Enteral Sodium Chloride Supplementation and Fluid Balance in Children Receiving Diuretics

The use of sodium chloride (NaCl) supplementation in children being prescribed diuretics is controversial due to concerns that supplementation could lead to fluid retention. This is a single-center retrospective study in which fluid balance and diuretic dosing was examined in children prescribed enteral NaCl supplements for hyponatremia while receiving loop diuretics. The aim of this study was to determine whether significant fluid retention occurred with the addition of NaCl. Fifty-five patients with 68 events were studied. The median age was 5.2 months, and 82% were hospitalized for cardiac disease. Daily fluid balance the seven days prior to NaCl supplementation was lower than the seven days after, with measurement of: median 17 mL/kg/day (7–26) vs. 22 mL/kg/day (13–35) (p = 0.0003). There was no change in patient weight after supplementation (p = 0.63). There was no difference in the median loop diuretic dose before and after supplementation, with the diuretic dose in furosemide equivalents of 3.2 mL/kg/day (2.3–4.4) vs. 3.2 mL/kg/day (2.2–4.7) (p = 0.50). There was no difference in the proportion of patients receiving thiazide diuretics after supplementation (56% before vs. 50% after (p = 0.10)). NaCl supplementation in children receiving loop diuretics increased calculated fluid balance, but weight was unchanged, and this was not associated with an increase in diuretic needs, suggesting clinicians did not consider the increase in fluid balance to be clinically significant.

Positive Cumulative Fluids Balance Related to Mortality Events in Sepsis Patients Treated at Intensive Care Unit, Dr. Mohammad Hoesin General Hospital Palembang

Introduction. Sepsis is a syndrome that describes physiological dysfunction, pathological, and biochemistry caused by infection. Fluid balance is an indicator that can monitor input and output. This study was aimed to evaluate the relationship between positive cumulative fluid balance and the mortality rate of sepsis patients treated in the intensive care unit. Method: This study design is a retrospective study. The inclusion criteria consist of patients diagnosed with sepsis written in the medical record, 18-65 years old, and patients admitted in intensive care unit dr Moh. Hoesin General Hospital. Data were analyzed using SPSS 22.0 with the normality of data distribution, independent sample t-test, Mann-Whitney analysis, chi-square, Fisher’s Exact to measure the relationship, and using Medcalc version 14 application to measure cut-off value, ROC curve AUC, cross-sectional point, sensitivity, and specificity. Result. The result showed that characteristic between age (p=0,491), gender (p=0,703) did not differ significantly between survived and non-survived patient. Length of stay (p=0,002), balance (p=0,000), and ward unit (p=0,014) has a significant different between survived and non survived patient. In chi square analysis, p value=0,000with odds ratio 7,083. Cut-off value of ROC curve is -97 mL with AUC 0,844, sensitivity 76,1% and specificity 79,3%. Conclusion. Cumulative positive balance patient in the sepsis patient correlates with increased mortality in a sepsis patient in Dr. Mohammad Hoesin General Hospital Palembang.

Pulmonary Interstitial Matrix and Lung Fluid Balance From Normal to the Acutely Injured Lung

This review analyses the mechanisms by which lung fluid balance is strictly controlled in the air-blood barrier (ABB). Relatively large trans-endothelial and trans-epithelial Starling pressure gradients result in a minimal flow across the ABB thanks to low microvascular permeability aided by the macromolecular structure of the interstitial matrix. These edema safety factors are lost when the integrity of the interstitial matrix is damaged. The result is that small Starling pressure gradients, acting on a progressively expanding alveolar barrier with high permeability, generate a high transvascular flow that causes alveolar flooding in minutes. We modeled the trans-endothelial and trans-epithelial Starling pressure gradients under control conditions, as well as under increasing alveolar pressure (Palv) conditions of up to 25 cmH2O. We referred to the wet-to-dry weight (W/D) ratio, a specific index of lung water balance, to be correlated with the functional state of the interstitial structure. W/D averages ∼5 in control and might increase by up to ∼9 in severe edema, corresponding to ∼70% loss in the integrity of the native matrix. Factors buffering edemagenic conditions include: (i) an interstitial capacity for fluid accumulation located in the thick portion of ABB, (ii) the increase in interstitial pressure due to water binding by hyaluronan (the “safety factor” opposing the filtration gradient), and (iii) increased lymphatic flow. Inflammatory factors causing lung tissue damage include those of bacterial/viral and those of sterile nature. Production of reactive oxygen species (ROS) during hypoxia or hyperoxia, or excessive parenchymal stress/strain [lung overdistension caused by patient self-induced lung injury (P-SILI)] can all cause excessive inflammation. We discuss the heterogeneity of intrapulmonary distribution of W/D ratios. A W/D ∼6.5 has been identified as being critical for the transition to severe edema formation. Increasing Palv for W/D > 6.5, both trans-endothelial and trans-epithelial gradients favor filtration leading to alveolar flooding. Neither CT scan nor ultrasound can identify this initial level of lung fluid balance perturbation. A suggestion is put forward to identify a non-invasive tool to detect the earliest stages of perturbation of lung fluid balance before the condition becomes life-threatening.

