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The New England Journal of Medicine Feb 2023Intravenous fluids and vasopressor agents are commonly used in early resuscitation of patients with sepsis, but comparative data for prioritizing their delivery are... (Comparative Study)
Comparative Study Randomized Controlled Trial
BACKGROUND
Intravenous fluids and vasopressor agents are commonly used in early resuscitation of patients with sepsis, but comparative data for prioritizing their delivery are limited.
METHODS
In an unblinded superiority trial conducted at 60 U.S. centers, we randomly assigned patients to either a restrictive fluid strategy (prioritizing vasopressors and lower intravenous fluid volumes) or a liberal fluid strategy (prioritizing higher volumes of intravenous fluids before vasopressor use) for a 24-hour period. Randomization occurred within 4 hours after a patient met the criteria for sepsis-induced hypotension refractory to initial treatment with 1 to 3 liters of intravenous fluid. We hypothesized that all-cause mortality before discharge home by day 90 (primary outcome) would be lower with a restrictive fluid strategy than with a liberal fluid strategy. Safety was also assessed.
RESULTS
A total of 1563 patients were enrolled, with 782 assigned to the restrictive fluid group and 781 to the liberal fluid group. Resuscitation therapies that were administered during the 24-hour protocol period differed between the two groups; less intravenous fluid was administered in the restrictive fluid group than in the liberal fluid group (difference of medians, -2134 ml; 95% confidence interval [CI], -2318 to -1949), whereas the restrictive fluid group had earlier, more prevalent, and longer duration of vasopressor use. Death from any cause before discharge home by day 90 occurred in 109 patients (14.0%) in the restrictive fluid group and in 116 patients (14.9%) in the liberal fluid group (estimated difference, -0.9 percentage points; 95% CI, -4.4 to 2.6; P = 0.61); 5 patients in the restrictive fluid group and 4 patients in the liberal fluid group had their data censored (lost to follow-up). The number of reported serious adverse events was similar in the two groups.
CONCLUSIONS
Among patients with sepsis-induced hypotension, the restrictive fluid strategy that was used in this trial did not result in significantly lower (or higher) mortality before discharge home by day 90 than the liberal fluid strategy. (Funded by the National Heart, Lung, and Blood Institute; CLOVERS ClinicalTrials.gov number, NCT03434028.).
Topics: Humans; Fluid Therapy; Sepsis; Hypotension; Time Factors; Treatment Outcome; Vasoconstrictor Agents
PubMed: 36688507
DOI: 10.1056/NEJMoa2212663 -
Clinical Medicine (London, England) Jan 2022Dengue is an arboviral infection that is hyperendemic in tropical and subtropical climates. Clinical manifestations of dengue can range from asymptomatic infection to...
Dengue is an arboviral infection that is hyperendemic in tropical and subtropical climates. Clinical manifestations of dengue can range from asymptomatic infection to severe infection with multi-organ failure. Dengue haemorrhagic fever (DHF) is a subcategory in dengue infection with a hallmark of plasma leak (ie critical phase). The plasma leak in DHF is selective (pleuroperitoneal spaces), transient and dynamic, and needs careful monitoring and meticulous fluid resuscitation. In addition, dengue fever may present with extended and unusual manifestations affecting any organ, including the heart, liver, kidney and brain. Studies on vaccine development and vector control are ongoing to prevent this infection of global importance. In this article, the clinicopathological features and management aspects of dengue are discussed.
