Balanced Crystalloid Versus Normal Saline as Resuscitative Fluid in Diabetic Ketoacidosis

Background: Large volume resuscitation with normal saline (NS) may be associated with iatrogenic hyperchloremia and renal injury. Objective: The purpose of this study was to assess clinical outcomes associated with the use of Lactated Ringer’s (LR) compared to NS as resuscitative fluid in diabetic ketoacidosis (DKA). Methods: Single-center, retrospective analysis of patients admitted for DKA. The primary objective of this study was to evaluate the incidence of iatrogenic hyperchloremia associated with fluid resuscitation using balanced crystalloid compared to NS. Results Iatrogenic hyperchloremia occurred more frequently in the NS group compared to the LR group (74.4% vs 64.2%; P = 0.05). Mean maximum serum chloride was higher in the NS group (115.7 mmol/L vs 113.7 mmol/L; P = 0.004). Incidence of hypernatremia was higher in the NS group (18.3% vs 9.3%; P = 0.02). There was no significant difference in the incidence of AKI; however, mean change in serum creatinine at 48 hours showed a significantly greater decrease in the LR group (-0.15 mg/dL vs -0.04 mg/dL; P = 0.002). No significant differences were found in intensive care unit (ICU) length of stay or total hospital length of stay. Conclusion and Relevance This study found a statistically significant reduction in the incidence of iatrogenic hyperchloremia with the use of LR compared to NS as fluid resuscitation in DKA. Serum creatinine was more improved in the LR group versus NS group at 48 hours. Preferential use of balanced crystalloid for fluid resuscitation in DKA may reduce incidence of hyperchloremia and support renal recovery in this population.

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Intermittent Phosphate Usage for Pediatric Diabetic Ketoacidosis in the Setting of a Phosphate Shortage

Hospital Pharmacy ◽

10.1177/0018578719867647 ◽

2019 ◽

pp. 001857871986764

Author(s):

Christopher T. Campbell ◽

Sarah Gattoline ◽

Brian Kelly

Keyword(s):

Length Of Stay ◽

Diabetic Ketoacidosis ◽

Group Versus ◽

Potassium Phosphate ◽

Hospital Length Of Stay ◽

Continuous Group ◽

Continuous Administration ◽

Improvement Project ◽

Total Phosphate ◽

Number Of Patients

Purpose: Hypophosphatemia during pediatric diabetic ketoacidosis (DKA) is often replaced through a continuous infusion of intravenous (IV) fluids with potassium phosphate. In 2012, during an IV potassium phosphate shortage, providers were directed to oral replacement strategies to restrict IV products to those patients with severe hypophosphatemia. Intermittent oral and IV as needed doses for low phosphate levels replaced continuous administration in pediatric DKA. The purpose of this quality-improvement project was to determine whether the implemented IV phosphate restrictions resulted in less IV phosphate usage with no change in clinically relevant outcomes. Methods: In a retrospective chart analysis, pediatric patients less than 18 years of age admitted with a DKA diagnosis from June 2011 to December 2016 were divided into 2 groups: continuous and intermittent phosphate administration. Patients were excluded if they received both therapies. The primary outcome was the difference in IV phosphate administered. Secondary outcomes included the following: total phosphate received, the number of patients requiring as needed doses, phosphate levels at admission and discharge from pediatric intensive care unit (PICU), hospital length of stay, and PICU length of stay. Results: Phosphate restrictions resulted in a significantly lower usage of IV phosphate products in the intermittent group versus the continuous group (38.5 vs. 0 mmol, P < .0001). While total phosphate replacement was similar, intermittent phosphate administration was also associated with significantly lower minimum and discharge phosphate levels. Conclusions: During a phosphate salt shortage, restriction of continuous phosphate replacement in pediatric DKA management can reduce the amount of IV phosphate products used without any clinically meaningful change in outcomes.

