Determinants of mortality among under-five children admitted with severe acute malnutrition in Addis Ababa, Ethiopia

Background Management of severe acute malnutrition (SAM) has been a program priority in Ethiopia, but it remains the leading cause of mortality in under-five children. Hence, this study aimed to identify the incidence density rate of mortality and determinants among under-five children with severe acute malnutrition in St. Paul’s Hospital Millennium Medical College, 2012 to 2019. Methods A retrospective cohort study was conducted and data were collected using a structured checklist from 673 charts, of which 610 charts were included in the final analysis. The Kaplan-Meier survival curve with Log-rank test was used to estimate the survival time. Bi-variable and multi-variable Cox proportional hazard regression models were fitted to identify determinants of death. Schoenfeld residuals test was used to check a proportional hazard assumption. Goodness of fit of the final model was checked using Nelson Aalen cumulative hazard function against Cox-Snell residual. Results In this study, 61 (10%) children died making the incidence density rate of death 5.6 (95% CI: 4.4, 7.2) per 1000 child-days. Shock (Adjusted Hazard Ratio) [AHR] =3.2; 95% CI: 1.6, 6.3)), IV fluid infusion (AHR = 5.2; 95% CI: 2.4, 10.4), supplementing F100 (AHR = 0.12; 95%CI: 0.06, 0.23) and zinc (AHR = 0.45; 95% CI: 0.22, 0.93) were determinants of death. Conclusion The overall proportion of deaths was within the range put forth by the Sphere standard and the national SAM management protocol. Shock and IV fluid infusion increased the hazard of death, whereas F100 & zinc were found to decrease the likelihood death. Children with SAM presented with shock should be handled carefully and IV fluids should be given with precautions.

Rheosorbilact in complex intensive therapy of burn toxemia

Background. Thermal injuries primarily cause coagulation necrosis and cell death with vascular thrombosis in the areas of the deepest lesion.Objective. To study the effectiveness of rheosorbilact in infusion therapy during the period of burn toxemia.Materials and Methods. The results of monitoring the daily volume of the injected fluid, infusion therapy and renal excretory activity of 25 patients admitted to the Department of Combustiology of Republican Research Center of Emergency Medicine due to burn injury were studied.Results. The average daily volume of infusion therapy in group 1, FI – 119.4 ± 38.4 units at the age of 27.3 ± 5.6 years, was 76 ± 7 ml/kg per day, in group 2 (50.7 ± 7.1 years), FI – 92.5 ± 20.8 units, the introduction of 64 ± 9 ml/kg was effective, in group 3 (71.3 ± 7.0 years), FI – 86.7 ± 12.8 units, the introduction of an average of 48 ± 11 ml/kg per day was sufficient. In the nonlinear nature of changes in intravenous infusion, 4–5-day periods can be noted, probably due to the current factors that determined the need to increase or decrease infusion therapy. The introduction of rheosorbilact in a volume of 10 ml/kg per day increased the hourly renal excretory activity in all patients during the period of toxemia. The diuretic effect was more pronounced in patients of group 1, which corresponded to a greater volume of water load and the severity of burn injury.Conclusions. The introduction of rheosorbilact in a volume of 10 ml/kg per day increased the hourly renal excretory activity in all patients during the period of toxemia.

Initial Results of the American Burn Association (ABA) Observational Multi-Center Evaluation on the Effectiveness of the Burn Navigator

The objective of this multi-center observational study was to evaluate resuscitation volumes and outcomes of patients who underwent fluid resuscitation utilizing the Burn Navigator (BN), a resuscitation clinical decision support tool. Two analyses were performed: examination of the first 24 hours of resuscitation, and the first 24 hours post-burn regardless of when the resuscitation began, to account for patients who presented in a delayed fashion. Patients were classified as having followed the BN (FBN) if all hourly fluid rates were within ±20 mL of BN recommendations for that hour at least 83% of the time, otherwise they were classified as not having followed BN (NFBN). Analysis of resuscitation volumes for FBN patients in the first 24 hours resulted in average volumes for primary crystalloid) and total fluids administered of 4.07 ± 1.76 mL/kg/TBSA (151.48 ± 77.46 mL/kg), and 4.68 ± 2.06 mL/kg/TBSA (175.01 ± 92.22 mL/kg), respectively. Patients who presented in a delayed fashion revealed average volumes for primary and total fluids of 5.28 ± 2.54 mL/kg/TBSA (201.11 ± 106.53 mL/kg), 6.35 ± 2.95 mL/kg/TBSA (244.08 ± 133.5 mL/kg), respectively. There was a significant decrease in the incidence of burn shock in the FBN group (p< 0.05). This study shows that the BN provides comparable resuscitation volumes of primary crystalloid fluid to the Parkland Formula, recommends total fluid infusion less than the Ivy Index, and was associated with a decreased incidence of burn shock. Early initiation of the BN device resulted in lower overall fluid volumes.

