure were analyzed by receiver operating characteristic curve (ROC).Results:Totally 207 patients were enrolled. There were significant differences in LUS before extubation [12 (10, 14) vs. 16 (14, 17) points], cumulative fluid balance [-318 (-1 116, 200) mL vs. 1 140 (685, 1 614) mL], RSBI [60 (55, 66) (times/min)/L vs. 70 (65, 78) (times/min)/L], pro-BNP [250 (122, 1 292) pg/mL vs. 1156 (285, 4 346) pg/mL], IAP >15 mmHg [32.8% vs. 46.6%], and ICU stay [8 (6, 12) days vs. 11 (8, 14) days] ( P<0.05). Logistic regression analysis showed that the COPD history, RSBI, LUS at the end of SBT, and cumulative fluid balance at 48 h before extubation were independent risk factors for extubation failure. Correlation analysis showed that LUS was moderately correlated with cumulative fluid balance at 48 h ( r=0.41, P<0.001), weakly correlated with RSBI ( r=0.381, P<0.001), and weakly correlated with pro-BNP ( r=0.220, P<0.001). Cumulative fluid balance at 48 h was weakly correlated with RSBI ( r=0.31, P<0.001), but not with pro-BNP. LUS at the end of SBT and cumulative liquid balance at 48 h had predictive value for extubation failure [AUC=0.87 (95% CI: 0.82-0.91), AUC=0.89 (95% CI: 0.85-0.94), P<0.001]. Conclusions:There is a moderate correlation between LUS at the end of SBT (before extubation) and 48 h cumulative fluid balance in patients with IAI and mechanical ventilation. LUS at the end of SBT (before extubation) and cumulative fluid balance at 48 h have some predictive value for extubation failure.

Effect of early continuous renal replacement therapy on in-hospital mortality of patients with sepsis / 中华急诊医学杂志

Objective:To investigate the effect of early continuous renal replacement therapy (CRRT) within 24 h on in-hospital mortality in patients with sepsis.Methods:This study retrospectively analyzed the patients diagnosed as sepsis in the Emergency Intensive Care Unit of the First Affiliated Hospital of Wenzhou Medical University from January 2013 to December 2017. According to the prognosis, the patients were divided into the survival group and death group. The clinical baseline data of the two groups were compared, and multivariate logistic regression analysis was performed to screen out the risk factors of death in patients with sepsis and evaluate the effect of CRRT on mortality. According to whether CRRT was performed within 24 h after admission, the patients were divided into the CRRT group and non-CRRT group to compare fluid balance.Results:Among the 612 patients, 416 (67.9%) patients were male, the median age was 66 years; 362 patients survived and 250 patients died, with a mortality rate of 40.8%. Multivariate logistic regression analysis showed that the independent risk factors for death in patients with sepsis were: sex, simplified acute physiology score Ⅱ, sequential organ failure assessment, lactate, procalcitonin, and complicated with chronic obstructive pulmonary disease. Multivariate logistic regression analysis showed that patients received CRRT within 24 h had a higher risk of mortality ( OR=1.981 95% CI: 1.120-3.504, P=0.019). There was a statistically significant difference in fluid balance between the CRRT group and the non-CRRT group on the first day ( P<0.05), and there was no significant difference in total fluid balance in the first 3 days ( P>0.05). Conclusions:Early CRRT within 24 h cannot reduce the in-hospital mortality of patients with sepsis. The failure of CRRT which did not timely correct the volume overload state of patients with sepsis after fluid resuscitation may affect the outcome.

Progress on the effect of high-dose fluid resuscitation on the prognosis of children with septic shock / 中国小儿急救医学

Septic shock refers to sepsis combined with severe circulatory disorders and cell metabolism disorders, with high incidence, high fatality rate, and dangerous condition.It is one of the leading cause of death in children in pediatric intensive care units.Therefore, early diagnosis and effective treatment of septic shock are very important.Among them, fluid resuscitation is an important part of treatment.However, the research in recent years has a lot of controversy about subsequent fluid balance management issues.This review summarized fluid balance therapy, focusing on the large dose of fluid resuscitation on the prognosis of children with septic shock, aiming to provide a reference for the future improvement of fluid therapy for children with sepsis.

Positive fluid balance as an early biomarker for acute kidney injury: a prospective study in critically ill adult patients

OBJECTIVES: Positive fluid balance is frequent in critically ill patients and has been considered a potential biomarker for acute kidney injury (AKI). This study aimed to evaluate positive fluid balance as a biomarker for the early detection of AKI in critically ill patients. METHODS: This was a prospective cohort study. The sample was composed of patients ≥18 years old who stayed ≥3 days in an intensive care unit. Fluid balance, urinary output and serum creatinine were assessed daily. AKI was diagnosed by the Kidney Disease Improving Global Outcome criteria. RESULTS: The final cohort was composed of 233 patients. AKI occurred in 92 patients (40%) after a median of 3 (2-6) days following ICU admission. When fluid balance was assessed as a continuous variable, a 100-ml increase in fluid balance was independently associated with a 4% increase in the odds of AKI (OR 1.04; 95% CI 1.01-1.08). Positive fluid balance categorized using different thresholds was always significantly associated with subsequent detection of AKI. The mixed effects model showed that increased fluid balance preceded AKI by 4 to 6 days. CONCLUSION: These results suggest that a positive fluid balance might be an early biomarker for AKI development in critically ill patients.