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Outcome of the use of 0.9% saline versus 0.45% saline for fluid rehydration in moderate and severe diabetic ketoacidosis in children

Egyptian Pediatric Association Gazette ◽

10.1186/s43054-021-00057-z ◽

2021 ◽

Vol 69 (1) ◽

Author(s):

Nora El Said Badawi ◽

Mona Hafez ◽

Heba Sharaf Eldin ◽

Hend Mehawed Abdelatif ◽

Shimaa Atef ◽

...

Keyword(s):

Blood Glucose ◽

Diabetic Ketoacidosis ◽

Normal Saline ◽

Sodium Concentration ◽

Saline Group ◽

Serum Electrolytes ◽

Serum Chloride ◽

Significant Difference ◽

Rehydration Solution ◽

The Moment

Abstract Background The debate for the optimum sodium concentration in the rehydration solution in diabetic ketoacidosis (DKA) persists till the moment. The aim was to compare the outcome of 0.9% saline versus 0.45% saline in children with moderate and severe (DKA) regarding the effect on serum electrolytes, duration of DKA resolution and the incidence of hyperchloremia. Results A retrospective analysis of 121 children with moderate or severe DKA was done. After the initial 4 h in which both groups received normal saline, patients were divided into two groups continuing on 0.9% (N=72) or switched to 0.45% saline (N=49). Serum chloride and Cl/Na ratios were significantly higher in 0.9% saline group at 4 and 8 h. The 0.9% saline group had significantly higher proportion of hyperchloremia at 4 and 8 h (P value: 0.002, 0.02). The median duration of correction of DKA (14 h among 0.9% saline versus 10 h among 0.45% saline) without significant difference (P value= 0.43). The change in plasma glucose, effective osmolarity, corrected Na levels were comparable between groups. Conclusion There is an unavoidable iatrogenically induced rise in serum chloride with higher incidence of hyperchloremia with the use of normal saline in rehydration of children presenting in DKA and shock. The use of 0.45% saline as post-bolus rehydration fluid is not associated with a decline in the corrected serum sodium concentration and does not affect the rate of correction of acidosis or rate of drop in blood glucose or duration of DKA resolution when compared to normal saline.

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Abstract 13811: Cognitive and Psychological Outcomes of Patients 6 Months After Cardiac Arrest or Intensive Care Stay

Circulation ◽

10.1161/circ.144.suppl_2.13811 ◽

2021 ◽

Vol 144 (Suppl_2) ◽

Author(s):

Matthew R Potter ◽

Marco Mion ◽

Eleni A Nikolopoulou ◽

Neil Magee ◽

Kelly Farrell ◽

...

Keyword(s):

Cardiac Arrest ◽

Cognitive Impairment ◽

Length Of Stay ◽

Assessment Tools ◽

Hospital Length Of Stay ◽

Post Discharge ◽

Icu Patients ◽

Icu Stay ◽

Sf 36 ◽

Significant Difference

Background: The neuropsychological and cognitive consequences of an ICU stay can cause a large burden on many patients. In this study, we assessed the outcomes of a group of patients attending a newly set up, multi-disciplinary outpatient clinic focused on assessing neuropsychological and cognitive outcomes following a significant (>72 hours) ICU stay, and compared patients whose ICU was post-OHCA (out of hospital cardiac arrest), and those non-OHCA. Methods: Between 2016 and 2019, 152 patients were assessed within the Care after REsuscitation (CARE) / ICU follow up clinic, 6 months following hospital discharge, using the SF-36, HADS, PTSS-14 and MoCA. The OHCA group were compared to other non-OHCA, ICU patients (>72 hour stay). Results: No significant differences (p<0.05) were found between the groups outcomes, however we found that 6 months post-discharge, the non-OHCA group experience significantly more pain, are older, and required a longer length of stay (p<0.05). However, we found compared to normative data of the SF-36, over half of the OHCA group (on 6 out of the 8 subscales) and the non-OHCA (on 7 out of the 8) were below population norms, especially Role-Physical (66.7% OHCA and 71.6% non-OHCA) and Energy/ fatigue (66.7% OHCA and 61.4% non-OHCA). Anxiety was observed in 33.3% of the OHCA group, and 35.2% of the non-OHCA group had an abnormal total HADS score. PTSD was seen in 12.7% of the OHCA group and 10.2% of the non-OHCA group. Cognitive impairment was observed in 61.9% of OHCA and 59.1% of non-OHCA patients. Age and hospital length of stay had no significant effect on outcomes on our OHCA population, however females had significantly worse health related quality of life (HRQoL) on 6 out of the 8 subscales (p<0.05). Conclusion: Despite the OHCA and non-OHCA groups having no significant difference between their outcomes, there is a great disease burden upon many individuals following ICU stay, with many experiencing poor HRQoL, mood disorders, PTSD and cognitive impairment. The factors contributing to poor outcome following both ICU related illness and cardiac arrest should be further studied. The creation and validation of new assessment tools is imperative to ensure we fully appreciate the extent of the morbidity in this group to improve care for all ICU patients.