What Is the Optimal Dialysate Sodium Concentration?

In haemodialysis, sodium and fluid balance (where intake matches loss) is achieved by ultrafiltration and by diffusion between the plasma water and dialysate. If a patient’s sodium intake does not change, any reduction in fluid gain obtained by lowering dialysate sodium concentration will result in less sodium removal by ultrafiltration. The corresponding change in diffusion to achieve balance may mean the benefit of lower fluid gain is offset by morbidity caused by a fall in serum sodium during dialysis. The standard dialysate sodium should minimise harm caused by both high ultrafiltration rates and osmotic disequilibrium. For most units, this is likely to be 138 to 140 mmol/L.

Thirst and Body Fluid Regulation

Body fluid regulation is pivotal to human health and is served by extensive clinical and pre-clinical science. By combining modern advances with previous findings in the field, this book presents a comprehensive treatment of major experiments, theories, and new advances in the field of body fluid regulation, thirst, and drinking. It features the main integrative brain mechanisms for fluid regulation, the development of such systems, fluid balance during heat and exercise, aging and clinical disorders, and comparative aspects of fluid regulation. The volume focuses on mammalian thirst or drinking behaviour alongside relevant aspects of the physiology of fluid balance. The principal fluid compartments and their regulation by both intakes and losses are highlighted, using both human and animal studies to illustrate the main concepts.

Risk factors and outcomes associated with postoperative ileus following ileostomy formation: a retrospective study

Background Postoperative ileus (POI) is associated with increased patient discomfort, length of stay (LOS), and healthcare cost. There is a paucity of literature examining POI in patients who have an ileostomy formed at the time of surgery. We aimed to identify risk factors for and outcomes associated with POI following ileostomy formation. Methods We included 261 consecutive non-emergent cases that included formation of an ileostomy by a board-certified colorectal surgeon at our institution from July 1, 2015, to June 30, 2020. Demographic, clinical, and intraoperative factors associated with increased odds of POI were evaluated. Post-procedure LOS, hospitalization cost, and re-admissions between patients with and without POI were compared. Results Out of 261 cases, 85 (32.6%) were associated with POI. Patients with POI had significantly higher body mass index (BMI) than those without POI (26.6 kg/m2 vs. 24.8kg/m2; p = 0.01). Intraoperatively, patients with POI had significantly longer procedure duration than those without POI (313 min vs. 279 min; p = 0.02). Patients with POI had a significantly higher net fluid balance at postoperative day (POD) 2 than those without POI (+ 2.65 L vs. + 1.80 L; p = 0.004), with POD2 fluid balance greater than + 807 mL (determined as the maximum Youden index for sensitivity over 80%) associated with a higher rate of POI (p = 0.006). This difference remained significant when adjusted for age, gender, BMI, pre-operative opioid use, procedure duration, and operative approach (p = 0.01). Patients with POI had significantly longer LOS (11.40 days vs. 5.12 days; p < 0.001) and direct cost of hospitalization ($38K vs. $22K; p < 0.001). Conclusions Minimizing fluid overload, particularly in the first 48 h after surgery, may be a strategy to reduce POI in patients undergoing ileostomy formation, and thus decrease postoperative LOS and hospitalization cost. Fluid restriction, diuresis, and changes in diet advancement or early stoma intubation should be considered measures that may improve outcomes and should be studied more intensively.

Excessive Positive Fluid Balance Has A Negative Effect On Short-Term Renal Outcomes After Kidney Transplantation

Background: Optimized postoperative fluid management is important for maintaining early allograft function after kidney transplantation (KT). However, there is still no clear guidance regarding fluid treatment after KT. In this study, we investigated the effect of perioperative fluid balance on postoperative allograft function.Methods: Recipients who underwent KT between March 2012 and August 2018 were included, and their medical records were reviewed retrospectively. We calculated fluid balance, which is the difference between total input and output during the 3 days after KT, and analyzed the change in estimated glomerular filtration rate (eGFR) according to fluid balance.Results: A total of 178 patients were included after excluding those with delayed graft function or urine output <2000 ml on the first day after KT. Among them, 116 received kidneys from living donors and 62 received kidneys from deceased donors. The total fluid balance up to day 3 was 4,236.9 ± 2830.4 ml. Old age, high body mass index (BMI), excessive positive fluid balance of the recipient, and high final creatinine of the donor were significantly associated with low eGFR at 1 week. In addition, old age, BMI, and fluid balance of the recipient predicted the 1-month eGFR. In multivariate analysis, an excessive positive fluid balance was an independent predictor of low 1-week eGFR (p=0.031). Conclusions: This study demonstrated that excessive positive fluid balance can negatively affect early graft function after KT. Proper fluid management strategies based on volume conditions may provide important therapeutic opportunities to improve early renal outcomes after KT.