Aggressive versus conservative fluid resuscitation in septic hemodialysis patients.

PURPOSE: Sepsis and bacterial infections are common in patients with end-stage renal disease (ESRD). We aimed to compare patients with ESRD on hemodialysis presenting to hospital with severe sepsis or septic shock who received <20 ml/kg of intravenous fluid to those who received ≥20 ml/kg during initial resuscitation. MATERIALS AND METHODS: We conducted a retrospective chart review of adult patients with ICD codes for discharge diagnosis of sepsis, severe sepsis, septic shock, ESRD, and hemodialysis admitted to our institution between 2015 and 2018. RESULTS: We present outcomes for a total of 104 patients - 51 patients in conservative group and 53 in aggressive group. The mean age was 69.5 ± 11.2 years and 71 ± 11.5 years in the conservative group and aggressive group, respectively. There was no significant difference in the rate of ICU admission, and ICU or hospital length of stay between the two groups. Complications such as volume overload, rate of intubation, and urgent dialysis were not found to be significantly different. CONCLUSION: We found that aggressive fluid resuscitation with ≥20 ml/kg may not be detrimental in the initial resuscitation of ESRD patients with SeS or SS. However, a clinical decision of volume responsiveness should be made on a case-by-case basis rather than a universal approach for fluid resuscitation in ESRD patients.

Fluid resuscitation in patients with end-stage renal disease on hemodialysis presenting with severe sepsis or septic shock: A case control study.

Due to the potential risk of volume overload, physicians are hesitant to aggressively fluid-resuscitate septic patients with end-stage renal disease (ESRD) on hemodialysis (HD). Primary objective: To calculate the percentage of ESRD patients on HD (Case) who received ≥30 mL/Kg fluid resuscitation within the first 6 h compared to non-ESRD patients (Control) that presented with severe sepsis (SeS) or septic shock (SS). Secondary objectives: Effect of fluid resuscitation on intubation rate, need for urgent dialysis, hospital length of stay (LOS), intensive care unit (ICU) admission and LOS, need for vasopressors, and hospital mortality. Medical records of 715 patients with sepsis, SeS, SS, and ESRD were reviewed. We identified 104 Case and 111 Control patients. In the Case group, 23% of patients received ≥30 mL/Kg fluids compared to 60% in the Control group (p < 0.001). There was no significant difference in in-hospital mortality, need for urgent dialysis, intubation rates, ICU LOS, or hospital LOS between the two groups. Subgroup analysis between ESRD patients who received ≥30 mL/Kg (N = 80) vs those who received <30 mL/Kg (N = 24) showed no significant difference in any of the secondary outcomes. Compliance with 30 mL/Kg fluids was low for all patients but significantly lower for ESRD patients. Aggressive fluid resuscitation appears to be safe in ESRD patients.

Bronchial Obstruction Caused by a Dilated Pulmonary Artery.

Airway obstruction from an enlarged pulmonary artery (PA) is not a common occurrence. We present a rare case of respiratory failure secondary to right bronchus obstruction from a dilated right PA. A 54-year-old male with a known history of pulmonary hypertension (PH) and obstructive sleep apnea (OSA) presented with worsening dyspnea. He was found to have collapse of his right middle and lower lobes. Intubation was required for respiratory failure. To our knowledge, this is the first case to be reported in the literature where PH caused PA dilatation to such a degree as to cause bronchial obstruction and subsequent lobar collapse.

Comparative evaluation of stress levels before, during, and after periodontal surgical procedures with and without nitrous oxide-oxygen inhalation sedation.

CONTEXT: Periodontal surgical procedures produce varying degree of stress in all patients. Nitrous oxide-oxygen inhalation sedation is very effective for adult patients with mild-to-moderate anxiety due to dental procedures and needle phobia. AIM: The present study was designed to perform periodontal surgical procedures under nitrous oxide-oxygen inhalation sedation and assess whether this technique actually reduces stress physiologically, in comparison to local anesthesia alone (LA) during lengthy periodontal surgical procedures. SETTINGS AND DESIGN: This was a randomized, split-mouth, cross-over study. MATERIALS AND METHODS: A total of 16 patients were selected for this randomized, split-mouth, cross-over study. One surgical session (SS) was performed under local anesthesia aided by nitrous oxide-oxygen inhalation sedation, and the other SS was performed on the contralateral quadrant under LA. For each session, blood samples to measure and evaluate serum cortisol levels were obtained, and vital parameters including blood pressure, heart rate, respiratory rate, and arterial blood oxygen saturation were monitored before, during, and after periodontal surgical procedures. STATISTICAL ANALYSIS USED: Paired t-test and repeated measure ANOVA. RESULTS: The findings of the present study revealed a statistically significant decrease in serum cortisol levels, blood pressure and pulse rate and a statistically significant increase in respiratory rate and arterial blood oxygen saturation during periodontal surgical procedures under nitrous oxide inhalation sedation. CONCLUSION: Nitrous oxide-oxygen inhalation sedation for periodontal surgical procedures is capable of reducing stress physiologically, in comparison to LA during lengthy periodontal surgical procedures.

Surgical re-entry evaluation of regenerative efficacy of bioactive Gengigel(®) and platelet-rich fibrin in the treatment of grade II furcation: A novel approach.

The furcation area creates situations in which routine periodontal procedures are somewhat limited, and surgical procedures are generally required. The introduction of bioactive agents, such as platelet concentrates, enamel matrix derivatives, bone morphogenic proteins, and matrix macromolecules such as hyaluronic acid has expanded the scope for better outcomes in furcation treatment. Hyaluronic acid is a naturally occurring nonsulfated high molecular weight glycosaminoglycan that forms a critical component of the extracellular matrix and contributes significantly to tissue hydrodynamics, cell migration, and proliferation. Platelet-rich fibrin (PRF) is an immune and platelet concentrate containing all the constituents of a blood sample, which are favorable for healing and immunity. The purpose of the present case report was to assess through surgical re-entry, the regenerative capacity of Gengigel(®) in conjunction with PRF in a patient with grade II furcation defect. It was observed that the combined approach resulted in significant furcation defect fill on re-evaluation at 6 months.