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Does emergency medicine length of stay predict trauma outcomes at a Level 1 Trauma Center?

Journal of Hospital Administration ◽

10.5430/jha.v4n5p1 ◽

2015 ◽

Vol 4 (5) ◽

pp. 1 ◽

Cited By ~ 2

Author(s):

Erin Powers Kinney ◽

Kamal Gursahani ◽

Eric Armbrecht ◽

Preeti Dalawari

Keyword(s):

Length Of Stay ◽

Trauma Center ◽

Injury Severity ◽

Hospital Length ◽

Hospital Length Of Stay ◽

Trauma Patients ◽

Hospital Capacity ◽

Significant Difference ◽

Level 1 ◽

Level 1 Trauma Center

Objective: Previous studies looking at emergency department (ED) crowding and delays of care on outcome measures for certain medical and surgical patients excluded trauma patients. The objectives of this study were to assess the relationship of trauma patients’ ED length of stay (EDLOS) on hospital length of stay (HLOS) and on mortality; and to examine the association of ED and hospital capacity on EDLOS.Methods: This was a retrospective database review of Level 1 and 2 trauma patients at a single site Level 1 Trauma Center in the Midwest over a one year period. Out of a sample of 1,492, there were 1,207 patients in the analysis after exclusions. The main outcome was the difference in hospital mortality by EDLOS group (short was less than 4 hours vs. long, greater than 4 hours). HLOS was compared by EDLOS group, stratified by Trauma Injury Severity Score (TRISS) category (< 0.5, 0.51-0.89, > 0.9) to describe the association between ED and hospital capacity on EDLOS.Results: There was no significant difference in mortality by EDLOS (4.8% short and 4% long, p = .5). There was no significant difference in HLOS between EDLOS, when adjusted for TRISS. ED census did not affect EDLOS (p = .59), however; EDLOS was longer when the percentage of staffed hospital beds available was lower (p < .001).Conclusions: While hospital overcrowding did increase EDLOS, there was no association between EDLOS and mortality or HLOS in leveled trauma patients at this institution.

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Comparison of perioperative outcomes in endovascular versus open repair for juxtarenal and pararenal aortic aneurysms: A propensity-matched analysis

Vascular ◽

10.1177/1708538116681911 ◽

2016 ◽

Vol 25 (4) ◽

pp. 339-345 ◽

Cited By ~ 7

Author(s):

Nathan T Orr ◽

Daniel L Davenport ◽

David J Minion ◽

Eleftherios S Xenos

Keyword(s):