Asociación entre el índice de agua extravascular pulmonar y el balance hídrico en pacientes críticamente enfermos / Association between extravascular lung water index and fluid balance in critically ill patients / Associação entre água extravascular pulmonar indexada e balanço hídrico em pacientes em estado crítico

Resumen: Introducción: El balance hídrico positivo y el agua extravascular pulmonar medida por termodilución transpulmonar son factores independientes de mortalidad. La inclusión del valor de agua extravascular pulmonar indexada (EVLWi) durante la reanimación inicial impacta en la cantidad de líquido administrado. Aunque no existen antecedentes, buscar una asociación entre ambos parámetros puede llevar a un balance hídrico global negativo guiado por la cantidad de EVLWi. En este estudio retrospectivo se buscó la asociación entre EVLWi y balance hídrico y su impacto en la mortalidad. Material y métodos: Se realizó un estudio retrospectivo de cohortes con 20 casos para establecer la asociación entre agua extravascular pulmonar indexada medida por termodilución transpulmonar y balance hídrico total a las 24, 48 y 72 horas, así como con la mortalidad a 30 días. Resultados: Un valor de corte > 11 mL/kg de EVLWi se asoció con un incremento de la mortalidad; a las 24 horas RR 8.0 (95% IC 1.2146-52.6944, p = 0.0306), a las 48 horas RR 4.3778 (95% IC 1.1643-15.7177, p = 0.0286) y a las 72 horas con RR 3.5000 (95% IC 0.9497-12.8983, p = 0.0598). El valor de corte del balance hídrico fue ≥ 3.5 L, sin asociación con la mortalidad RR 0.1789 (95% IC 0.0125-2.5668, p = 0.2054) a las 24 horas, RR 0.5000 (95% IC 0.0854-2.9258, p = 0.4419) a las 48 horas y RR 0.3750 (95% IC 0.0610-2.3059, p = 0.2897) a las 72 horas. La asociación entre balance hídrico total y EVLWi fue r (2) Pearson = 0.01269. Conclusiones: El EVLWi > 11 mL/kg se asoció a un incremento en la mortalidad, a diferencia del balance hídrico. No encontramos correlación entre el balance hídrico y el EVLWi.

Abstract: Introduction: Positive fluid balance and extravascular lung water index (EVLWi) quantified by transpulmonary thermodilution have been important independent mortality prognostic factors. Including EVLWi to guide initial fluid reanimation therapy has a high impact in the amount of administered fluid. Although there is not enough evidence, search for an association between EVLWi and fluid balance could lead to a negative fluid balance driven by EVLWi to improve survival rates. In this retrospective study we search for the association between EVLWi, fluid balance and its impact on mortality. Material and methods: Retrospective, cohort study of 20 cases. We looked for any association between EVLWi by transpulmonary thermodilution and daily fluid balance at 24, 48 and 72 hours and reviewed mortality at 30 days. Results: An EVLWi cutoff value of > 11 mL/kg was associated with a higher mortality; on the first 24 hours with an RR 8.0 (95% CI 1.2146-52.6944, p = 0.0306), at 48 hours RR 4.3778 (95% CI 1.1643-15.7177, p = 0.0286) and at 72 hours RR 3.5000 (95% CI 0.9497-12.8983 p = 0.0598). Fluid balance cutoff value was established at ≥ 3.5 L, but we can't find any association with mortality, RR 0.1789 (95% CI 0.0125-2.5668, p = 0.2054) at 24 hours, RR 0.5000 (95% CI 0.0854-2.9258, p = 0.4419) at 48 hours y RR 0.3750 (95% CI 0.0610-2.3059, p = 0.2897) at 72 hours. The correlation between fluid balance and EVLWi was negative, Pearson's r (2) = 0.01269. Conclusions: EVLWi was associated to a higher mortality. We could not demonstrate an association between fluid balance and EVLWi.

Resumo: Introdução: O balanço hídrico positivo e a água extravascular pulmonar medida por termodiluição transpulmonar são fatores independentes da mortalidade. A inclusão do valor de água extravascular pulmonar indexada (EVLWi) durante a ressuscitação inicial impacta a quantidade de fluido entregue. Embora não haja precedente, buscar uma associação entre os dois parâmetros pode levar a um balanço hídrico global negativo guiado pela quantidade de EVLWi. Neste estudo retrospectivo, buscou-se a associação entre EVLWi e balanço hídrico e seu impacto na mortalidade. Material e métodos: Foi realizado um estudo de coorte retrospectivo com 20 casos para estabelecer a associação entre a água pulmonar extravascular indexada medida por termodiluição transpulmonar e balanço hídrico total em 24, 48 e 72 horas, bem como mortalidade em 30 dias. Resultados: Um valor de corte > 11 mL/kg de EVLWi foi associado a um aumento na mortalidade; às 24 horas RR 8.0 (95% IC 1.2146-52.6944, p = 0.0306), 48 horas RR 4.3778 (95% IC 1.1643-15.7177, p = 0.0286) e 72 horas com RR 3.5000 (95% IC 0.9497-12.8983 p = 0.0598). O valor de corte do balanço hídrico foi ≥ 3.5 L, sem associação com mortalidade RR 0.1789 (IC 95% 0.0125-2.5668, p = 0.2054) em 24 horas, RR 0.5000 (IC 95% 0.0854-2.9258 p = 0.4419) em 48 horas e RR 0.3750 (IC 95% 0.0610-2.3059 p = 0.2897) às 72 horas. A associação entre balanço hídrico total e EVLWi foi r 2 Pearson = 0.01269. Conclusões: EVLWi > 11 mL/kg foi associado a um aumento da mortalidade, em contraste com o balanço hídrico. Não encontramos correlação entre o balanço hídrico e o EVLWi.

Post-exercise ingestion of lactose-free skim milk affects thirst but not subsequent performance and net fluid balance of collegiate badminton athletes

@#Introduction: The hydration and nutritional needs of badminton athletes are of interest because of the unique demands of the sport on the player’s physiology and skill. Objectives: The current study investigated the acute effect of lactose-free skim milk (LFM) compared with a iso-volumic carbohydrate electrolyte sport drink (iCE) taken post exercise, on subsequent performance, net fluid balance (NFB) and other selected subjective variables (thirst, gastrointestinal comfort and palatability). Methods: Eleven collegiate badminton athletes (five male and six female, mean age=19.6±1.7 years, body mass=56.8±5.0 kg) volunteered to participate in this crossover study, with ≥7-day washout between trials. After a 2 h training session, the participants rested for 2 h, ingested the same volume of either LFM or iCE matched for carbohydrate content of 1.0 g carbohydrate/kg body mass. Performance tests were done post-ingestion. The body mass was taken, as well as visual analog scales administered throughout the protocol. Results: No significant difference between groups was found in terms of performance: aerobic capacity t(10)=0.147, p=0.886 and agility (sideways agility test: t(10)=0.191, p=0.852 and four-corner agility test: t(10)=0.397, p=0.700); and NFB t(10)=0.434, p=0.670. Thirst ratings between groups were significantly different at the end of the performance tests (LFM 6.71±2.09 and iCE 8.03±1.28, t(10)=-2.35, p=0.041). However, the subjective ratings for gastrointestinal comfort and palatability were similar. Conclusion: When matched for carbohydrate content, acute post-exercise ingestion of LFM offered a significant advantage over the sports drink in terms of thirst after subsequent performance.