CANINE PANCREATITIS: THE DEVELOPMENT OF THE PANCREATIC INFLAMMATORY CONDITION AND THE CLINICAL-THERAPEUTIC APPROACH

Pancreatitis, acute or chronic, is a serious disease for dogs, due to its harmful potential and the existence of underdiagnosis. The disease is still the target of studies regarding its pathophysiology and therapeutic mechanisms, because the signs presented by the animals are nonspecific, ranging from mild to severe presentations. It can cause morphofunctional changes in the pancreas and adjacent organs. The diagnosis can be a very difficult task, either due to the variable symptoms and severity of the disease, or the impasses experienced at the time of the complementary exams. Therapeutic management is defined based on the symptoms presented by the animals, ranging from fluid infusion for volume replacement, analgesics, antiemetics, antibiotics, special food, among others.

State of the Art: An Update on Adult Burn Resuscitation

Treatment of patients with severe burn injuries is complex, relying on attentive fluid resuscitation, successful management of concomitant injuries, prompt wound assessment and closure, early rehabilitation, and compassionate psychosocial care. The goal of fluid resuscitation is to maintain organ perfusion at the lowest possible physiologic cost. This requires careful, hourly titration of the infusion rate to meet individual patient needs, and no more; the risks of over-resuscitation, such as compartment syndromes, are numerous and life-threatening. Recognizing runaway resuscitations and understanding how to employ adjuncts to crystalloid resuscitation are paramount to preventing morbidity and mortality. This article provides an update on fluid resuscitation techniques in burn patients, to include choosing the initial fluid infusion rate, using alternate endpoints of resuscitation, and responding to the difficult resuscitation.

Glucagon-Like Peptide-2 Modulates Enteric Paneth Cells Immune Response and Alleviates Gut Inflammation During Intravenous Fluid Infusion in Mice With a Central Catheter

Background: Glucagon-like peptide-2 (GLP-2) has protective effects on gastrointestinal functions. Our previous study found that GLP-2 could significantly reduce intestinal permeability and bacterial translocation in total parenteral nutrition (TPN) animal model. However, the effects of GLP-2 on the impairment of the intestinal Paneth cells immune function and gut inflammation during intravenous fluid infusion mainly consisted of nutritional materials is currently scattered.Objective: The current study was aimed to investigate the efficacy of the GLP-2 in alleviating gut inflammation and modulating enteric Paneth cells immune response in parenterally fed mice and its underlying mechanisms.Methods: Thirty-six male ICR mice underwent venous catheterization were divided into 3 groups: Chow, TPN, and TPN+GLP-2 groups. GLP-2 was administered intravenously at 60 μg/day for 5 days. The small intestine tissue and serum samples were collected on the 7th day.Results: Compared with the TPN group, the expression of tight junction proteins occludin and claudin-1 were significantly increased in the TPN+GLP-2 group. In addition, the expression of lysozyme, sPLA2, insulin-like growth factor-1, and epithelial protection and repair genes were improved in the TPN+GLP-2 group. The levels of IL-6 and TNF-α proteins and mRNAs in the ileum tissues were remarkably reduced in the TPN+GLP-2 group, while IL-10 protein and mRNA level were elevated in the TPN+GLP-2 group (all p < 0.05). Moreover, the TPN+GLP-2 group has higher levels of serum endotoxin, D-lactic acid, and MPO than those of the TPN group.Conclusions: GLP-2 alleviated gut inflammation and improved enteric Paneth cells immune responses through intravenous fluid infusion, possibly by improving the functioning of epithelial protection and repair, and reducing mucosal inflammatory responses.

Interstitial washdown and vascular albumin refill during fluid infusion: novel kinetic analysis from three clinical trials

Background and aims Increased capillary filtration may paradoxically accelerate vascular refill of both fluid and albumin from the interstitial space, which is claimed to be edema-preventing. We characterized this proposed mechanism, called “interstitial washdown”, by kinetic analyses of the hemodilution induced by intravenous infusion of crystalloid fluid during 3 distinct physiological states. Methods Greater plasma dilution of hemoglobin as compared to albumin during fluid therapy indicated recruitment of albumin, which was compared to the flow of interstitial fluid to the plasma as indicated by population volume kinetic analysis. Data for the comparison were derived from 24 infusions of crystalloid fluid in conscious volunteers, 30 in anesthetized patients, and 31 in patients with ketoacidosis from hyperglycemia. Results “Interstitial washdown” increased the plasma albumin concentration by between 0.3 and 1.0 g/L in the three series of infusions. The initial albumin concentration in the interstitial fluid returning to the plasma was estimated to between 22 g/L and 29 g/L, which decreased to an average of 50–75% lower during the subsequent 2–3 h. Kinetic simulations show that pronounced washdown was associated with increased capillary filtration (high k12) and, in conscious subjects, with greater plasma and interstitial volume expansion and restricted urine flow. During anesthesia, the main effect was an increase in the non-exchangeable fluid volume (“third-spacing”). Conclusions Crystalloid fluid accelerates lymphatic flow that moderately increases plasma albumin, but more clearly helps to maintain the intravascular volume. This “interstitial washdown” mechanism becomes exhausted after a few hours.