Length Of Stay ◽

Mortality Rates ◽

Aortic Aneurysms ◽

Endovascular Aortic Repair ◽

Hospital Length Of Stay ◽

Perioperative Outcomes ◽

Propensity Scoring ◽

Aortic Repair ◽

Open Aortic Repair ◽

Significant Difference

Objective Endoluminal aortic aneurysm repair is suitable within certain anatomic specifications. This study aims to compare 30-day outcomes of endovascular versus open repairs for juxtarenal and pararenal aortic aneurysms (JAA/PAAs). Methods The ACS-NSQIP database was queried from 2012 to 2015 for JAA/PAA repairs. Procedures characterized as emergent were included in the study; however, failed prior repairs and ruptured aneurysms were excluded. The preoperative and perioperative patient characteristics, operative techniques, and outcome variables were compared between the open aortic repair and the endovascular aortic repair groups. Propensity scoring was performed to clinically match open aortic repair and endovascular aortic repair groups on preoperative risk and select perioperative factors that differed significantly in the unmatched groups. Outcome comparisons were then performed between matched groups. Results A total of 1005 (789 JAAs and 216 PAAs) aneurysm repairs were included in the study. Of these, there were 395 endovascular aortic repairs and 610 open aortic repairs. Propensity scoring created a matched group of 263 endovascular aortic repair and 263 open aortic repair patients. There was no statistically significant difference in 30-day mortality rates between matched endovascular aortic repair and open aortic repair patients (2.7% vs. 5.7%). The endovascular aortic repair group had a shorter ICU length of stay and overall hospital stay. The 30-day morbidity significantly favored endovascular aortic repair over open aortic repair (16% vs. 35%, p < 0.001). The main drivers of morbidity for endovascular aortic repair versus open aortic repair included return to the OR (6.8% vs. 15%, p < 0.001), rate of cardiac or respiratory failure (7.6% vs. 21%, p = 0.001), rate of renal insufficiency or failure (3.8% vs. 9.9%, p = 0.009), and rate of pneumonia (1.5% vs. 6.8%, p = 0.004). Conclusions There is no difference in mortality rates between endovascular aortic repair versus open aortic repair when repairing JAAs/PAAs. There is a significant difference in overall morbidity, and ICU and hospital length of stay favoring endovascular aortic repair over open aortic repair. This supports the expanded applicability and efficacy of endovascular repair for complex aneurysms.

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Effects of statins on clinical outcomes in hospitalized patients with community-acquired pneumonia

Journal of International Medical Research ◽

10.1177/0300060520938586 ◽

2020 ◽

Vol 48 (8) ◽

pp. 030006052093858

Author(s):

Rony M. Zeenny ◽

Hanine Mansour ◽

Wissam K Kabbara ◽

Nibal Chamoun ◽

Myriam Audi ◽

...

Keyword(s):

Retrospective Study ◽

Length Of Stay ◽

Hospital Length ◽

Community Acquired Pneumonia ◽

Hospital Length Of Stay ◽

Comorbid Conditions ◽

C Reactive Protein ◽

Reactive Protein ◽

Significant Difference ◽

Chronic Use

Objective We evaluated the effect of chronic use of statins based on C-reactive protein (CRP) levels and hospital length of stay (LOS) in patients admitted with community-acquired pneumonia (CAP). Methods We conducted a retrospective study over 12 months at a teaching hospital in Lebanon comparing patients with CAP taking chronic statins with patients not taking statins. Included patients with CAP were older than age 18 years and had two CRP level measures during hospitalization. CURB-65 criteria were used to assess the severity of pneumonia. A decrease in CRP levels on days 1 and 3, LOS, and normalization of fever were used to assess the response to antibiotics. Results Sixty-one patients were taking statins and 90 patients were not taking statins. Patients on statins had significantly more comorbid conditions; both groups had comparable CURB-65 scores. In both groups, no statistically significant difference was seen for the decrease in CRP level on days 1 and 3 and LOS. No difference in days to normalization of fever was detected in either group. Conclusion No association was found between the chronic use of statins and CRP levels, LOS, or days to fever normalization in patients with CAP.