Análisis función ventricular derecha, función renal y fluidos tras resucitación en pacientes con ventilación mecánica / Right ventricular, renal function, and fluids balance analysis after resuscitation in patients on mechanical ventilation

INTRODUCTION: Hemodynamic optimization is a main goal in the management of critically ill patients. Right ventricular function, renal failure and fluid balance are part of this process. Our goal is to analysis those, after the initial resuscitation. MATERIAL AND METHODS: A prospective, observational study was performed with all the patients admitted to a Medical Service of Intensive Care of a Tertiary, University Hospital. All patients analyzed required mechanical ventilation as a support for their underling pathology. All consecutive patients admitted to the unit under mechanical ventilation were collected, in the absence of shock, with the expectation of remaining under mechanical ventilation for at least 24 more hours after data collection. The incidence of right ventricular failure according to the defined parameters, renal failure, and fluid balance were described. We had described its association with mechanical ventilation and mortality. RESULTS: A total of 30 patients were selected. Right ventricular failure was observed in 16.6% of patients (5/30). There was no statistically significant association with the need of tracheotomy, renal failure or mortality. It was not associated with longer average stay, days of mechanical ventilation or higher severity scores. 40% of the patients presented acute renal failure. Renal failure was not associated statistically significant with the need of tracheotomy or failure in scheduled extubation, however, it was associated with higher mortality. Patients requiring mechanical ventilation with normal creatinine values ​​after initial resuscitation, had a mortality rate of 28.5% in comparison to patients who had altered values in which the mortality rate was 77.7%, (p < 0.018). Regarding the post-resuscitation net fluid balance, no statistically significant differences were found in the comparison of means between survivors and non survivors, with renal failure or right ventricular failure. No even was it associated with higher mortality. CONCLUSIONS: Right ventricular failure, despite not being associated with mortality, days of mechanical ventilation or failure in extubation in a statistically significant way, presents an incidence of 16.6% in patients connected to mechanical ventilation admitted to a polyvalent icu. Acute renal failure is associated in a statistically significant way with mortality in our sample. We had not found association between fluid overload and renal failure in our sample.

INTRODUCCIÓN: La optimización hemodinámica es piedra angular en el manejo del enfermo crítico. La función ventricular derecha, el fallo renal y el balance hídrico son parte de este proceso. Nuestro objetivo es su análisis tras la resucitación inicial. MATERIAL Y MÉTODOS: Se realiza un estudio prospectivo, observacional, con todos los enfermos que ingresan en un Servicio médico de Medicina Intensiva de un Hospital Terciario y Universitario. Todos los enfermos analizados precisan ventilación mecánica como soporte de su patología. Se recogen todos los enfermos consecutivos ingresados en la unidad bajo ventilación mecánica, en ausencia de shock, con previsión de permanecer bajo ventilación mecánica al menos 24 horas más tras la recogida de datos. Se describe la incidencia de fallo ventricular derecho según los parámetros definidos, fallo renal, balance. Describiremos también su asociación con ventilación mecánica, mortalidad. RESULTADOS: Se seleccionaron un total de 30 pacientes. Se objetivó fallo ventricular derecho en el 16,6% de los pacientes (5/30). No se asoció de forma estadísticamente significativa a la necesidad de traqueotomía, fallo renal o mortalidad. Tampoco se asoció a mayor estancia media, días de ventilación mecánica o índices de gravedad mayores. El 40% de los pacientes presentaron fallo renal agudo. El fallo renal no se asocia de forma estadísticamente significativa con la necesidad de traqueotomía ni fracaso en la extubación, sin embargo, se asocia a mayor mortalidad. Los pacientes que precisan ventilación mecánica y presentan valores de creatinina normales tras resucitación inicial, cuentan con una tasa de mortalidad del 28,5% en comparación con aquellos pacientes que presentan cifras alteradas en las cuales la tasa de mortalidad es del 77,7%, (p < 0,018). Con respecto al balance hídrico neto post resucitación, no se encontraron diferencias estadísticamente significativas en la comparación de medias de los supervivientes, con fallo renal o fallo en ventrículo derecho. Tampoco se asoció a mayor mortalidad. CONCLUSIONES: El fallo ventricular derecho, pese a no asociarse a la mortalidad, días de ventilación mecánica o fallo en la extubación de forma estadísticamente significativa, presenta una incidencia del 16,6% en los enfermos conectados a ventilación mecánica ingresados en una uci polivalente. El fallo renal agudo sí se asocia de forma estadísticamente significativa a la mortalidad en nuestra muestra. No hemos encontrado asociación entre sobrecarga hídrica y fallo renal en nuestro estudio.