Topics: Dengue; Fluid Therapy; Humans; Severe Dengue
PubMed: 35078789
DOI: 10.7861/clinmed.2021-0791 -
Clinical Journal of the American... May 2022One of the primary reasons for intensive care admission is shock. Identifying the underlying cause of shock (hypovolemic, distributive, cardiogenic, and obstructive) may... (Review)
Review
One of the primary reasons for intensive care admission is shock. Identifying the underlying cause of shock (hypovolemic, distributive, cardiogenic, and obstructive) may lead to entirely different clinical pathways for management. Among patients with hypovolemic and distributive shock, fluid therapy is one of the leading management strategies. Although an appropriate amount of fluid administration might save a patient's life, inadequate (or excessive) fluid use could lead to more complications, including organ failure and mortality due to either hypovolemia or volume overload. Currently, intensivists have access to a wide variety of information sources and tools to monitor the underlying hemodynamic status, including medical history, physical examination, and specific hemodynamic monitoring devices. Although appropriate and timely assessment and interpretation of this information can promote adequate fluid resuscitation, misinterpretation of these data can also lead to additional mortality and morbidity. This article provides a narrative review of the most commonly used hemodynamic monitoring approaches to assessing fluid responsiveness and fluid tolerance. In addition, we describe the benefits and disadvantages of these tools.
Topics: Critical Care; Fluid Therapy; Hemodynamic Monitoring; Hemodynamics; Humans; Hypovolemia; Shock
PubMed: 35379765
DOI: 10.2215/CJN.14191021 -
The Veterinary Clinics of North... Nov 2020Canine parvoviral enteritis is one of the most common causes of morbidity and mortality in dogs worldwide. Tests can detect viral antigen in feces, and characteristic... (Review)
Review
Canine parvoviral enteritis is one of the most common causes of morbidity and mortality in dogs worldwide. Tests can detect viral antigen in feces, and characteristic decreases in total leukocyte, neutrophil, and lymphocyte counts can increase the index of suspicion in affected cases and can be used to prognosticate morbidity and mortality. The standard of care for infected animals includes IV crystalloid and sometimes colloid fluids, antiemetics, broad-spectrum antibiotics, and early enteral nutrition. Vaccination induces protective immunity in most dogs. Vaccination, along with limiting exposure in young puppies, is the most effective means of preventing parvoviral enteritis in dogs.
Topics: Animals; Crystalloid Solutions; Dog Diseases; Dogs; Enteritis; Fluid Therapy; Parvoviridae Infections; Parvovirus, Canine
PubMed: 32891439
DOI: 10.1016/j.cvsm.2020.07.008 -
Critical Care (London, England) Mar 2023During septic shock, fluid therapy is aimed at increasing cardiac output and improving tissue oxygenation, but it poses two problems: it has inconsistent and transient... (Review)
Review
During septic shock, fluid therapy is aimed at increasing cardiac output and improving tissue oxygenation, but it poses two problems: it has inconsistent and transient efficacy, and it has many well-documented deleterious effects. We suggest that there is a place for its personalization according to the patient characteristics and the clinical situation, at all stages of circulatory failure. Regarding the choice of fluid for volume expansion, isotonic saline induces hyperchloremic acidosis, but only for very large volumes administered. We suggest that balanced solutions should be reserved for patients who have already received large volumes and in whom the chloremia is rising. The initial volume expansion, intended to compensate for the constant hypovolaemia in the initial phase of septic shock, cannot be adapted to the patient's weight only, as suggested by the Surviving Sepsis Campaign, but should also consider potential absolute hypovolemia induced by fluid losses. After the initial fluid infusion, preload responsiveness may rapidly disappear, and it should be assessed. The choice between tests used for this purpose depends on the presence or absence of mechanical ventilation, the monitoring in place and the risk of fluid accumulation. In non-intubated patients, the passive leg raising test and the mini-fluid challenge are suitable. In patients without cardiac output monitoring, tests like the tidal volume challenge, the passive leg raising test and the mini-fluid challenge can be used as they can be performed by measuring changes in pulse pressure variation, assessed through an arterial line. The mini-fluid challenge should not be repeated in patients who already received large volumes of fluids. The variables to assess fluid accumulation depend on the clinical condition. In acute respiratory distress syndrome, pulmonary arterial occlusion pressure, extravascular lung water and pulmonary vascular permeability index assess the risk of worsening alveolar oedema better than arterial oxygenation. In case of abdominal problems, the intra-abdominal pressure should be taken into account. Finally, fluid depletion in the de-escalation phase is considered in patients with significant fluid accumulation. Fluid removal can be guided by preload responsiveness testing, since haemodynamic deterioration is likely to occur in patients with a preload dependent state.