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Ketamine as an Analgesic Adjuvant in Adult Trauma Intensive Care Unit Patients With Rib Fracture

Annals of Pharmacotherapy ◽

10.1177/1060028018768451 ◽

2018 ◽

Vol 52 (9) ◽

pp. 849-854 ◽

Cited By ~ 11

Author(s):

Mary K. Walters ◽

Joseph Farhat ◽

James Bischoff ◽

Mary Foss ◽

Cory Evans

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Length Of Stay ◽

Group Versus ◽

Standard Of Care ◽

Pain Scale ◽

Rib Fracture ◽

Hospital Length Of Stay ◽

Control Group ◽

Opioid Use

Background: Rib fracture associated pain is difficult to control. There are no published studies that use ketamine as a therapeutic modality to reduce the amount of opioid to control rib fracture pain. Objective: To examine the analgesic effects of adjuvant ketamine on pain scale scores in trauma intensive care unit (ICU) rib fracture. Methods: This retrospective, case-control cohort chart review evaluated ICU adult patients with a diagnosis of ≥1 rib fracture and an Injury Severity Score >15 during 2016. Patients received standard-of-care pain management with the physician’s choice analgesics with or without ketamine as a continuous, fixed, intravenous infusion at 0.1 mg/kg/h. Results: A total of 15 ketamine treatment patients were matched with 15 control standard-of-care patients. Efficacy was measured via Numeric Pain Scale (NPS)/Behavioral Pain Scale (BPS) scores, opioid use, and ICU and hospital length of stay. Safety of ketamine was measured by changes in vital signs, adverse effects, and mortality. Average NPS/BPS, severest NPS/BPS, and opioid use were lower in the ketamine group than in controls (NPS: 4.1 vs 5.8, P < 0.001; severest NPS: 7.0 vs 8.9, P = 0.004; opioid use: 2.5 vs 3.5 mg morphine equivalents/h/d, P = 0.015). No difference was found between the cohort’s length of stay or mortality. Average diastolic blood pressure was higher in the treatment group versus the control group (75.3 vs 64.6 mm Hg, P = 0.014). Conclusion: Low-dose ketamine appears to be a safe and effective adjuvant option to reduce pain and decrease opioid use in rib fracture.

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Rotavirus vaccination impact, Ireland, implications for vaccine confidence and screening

European Journal of Public Health ◽

10.1093/eurpub/ckz238 ◽

2020 ◽

Vol 30 (2) ◽

pp. 281-285 ◽

Cited By ~ 2

Author(s):

Heather E Burns ◽

Abigail M Collins ◽

Una B Fallon ◽

Paul V Marsden ◽

Caitlin M Ni Shuilleabhain

Keyword(s):

Length Of Stay ◽

Positive Impact ◽

Incidence Rates ◽

Hospital Length Of Stay ◽

Vaccine Hesitancy ◽

Rotavirus Vaccine ◽

Immunization Schedule ◽

Primary Immunization ◽

Rotavirus Infection ◽

Significant Difference

Abstract Background Rotavirus vaccine efficacy is well established. However, it is important to consistently demonstrate the positive impact of vaccination programmes in order to optimize uptake rates and combat vaccine hesitancy. Methods Routine data were used to examine rotavirus vaccine effectiveness in Ireland, including changes in age-specific crude incidence rates (CIRs), hospitalizations and hospital length of stay. National intussusception incidence was interrogated. Vaccination status of vaccine-eligible cases of rotavirus infection was determined. Results Nationally, a reduction in the CIR of rotavirus infection of 77.2% [95% confidence interval (CI) 57.8–88.5%, P<0.001] was observed post-inclusion of the rotavirus vaccine in the primary immunization schedule. A decrease in hospitalizations of 85.5% (95% CI 79.3–90.2%, P<0.001), 86.5% (95% CI 82.9–89.4%, P<0.001) and 78.5% (95% CI 74.7–81.9%, P<0.001) was observed in children aged <1, <2 and <5 years, respectively. Most hospitalizations occurred in infants too young to have been vaccinated. There was no significant difference in median length of stay for children hospitalized with rotavirus infection. Decreased CIRs and hospitalization rates in unvaccinated children aged between 2 and 5 years suggest community immunity. Vaccine non-protection was 0.13%. No increase in the national CIR of intussusception was observed. Conclusions Inclusion of the rotavirus vaccine in the Irish primary immunization schedule has resulted in a significant reduction in the burden of rotavirus infection. However, vaccine hesitancy remains a concern. With new vaccination programmes, risk of vaccine harms should be considered and mitigated in order to protect individuals and the integrity of the programme.

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