Effect of early negative fluid balance on the early postoperative recovery in children after surgical repair of congenital heart disease with enlarged right ventricle / 中国小儿急救医学

Objective To estimate the effect of early fluid removal on the early postoperative recov-ery in children after surgical repair of congenital heart disease with enlarged right ventricle via a randomized trial. Methods One hundred and twenty patients with right-sided complex congenital heart defect who un-derwent cardiac surgery by cardiopulmonary bypass during January 2017 to June 2017 were enrolled and were divided into two groups,Group-E and Group-C,when the hemodynamics was stable within 3 hours after the surgery. Patients in Group-E were treated with early fluid removal,but Group-C remained conventional thera-py. The data of the hemodynamics and outcomes were collected from the postoperative day to the 2nd day post-operation. Results Fluid removal therapy was started in Group-E at (4. 39 ± 0. 85) h postoperatively vs (10. 17 ± 2. 77) h in Group-C (P < 0. 05). Patients in Group-E showed lower extravascular lung water index (ELWI),lower fluid overload and lower NT-proBNP compared with patients in Group-C on the first day of post-operation(P < 0. 01). Also, the advantages remained in Group-E on the second day but the ELWI showed no remarkable difference. The rate of reintubation(P < 0. 05),the duration of mechanical ventilation and the length of ICU stay (P < 0. 01)were significantly reduced in Group-E. Conclusion In patients with right ventricle enlarged complex congenital heart defect who underwent cardiac surgery by cardiopulmonary bypass,utilizing early negative fluid balance when the hemodynamics are stable and the right ventricle is ob-viously enlarged could achieve negative fluid balance,get extubated and discharge from ICU earlier,also pres-ent lower extravascular lung water index, lower incidence of weaning-induced pulmonary edema and reintubation.

Balance de líquidos y lesión renal aguda en el choque séptico / Fluid balance and acute kidney injury in septic shock

Resumen: Introducción: En el paciente con choque séptico, la administración excesiva de líquidos puede incrementar la morbilidad y mortalidad. El objetivo de este estudio fue evaluar la asociación entre el balance de líquidos, la lesión renal aguda y la mortalidad en pacientes con choque séptico. Métodos: Se realizó un estudio de casos y controles en una unidad de terapia intensiva pediátrica. Se comparó el balance de líquidos en las primeras 72 h y la presencia de lesión renal aguda en pacientes con diagnóstico de choque séptico que fallecieron contra pacientes que sobrevivieron a la misma patología. Se realizó un análisis univariado y multivariado. Resultados: Se incluyeron 45 casos y 45 controles en el análisis. La mortalidad se asoció con riesgo pediátrico de mortalidad (PRISM) ≥ 26 puntos (RM 7.5, IC 95% 2.8-18.7; p = 0.000), disfunción orgánica logística pediátrica (PELOD) ≥ 24 puntos (RM 11.0, IC 95% 4.1-29.4; p = 0.000), creatinina ≥ 0.65 mg/dl (RM 5.6, IC 95% 2.2-13.9; p = 0.000), lactato ≥ 2.5 mmol/l (RM 2.5, IC 95% 1.1-5.9; p = 0.033), SvO2 < 60% (RM 4.6, IC 95% 4.5-4.5; p = 0.001), balance positivo > 9% en 72 h (RM 4.3, IC 95% 1.6-11.7; p = 0.003), lesión renal aguda (RM 5.7, IC 95% 2.2-15.1; p = 0.000). En el modelo multivariado, PRISM ≥ 26 y PELOD ≥ 24 puntos permanecieron significativas. Conclusiones: En los pacientes que fallecieron por choque séptico, el modelo multivariado mostró una asociación con PRISM ≥26 y PELOD ≥24 y una tendencia hacia la asociación con SvO2 <60% y balance de líquidos positivo >9%.

Abstract: Background: In patients with septic shock, excessive fluid administration can lead to increased morbidity and mortality. The aim of this study was to evaluate the association between fluid balance, acute kidney injury and mortality in patients with septic shock. Methods: A study of cases and controls was conducted in a Pediatric Intensive Care Unit. The fluid balance in the first 72 h and the presence of acute kidney injury was compared in patients diagnosed with septic shock who died against patients who survived the same condition. Univariate and multivariate analyses were performed. Results: Forty-five cases and forty-five controls were included in the analysis. Mortality was associated with Pediatric Risk of Mortality (PRISM III) ≥ 26 points (OR 7.5, 95% CI 2.8-18.7; p = 0.000), Pediatric Logistic Organ Dysfunction (PELOD) ≥ 24 points (OR 11.0, 95% CI 4.1-29.4; p = 0.000), creatinine ≥ 0.65 mg/dl (OR 5.6, 95% CI 2.2-13.9; p = 0.000), lactate ≥ 2.5 mmol/l (OR 2.5, 95% CI 1.1-5.9; p = 0.033), SvO2 < 60% (OR 4.6, 95% CI 4.5-4.5; p = 0.001), positive balance > 9% in 72 h (OR 4.3, 95% CI 1.6-11.7; p = 0.003), acute kidney injury (OR 5.7, 95% CI: 2.2-15.1; p = 0.000). In the multivariate model, the values of PRISM ≥26 and PELOD ≥24 points were significant. Conclusions: In patients who died due to septic shock, the multivariate model showed an association with PRISM ≥26 and PELOD ≥24 and a trend toward association with SvO2 <60% and positive balance of liquids > 9%.

Sobrecarga hídrica y falla renal en niños con sepsis grave y shock séptico: un estudio de cohortes / Fluid overload and kidney failure in children with severe sepsis and septic shock: A cohort study

Introducción. En niños con sepsis, la sobrecarga hidrica como resultado de una terapia de resucitación agresiva o por la administración excesiva de fluidos puede afectar la función renal y aumentar la mortalidad. Objetivo. Determinar la asociación entre la sobrecarga hidrica y la tasa de falla renal en un grupo de niños con sepsis grave y shock séptico. Población y métodos. Estudio de cohortes prospectivo realizado en la Unidad de Cuidados Intensivos del Hospital Universitario de Pediatría "Dr. Agustín Zubillaga" (Barquisimeto, Estado Lara, Venezuela), entre marzo de 2013 y mayo de 2016, en niños con sepsis grave o shock séptico. Resultados. Un total de 149 niños fueron incluidos en el análisis. La sepsis predominó en el 59,7% de los casos; el promedio de edad fue 6,4 ± 3,3 años; el peso promedio fue 17,8 ± 3,6 kg; en el 30,2%, hubo sobrecarga hidrica y la mortalidad general fue 25,5%. Hubo falla renal en el 16,1% de los casos. Mediante un modelo de regresión logística binaria, se identificaron como predictores independientes de falla renal sobrecarga hidrica (OR 1,5; IC 95%: 1,2-4,9; p= 0,028) y shock mayor de dos días (OR 1,7; IC 95%: 1,3-6,3; p= 0,039). Además, se observó un incremento significativo del riesgo de mortalidad en los niños con falla renal y sobrecarga hidrica, según el método de Kaplan-Meier (p= 0,019). Conclusión. La sobrecarga hidrica y una duración del shock mayor de dos dias incrementan el riesgo de falla renal en niños criticamente enfermos con sepsis grave y shock séptico.