Topics: Humans; Shock, Septic; Sepsis; Blood Pressure; Shock; Fluid Therapy; Hemodynamics; Cardiac Output
PubMed: 36964573
DOI: 10.1186/s13054-023-04363-3 -
Kidney International Jul 2019Fluid therapy, which is provided to restore and maintain tissue perfusion, is part of routine management for almost all critically ill patients. However, because either... (Review)
Review
Fluid therapy, which is provided to restore and maintain tissue perfusion, is part of routine management for almost all critically ill patients. However, because either too much or too little fluid can have a negative impact on patient outcomes, fluid administration must be titrated carefully for each patient. The "salvage, optimization, stabilization, de-escalation" (SOSD) mnemonic should be used as a general guide to fluid resuscitation, and fluid administration should be adapted according to the course of the disease. In the initial salvage phase, lifesaving fluid should be administered generously. Once hemodynamic monitoring is available, fluid administration should be optimized by determining the patient's fluid status and the need for further fluid. This determination can be difficult, however; clinical indicators of hypovolemia, such as heart rate, blood pressure, and urine output, may not detect early hypovolemia, and edema is a late sign of fluid overload. Dynamic tests of fluid responsiveness such as pulse pressure or stroke volume variation can be used in only a small percentage of critically ill patients, and thus a fluid challenge technique is most frequently used to assess ongoing fluid requirements. Once a patient has been stabilized, efforts should start to concentrate on removing excess fluid. Which fluid should be used remains a matter of some debate. Crystalloid solutions are cheaper than colloid solutions, but colloid solutions remain in the intravascular space for a longer period, making edema less likely. Thus crystalloids and colloids should be used together, especially in patients likely to require large fluid volumes. Human albumin is a natural colloid and may have beneficial effects in patients with sepsis in addition to its volume effects. Fluids should be prescribed as are other medications, taking into account individual patient factors, disease processes, and other treatments.
Topics: Colloids; Critical Illness; Fluid Therapy; Humans; Hypovolemia; Isotonic Solutions; Monitoring, Physiologic; Plasma Substitutes; Resuscitation; Treatment Outcome
PubMed: 30926137
DOI: 10.1016/j.kint.2018.11.047 -
Internal and Emergency Medicine Sep 2021Early management of sepsis and septic shock is crucial for patients' prognosis. As the Emergency Department (ED) is the place where the first medical contact for septic... (Review)
Review
Early management of sepsis and septic shock is crucial for patients' prognosis. As the Emergency Department (ED) is the place where the first medical contact for septic patients is likely to occur, emergency physicians play an essential role in the early phases of patient management, which consists of accurate initial diagnosis, resuscitation, and early antibiotic treatment. Since the issuing of the Surviving Sepsis Campaign guidelines in 2016, several studies have been published on different aspects of sepsis management, adding a substantial amount of new information on the pathophysiology and treatment of sepsis and septic shock. In light of this emerging evidence, the present narrative review provides a comprehensive account of the recent advances in septic patient management in the ED.
Topics: Anti-Bacterial Agents; Disease Management; Emergency Service, Hospital; Fluid Therapy; Humans; Monitoring, Physiologic; Resuscitation; Sepsis; Shock, Septic; Vasoconstrictor Agents
PubMed: 33890208
DOI: 10.1007/s11739-021-02735-7 -
Indian Journal of Pediatrics Feb 2023Dengue is an important public health problem with a wide clinical spectrum. The World Health Organization classifies dengue into probable dengue, dengue with warning... (Review)
Review
Dengue is an important public health problem with a wide clinical spectrum. The World Health Organization classifies dengue into probable dengue, dengue with warning signs, and severe dengue. Severe dengue, characterized by plasma leakage, severe bleeding, or organ impairment, entails significant morbidity and mortality if not treated timely. There are no definitive curative medications for dengue; management is supportive. Judicious fluid resuscitation during the critical phase of dengue is the cornerstone of management. Crystalloids are the initial fluid of choice. Prophylactic platelet transfusion is not recommended. Organ involvement in severe dengue should be carefully looked for and managed. Secondary hemophagocytic lymphohistiocytosis is a potentially fatal complication of dengue that needs to be recognized, as specific management with steroids or intravenous immunoglobulin may improve outcomes. Several compounds with anti-dengue potential are being studied; no anti-dengue drug is available so far.