Introduction. In children with sepsis, fluid overload as a result of an aggressive fluid replacement or excessive fluid administration may result in kidney impairment and increased mortality.Objective. To determine the association between fluid overload and the rate of kidney failure in a group of children with severe sepsis and septicshock. Population and methods. This was a prospective cohort study conducted in the intensive care unit of Hospital Universitario de Pediatría Dr. Agustín Zubillaga (Barquisimeto, Lara State, Venezuela), between March 2013 and May 2016, in children with severe sepsis or septic shock.Results. One hundred and forty-nine patients were included in the analysis. Sepsis predominated in 59.7% of cases; patients' average age was 6.4 ± 3.3 years old, their average weight was 17.8 ± 3.6 kg, 30.2% had fluid overload, and overall mortality was 25.5%. Kidney failure occurred in 16.1% of cases. A binary logistic regression model was used to identify fluid overload (odds ratio [OR]: 1.5; 95% confidence interval [CI]: 1.2-4.9, p = 0.028) and shock for more than 2 days (OR: 1.7; 95% CI: 1.3-6.3, p = 0.039) as independent predictors of kidney failure. In addition, a significant increase in the risk of mortality among children with kidney failure and fluid overload was observed as per the Kaplan-Meier method (p= 0.019). Conclusion. Fluid overload and shock for more than 2 days increase the risk for kidney failure in critically ill children with severe sepsis and septic shock.

A retrospective study about the factors of early postoperative fluid balance of patients undergoing cardiopulmonary bypass / 中国实用护理杂志

Objective To explore the possible factors of early postoperative fluid balance and the influence of early postoperative fluid balance on the prognosis of patients undergoing cardiopulmonary bypass. Methods A retrospective study was conducted on the clinical data of 180 adult patients undergoing cardiopulmonary bypass from January 2012 to December 2015.All the patients were from Sun Yat-sen Memorial Hospital, Sun Yat-Sen University. The data were input and analyzed by SPSS 17.0 software. Results The early postoperative fluid balance of cardiovascular surgery with cardiopulmonary bypass was (540.94 ± 135.86) ml. The value of the early postoperative fluid balance (the difference of the total input amount and the total output amount/body quality) in predicting the major clinical outcome was analyzed by ROC curve. The area under the ROC curve from fluid balance was 0.850 (95%CI 0.736-0.965, P<0.01) and it had the sensitivity of 80.0%, and the specificity was 84.6%. The result showed that the cut off values had a good prediction ability for outcome. The cut off values determined by the biggest Youden index were 28.63 ml/kg, indicated that patients may had better outcome when they had the fluid balance of 28.63 ml/kg. The level of early postoperative fluid balance of patients undergoing cardiopulmonary bypass was correlated with mechanical ventilation time, ICU length of stay, higher risk of acute kidney injury, mixed venous oxygen saturation and clinical outcome (P<0.05). Multivariate analysis indicated that European System for Cardiac Operative Risk Evaluation Ⅱ(EuroSCORE Ⅱ), other types of surgery, body mass index, early postoperative urine output and early postoperative drainage flow were independently associated with postoperative fluid balance of patients undergoing cardiopulmonary bypass. Conclusions Early postoperative fluid balance has a good prediction ability for prognosis of patients undergoing cardiopulmonary bypass. Compared with patients having lower level of fluid balance, the patients with a higher level would be more likely to have longer mechanical ventilation time, longer ICU length of stay, higher risk of acute kidney injury and lower level of mixed venous oxygen saturation. By analysis of ROC curves, the cut-off value for early postoperative fluid balance is 28.63 ml/kg, worse prognosis may be predicted if fluid balance is above 28.63 ml/kg. EuroSCORE Ⅱ, other types of surgery, body mass index, early postoperative urine output and early postoperative drainage flow are independently associated with the postoperative fluid balance of patients undergoing cardiopulmonary bypass.

The relation between positive fluid balance and the prognosis in severe sepsis patients with acute kidney injury / 中华急诊医学杂志

Objective To investigate the relation between positive fluid balance and the prognosis in severe sepsis patients with acute kidney injury (AKI).Methods A retrospective analysis of clinical data of 90 patients in our department was carried out.According to the final outcome,patients were divided into survival group (n =26) and non-survival group (n =64),in which the relation between patients' positive fluid balance and the prognosis was evaluated.Results (1) There was no statistically significant difference in the age and severity between survival group and non-survival group of patients with severe sepsis and consequent AKI,but the patients in non-survival group had greater volume overload.Compared with the survival group,higher mean fluid balance [(1 112.12±546.85) mLvs.(644.69±474.93) mL,P=0.00],and less urine output [(1 224.07 ± 708.79) mL vs.(2 032.36 ± 723.53) mL,P =0.00) in non-survival group.(2) There was no significant difference in mortality between early and late continuous renal replacement therapy (CRRT) during ICU care.However,the average daily fluid load in late CRRT patients was significantly greater than that in early CRRT patients [(1178.81 ±397.03) mLvs.(287.22 ± ± 433.53) mL,P =0.00] and the lung oxygenation index in late CRRT patients was significantly worse thanthat in early CRRT patients [(211.22±42.56) vs.(169.46±57.40),P=0.04] (3) The relevant variables to 28-day mortality in AKI patients with severe sepsis included CRRT treatment,oxygenation index and the average daily fluid balance ＞ 500 mL.Among them,fluid balance ＞ 500mL was an independent risk factor for AKI patients with severe sepsis.Their prognosis was worse if they had greater positive fluid balance.CRRT was the protective factor which could affect the prognosis of patients with severe sepsis complicated by AKI.Conclusions Patients with severe sepsis complicated by AKI has a high mortality.Persistent fluid overload can lead to increased mortality in patients with severe sepsis complicated by AKI.Early CRRT can reduce fluid retention in patients with renal failure and improve oxygenation index.

The Role of Oliguria and the Absence of Fluid Administration and Balance Information in Illness Severity Scores / 대한구급학회지

Urinary examination has formed part of patient assessment since the earliest days of medicine. Current definitions of oliguria are essentially arbitrary, but duration and intensity of oliguria have been associated with an increased risk of mortality, and this risk is not completely attributable to the development of concomitant acute kidney injury (AKI) as defined by changes in serum creatinine concentration. The increased risk of death associated with the development of AKI itself may be modified by directly or indirectly by progressive fluid accumulation, due to reduced elimination and increased fluid administration. None of the currently extant major illness severity scoring systems or outcome prediction models use modern definitions of AKI or oliguria, or any values representative of fluid volumes variables. Even if a direct relationship with mortality is not observed, then it is possible that fluid balance or fluid volume variables mediate the relationship between illness severity and mortality in the renal and respiratory physiological domains. Fluid administration and fluid balance may then be an important, easily modifiable therapeutic target for future investigation. These relationships require exploration in large datasets before being prospectively validated in groups of critically ill patients from differing jurisdictions to improve prognostication and mortality prediction.

The Role of Oliguria and the Absence of Fluid Administration and Balance Information in Illness Severity Scores / 대한중환자의학회지

Urinary examination has formed part of patient assessment since the earliest days of medicine. Current definitions of oliguria are essentially arbitrary, but duration and intensity of oliguria have been associated with an increased risk of mortality, and this risk is not completely attributable to the development of concomitant acute kidney injury (AKI) as defined by changes in serum creatinine concentration. The increased risk of death associated with the development of AKI itself may be modified by directly or indirectly by progressive fluid accumulation, due to reduced elimination and increased fluid administration. None of the currently extant major illness severity scoring systems or outcome prediction models use modern definitions of AKI or oliguria, or any values representative of fluid volumes variables. Even if a direct relationship with mortality is not observed, then it is possible that fluid balance or fluid volume variables mediate the relationship between illness severity and mortality in the renal and respiratory physiological domains. Fluid administration and fluid balance may then be an important, easily modifiable therapeutic target for future investigation. These relationships require exploration in large datasets before being prospectively validated in groups of critically ill patients from differing jurisdictions to improve prognostication and mortality prediction.

Modelos de reanimación en la terapia intensiva y desarrollo de complicaciones en el postoperatorio de trasplante hepático / Resuscitation models for liver transplantation at the intensive care unit and the development of postoperatory complications / Modelos de reanimação na terapia intensiva e desenvolvimento das complicações pós-operatórias em transplante hepático

Resumen: El periodo de reanimación después del trasplante hepático ortotópico (THO) es un desafío debido a las alteraciones fisiológicas relacionadas con la enfermedad hepática terminal (EHT). Material y métodos: Este es un estudio retrospectivo que evalúa las primeras 48 horas de manejo en la unidad de cuidados intensivos (UCI) de un hospital de la Ciudad de México. Los pacientes se clasificaron en 4 grupos según la dosis de norepinefrina (NADR) utilizada y el balance neto de líquidos (BalT): Grupo 1 norepinefrina menos de 0.1 μg/1 kg/min/BalT 3,805 ml, grupo 2 norepinefrina mayor de 0.1 μg/kg/min/BalT menos de 3,805 ml, grupo 3 norepinefrina menos de 0.1 μg/kg/min/BalT mayor de 3,805 ml, grupo 4 norepinefrina mayor de 0.1 μg/kg/min/BalT mayor de 3,805 ml. Se evaluó el desarrollo de complicaciones Post-THO. Las variables principales de valoración fueron; complicaciones médicas generales, reoperación quirúrgica y duración de estancia en el hospital (DEH), duración de la ventilación mecánica, lesión renal aguda, función anormal del injerto y cultivos positivos. Resultados: 36.6% de los pacientes pertenecían al grupo 1, 18.8% al grupo 2, 17.8% al grupo 3 y 26.7% al grupo 4. La duración de la estancia fue de 3.39 días, tiempo medio de ventilación mecánica de 16.5 horas. El 67% desarrolló complicaciones médicas, el 15.8% de reoperación quirúrgica, el 62% de lesión renal aguda, el 50.5% de función anormal del injerto y el 45.5% de cultivos perioperatorios positivos. La duración de la estancia fue de 3.39 días, tiempo medio de ventilación mecánica de 16.5 horas. De estos criterios de valoración primarios, sólo la duración de la estancia y la duración de la ventilación mecánica fueron diferentes entre los grupos. Conclusiones: La duración de la estancia y la necesidad de ventilación mecánica, fueron diferentes entre los grupos. El desarrollo de otros criterios de valoración primarios fue independiente del modelo de resucitación.