Topics: Humans; Severe Dengue; Hemorrhage; Fluid Therapy; Immunoglobulins, Intravenous; World Health Organization
PubMed: 36574088
DOI: 10.1007/s12098-022-04394-8 -
American Family Physician Apr 2020Guidelines published in 2016 provide a revised definition of sepsis: life-threatening organ dysfunction caused by a dysregulated host response to infection. The...
Guidelines published in 2016 provide a revised definition of sepsis: life-threatening organ dysfunction caused by a dysregulated host response to infection. The guidelines define septic shock as sepsis with circulatory, cellular, and metabolic dysfunction that is associated with a higher risk of mortality. The measurement of serum lactate has been incorporated into the latest septic shock definition. The guidelines recommend the Sequential Organ Failure Assessment (original and quick versions) as an important tool for early diagnosis. Respiratory, gastrointestinal, genitourinary, and skin and soft tissue infections are the most common sources of sepsis. Pneumonia is the most common cause of sepsis. Although many patients with sepsis have fever, the clinical manifestation can be subtle, particularly in older patients and those who are immunocompromised. Initial evaluation of patients with suspected sepsis includes basic laboratory tests, cultures, imaging studies as indicated, and sepsis biomarkers such as procalcitonin and lactate levels. Fluid resuscitation is the priority in early management, including administering an intravenous crystalloid at 30 mL per kg within the first three hours. Antimicrobial therapy should also be initiated early. Most research indicates that antimicrobial therapy should be started within three hours of presentation. The latest guidelines recommend starting antimicrobials within one hour, but this is controversial. Vasopressor therapy is indicated if hypotension persists despite fluid administration. Future trials of sepsis management are focusing on improving long-term rates of readmission and death, physical disability, cognitive impairment, and quality of life.
Topics: Anti-Bacterial Agents; Biomarkers; Early Diagnosis; Fluid Therapy; Humans; Oxygen Inhalation Therapy; Quality of Life; Respiration, Artificial; Sepsis; Shock, Septic; Time Factors
PubMed: 32227831
DOI: No ID Found -
American Family Physician Sep 2019Acute upper respiratory tract infections are extremely common in adults and children, but only a few safe and effective treatments are available. Patients typically...
Acute upper respiratory tract infections are extremely common in adults and children, but only a few safe and effective treatments are available. Patients typically present with nasal congestion, rhinorrhea, sore throat, cough, general malaise, and/or low-grade fever. Informing patients about the self-limited nature of the common cold can help manage expectations, limit antibiotic use, and avoid over-the-counter purchases that may not help. Treatments with proven effectiveness for cold symptoms in adults include over-the-counter analgesics, zinc, nasal decongestants with or without antihistamines, and ipratropium for cough. Lower-quality evidence suggests that Lactobacillus casei may be beneficial in older adults. The only established safe and effective treatments for children are acetylcysteine, honey (for children one year and older), nasal saline irrigation, intranasal ipratropium, and topical application of ointment containing camphor, menthol, and eucalyptus oils. Over-the-counter cold medications should not be used in children younger than four years. Counseling patients about the importance of good hand hygiene is the best way to prevent transmission of cold viruses.
Topics: Adult; Ascorbic Acid; Child; Common Cold; Echinacea; Fluid Therapy; Humans; Nasal Decongestants; Nonprescription Drugs; Patient Education as Topic
PubMed: 31478634
DOI: No ID Found