Abstract: The resuscitation period after orthotopic liver transplantation (OLT) is challenging due to the physiological alterations related to end stage liver disease (ESLD). Material and methods: This is a retrospective study assessing the first 48 hours management at the intensive care unit (ICU) of at hospital in México City. Patients were categorized into 4 groups according to norepinephrine (NADR) dose used and net fluid balance (BalT): group 1 norepinephrine < 0.1 μg/1 kg/min/BalT 3,805 mL, group 2 norepinephrine > 0.1 μg/kg/min/BalT < 3,805 mL, group 3 norepinephrine < 0.1 μg/kg/min/BalT > 3,805 mL, group 4 norepinephrine > 0.1 μg/kg/min/BalT > 3,805 mL. The relationship with the development of Po-OLT complications was assessed. Primary endpoints were general medical complications, surgical reoperation, and length of stay (LOS), length of mechanical ventilation, acute kidney injury, abnormal graft function and positive cultures. Results: 36.6% of the patients belonged to group 1, 18.8% to group 2, 17.8% to group 3, and 26.7% to group 4. The length of stay was 3.39 days, mean time of mechanical ventilation of 16.5 hours. 67% developed medical complications, 15.8% surgical reoperation, 62% acute kidney injury, 50.5% abnormal graft function and 45.5% positive perioperative cultures. Of these primary endpoints, only length of stay and length of mechanical ventilation were different among groups. Conclusions: Length of stay and mechanical ventilation need was different among groups. Development of other primary endpoints was independent of the resuscitation model.

Resumo: O período de reanimação no pós-operatório de transplante hepático ortotópico (THO) é um desafio devido a alterações fisiológicas relacionados com a doença hepática terminal (DHT). Material e métodos: Realizou-se um estudo retrospectivo que avaliou as primeiras 48 horas do THO na unidade de terapia intensiva (UTI) de um hospital na Cidade do México. Os pacientes foram classificados em 4 grupos de acordo com a dose de norepinefrina (NADR) utilizada e o balaço hidrico (BalT): grupo 1 norepinefrina menor de 0.1 μg/1 kg/min/BalT menor de 3.805 ml, grupo 2 norepinefrina maior de 0.1 μg/kg/min/BalT menor de 3.805 ml, grupo 3 norepinefrina menor de 0.1 μg/kg/min/BalT maior de 3.805 ml, grupo 4 norepinefrina maior de 0.1 μg/kg /min/BalT maior de 3.805 ml. Analizou-se a relação que existe com o desenvolvimento de complicações Post-THO. As principais variáveis da avaliação foram: complicações médicas, reintervenção cirúrgica e tempo de permanência hospitalária, duração da ventilação mecânica, lesão renal aguda, função anormal do enxerto e cultivos positivos. Resultados: 36.6% dos pacientes pertenciam ao grupo 1, 18.8% ao grupo 2, 17.8% para o grupo 3 e 26.7% ao grupo 4. O tempo de permanência hospitalar foi 3.39 dias, ventilação mecânica de 16.5 horas tempo médio. 67% desenvolveram complicações médicas, 15.8% reintervenção cirúrgica, 62% de lesão renal aguda, 50.5% função anormal do enxerto e 45.5% de cultivos pré-operatórios positivos. Destes parâmetros, o TEUTI e TVM apresentaram diferenças entre os modelos de reanimação. Conclusão: O TEUTI e TVM variaram de acordo ao modelo de reanimação. Os outros resultados primários foram independentes ao modelo de reanimação.

Balance de fluidos y duración de la ventilación mecánica en niños internados en una Unidad de Terapia Intensiva Pediátrica / Fluid balance and length of mechanical ventilation in children admitted to a single Pediatric Intensive Care Unit

Introducción. Se han descrito asociaciones entre balance de fluido acumulado y mayor estadía en asistencia respiratoria mecánica en adultos. El objetivo fue evaluar si el balance de las primeras 48 horas de iniciada la asistencia respiratoria mecánica se asociaba a su prolongación en niños internados en Terapia Intensiva Pediátrica (UCIP). Métodos. Cohorte retrospectiva de pacientes de la UCIP del Hospital Italiano de Buenos Aires, entre el 1/1/2010 y el 30/6/2012. El balance se calculó en porcentaje del peso corporal; ventilación mecánica prolongada se definió como > 7 días y se registraron confundidores. Se realizó un análisis univariado y multivariado. Resultados. 249 pacientes permanecieron ventilados más de 48 horas; se incluyeron 163. El balance de las primeras 48 horas en ventilación mecánica fue 5,7%±5,86; 82 pacientes (50,3%) permanecieron más de 7 días con respirador. La edad < 4 años (OR 3,21; IC 95% 1,38-7,48; p 0,007), enfermedad respiratoria (OR 4,94; IC 95% 1,51-16,10; p 0,008), shock séptico (OR 4,66; IC 95% 1,10-19,65; p 0,036), puntaje de disfunción orgánica (PELOD) > 10 (OR 2,44; IC 95% 1,23-4,85; p 0,011) y balance positivo > 13% (OR 4,02; IC 95% 1,08-15,02; p 0,038) se asociaron a ventilación mecánica prolongada. El modelo multivariado mostró para PELOD > 10 un OR 2,58; IC 95%: 1,17-5,58; p 0,018, y para balance positivo > 13% un OR 3,7; IC 95%: 0,91-14,94; p 0,066. Conclusiones. En relación a ventilación mecánica prolongada, el modelo multivariado mostró una asociación independiente con disfunción de órganos (PELOD > 10) y una tendencia hacia la asociación con balance positivo > 13%.

Introduction. Associations between cumulative fluid balance and a prolonged duration of assisted mechanical ventilation have been described in adults. The aim of this study was to evaluate whether fluid balance in the first 48 hours of assisted mechanical ventilation initiation was associated with a prolonged duration of this process among children in the Pediatric Intensive Care Unit (PICU). Methods. Retrospective cohort of patients in the PICU of Hospital Italiano de Buenos Aires, between 1/1/2010 and 6/30/2012. Balance was calculated in percentage of body weight; prolonged mechanical ventilation was defined as >7 days, and confounders were registered. Univariate and multivariate analyses were performed. Results. Two hundred and forty-nine patients were mechanically ventilated for over 48 hours; 163 were included in the study. Balance during the first 48 hours of mechanical ventilation was 5.7% ± 5.86; 82 patients (50.3%) were on mechanical ventilation for more than 7 days. Age < 4 years old (OR 3.21, 95% CI 1.38-7.48, p 0.007), respiratory disease (OR 4.94, 95% CI 1.51-16.10, p 0.008), septic shock (OR 4.66, 95% CI 1.10-19.65, p 0.036), Pediatric Logistic Organ Dysfunction (PELOD) > 10 (OR 2.44, 95% CI 1.234.85, p 0.011), and positive balance > 13% (OR 4.02, 95% CI 1.08-15.02, p 0.038) were associated with prolonged mechanical ventilation. The multivariate model resulted in an OR 2.58, 95% CI: 1.17-5.58, p= 0.018 for PELOD > 10, and an OR 3.7, 95% CI: 0.91-14.94, p= 0.066 for positive balance > 13%. Conclusions. Regarding prolonged mechanical ventilation, the multivariate model showed an independent association with organ dysfunction (PELOD > 10) and a trend towards an association with positive balance > 13%.

Research on congestive refractory heart failure with renal failure treated by slow continuous ultrafiltration and relationship between negative fluid balance and predicts prognosis / 中国医学装备

Objective:To investigate the curative effect and safety of slow continuous ultrafiltration(SCUF) treatment on congestive refractory heart failure with renal failure, and to investigate the correlation between fluid balance and the postoperative complications.Methods:Thirty patients with congestive refractory heart failure with renal failure were chosen to receive slow continuous ultrafiltration treatment after deep vein catheterization, blood flow volume being 100-150 ml/min and therapy time being 24h. PiCCO was used to monitor the hemodynamic parameters, along with the change of blood pressure, blood oxygen saturation, heart beat and electrolyte.Results: After the slow continuous ultrafiltration treatment, the hemodynamic parameters of all patients showed obvious improvements, with better results on cardiac function and electrolyte balance. All the patients patients developed cardiopulmonary complications postoperatively have a larger total fluid balance of the first two days postoperatively than those without complications.Conclusion:SCUF have therapeutic effect and safety for treating congestive refractory heart failure with renal failure, and the status of the fluid balance can be a predictor of the postoperative morbidity and mortality.

The Impact of Fluid Balances in the First 48 Hours on Mortality in the Critically Ill Patients

Introduction: There has been increasing evidence of detrimental effects of cumulative positive fluid balance in critically ill patients. The postulated mechanism of harm is the development of interstitial oedema, with resultant increase morbidity and mortality. We aim to assess the impact of positive fluid balance within the first 48 hours on mortality in our local ICU population. Methods: This was a secondary analysis of a single centre, prospective observational study. All ICU patients more than 18 years were screened for inclusion in the study. Admission of less than 48 hours, post-elective surgery and ICU readmission were excluded. Cumulative fluid balance either as volume or percentage of body weight from admission was calculated over 6, 24 and 48 hour period from ICU admission. Results: A total of 143 patients were recruited, of these 33 died. There were higher cumulative fluid balances at 6, 24 and 48 hours in nonsurvivors compared to survivors. However, after adjusted for severity of illness, APACHE II Score, they were not predictive of mortality. Sensitivity analysis on sub-cohort of patients with acute kidney injury (AKI) showed only an actual 48-hour cumulative fluid balance was independently predictive of mortality (1.21 (1.03 to 1.42)). Conclusions: Cumulative fluid balance was not independently predictive of mortality in a heterogenous group of critically ill patients. However, in subcohort of patients with AKI, a 48-hour cumulative fluid balance was independently predictive of mortality. An additional tile is thus added to the mosaic of findings on the impact of fluid balance in a hetergenous group of critically ill patients, and in subcohort of AKI patients.

Risk factors for acute kidney injury after Sun’ s procedure in patients with acute aortic dissection / 中华胸心血管外科杂志

Objective To analyze the independent risk factors associated with acute kidney injury(AKI)after Sun’s pro-cedure in the patients with acute aortic dissection .Methods Clinical data of 400 patients who underwent Sun ’ s procedure from February 2009 to August 2013 were collected.Data included preoperative GFR, Cleveland values, CPB time and fluid balance of 24 h intra and after operation were gathered .The patients were divided into the group of AKI and the group of non-AKI accounting to the changing of serum creatinine.Results AKI was occurred in 150(37.5%) patients.Hospital mortality in AKI group was significant higher than that in the non-AKI group(11.3% vs.2.4%, P<0.05).Univariable analysis re-vealed male, BWI, hypertension, preoperative MAP,WBC, eGFR, Cleveland value, cardiopulmonary bypass time, intra and postoperative fluid balance for 24 h have significant difference between 2 groups.Multivariate logistic regression analysis showed hypertension, Cleveland value, cardiopulmonary bypass time and fluid balance were independent risk factors for AKI .Conclu-sion AKI after acute aortic dissection was a severe complication .Hypertension, Cleveland value, cardiopulmonary time and fluid balance were associated with AKI.

Influence of Daily Fluid Balance prior to Continuous Renal Replacement Therapy on Outcomes in Critically Ill Patients

Positive fluid balance is a risk factor for mortality in critically ill patients, especially those requiring continuous renal replacement therapy (CRRT). However, the association between daily fluid balance and various organ impairments remains unclear. This study investigated the impacts of daily fluid balance prior to CRRT on organ dysfunction, as well as mortality in critically ill patients. We identified daily fluid balance between intensive care unit (ICU) admission and CRRT initiation. According to daily fluid balance, the time to CRRT initiation and the rate of organ failure based on the sequential organ failure assessment (SOFA) score were assessed. We recruited 100 patients who experienced CRRT for acute kidney injury. CRRT was initiated within 2 [0, 4] days. The time to CRRT initiation was shortened in proportion to daily fluid balance, even after the adjustment for the renal SOFA score at ICU admission (HR 1.14, P = 0.007). Based on the SOFA score, positive daily fluid balance was associated with respiratory, cardiovascular, nervous, and coagulation failure, independent of each initial SOFA score at ICU admission (HR 1.36, 1.26, 1.24 and 2.26, all P < 0.05). Ultimately, we found that positive fluid balance was related with an increase in the rate of 28-day mortality (HR 1.14, P = 0.012). Positive daily fluid balance may accelerate the requirement for CRRT, moreover, it can be associated with an increased risk of multiple organ failure in critically ill patients.