Effects of Intraoperative Fluid Management on Postoperative Outcomes After Pericardiectomy

Background: The effects of intraoperative fluid management on the patients with constrictive pericarditis undergoing pericardiectomy remain unclear. This study explored the relationship between intraoperative fluid management and postoperative outcomes in these patients.Methods: We retrospectively studied 92 patients with constrictive pericarditis undergoing pericardiectomy and assigned them to the restrictive group and the liberal group according to the intraoperative total fluid infusion rate. Postoperative outcomes were compared between the two groups. Binary logistic regression analysis was performed to determine the relationship between the intraoperative total fluid infusion rate and postoperative outcomes.Results: There were 46 (50.0%) cases in the restrictive group and 46 (50.0%) cases in the liberal group. Compared with the liberal group, the restrictive group had significantly lower incidences of postoperative complications and cardiac complications (P = 0.005 and P = 0.006, respectively). Binary logistics regression analysis also showed the increased risks of postoperative complications (OR, 3.551; 95% CI, 1.192–10.580; P = 0.023) and cardiac complications (OR, 6.037; 95% CI, 1.472–25.052; P = 0.013) at the liberal group. In addition, the restrictive group had shorter postoperative hospital stay (P = 0.026) in comparison to the liberal group.Conclusion: In patients with constrictive pericarditis undergoing pericardiectomy the intraoperative total fluid infusion rate was significantly associated with postoperative outcomes. Restrictive fluid management strategy was related to the positive effects on enhanced recovery after surgery and could be advised as the preferred intraoperative fluid management policy.

Clinical efficacy of an enhanced recovery after surgery protocol in patients undergoing robotic-assisted laparoscopic prostatectomy

Objective To evaluate the application of an enhanced recovery after surgery (ERAS) protocol in patients undergoing robot-assisted laparoscopic prostatectomy (RALP). Methods We conducted a retrospective cohort study of 136 patients who underwent RALP between August 2017 and June 2018 as the control group and a prospective analysis of 106 patients who underwent RALP between January 2019 and January 2020 as the ERAS group. ERAS focused on preoperative education, nutritional intervention, electrolyte solution intake, restrictive fluid infusion, body warming, no indwelling central venous catheter, use of nonsteroidal anti-inflammatory drugs (NSAIDs), early mobilization, and eating recovery. Results The times from RALP to the first intake of clear liquid; first ambulation; first defecation; first fluid, semi-liquid, and general diet; drain removal; and length of hospital stay (LOS) were significantly shorter, and operative time, fluid infusion within 24 hours, postoperative day (POD) 1 albumin, POD 1 hemoglobin, and POD 2 drainage were significantly higher in the ERAS group. Five patients (3.8%) in the ERAS group developed postoperative complications (urine leakage, n = 4; intestinal obstruction, n = 1), while 1 patient (0.7%) in the control group developed intestinal obstruction. Conclusions ERAS effectively accelerated patient rehabilitation and reduced the LOS for patients undergoing RALP.

Non-invasive Assessment of Intravascular Volume Status for Postoperative Patients: The Correlation Between the Internal Jugular Vein/Common Carotid Artery Cross-Sectional Area Ratio and the Inferior Vena Cava Diameter

Background: This study aimed to assess the correlation between the internal jugular vein/common carotid artery (IJV/CCA) cross-sectional area (CSA) ratio and the inferior vena cava (IVC) diameter as non-invasive techniques for the assessment of intravascular volume. Methods: The study samples included 35 adult patients of both sexes (age range: 20 - 60 years) according to the criteria of the American Society of Anaesthesiology (ASA) physical status II - III, who were admitted to the surgical intensive care unit (SICU) after major surgeries for the assessment of intravascular volume status. Results: There was a positive correlation between the IJV/CCA CSA ratio and the IVC maximum and minimum diameter before and after fluid infusion (r = 0.923, P < 0.001 and r = 0.390, P = 0.021, respectively) and between the IJV/CCA CSA ratio at inspiration and the IVC minimum diameter before and after fluid infusion (r = 0.605, P < 0.001 and r = 0.496, P < 0.001, respectively). The sensitivity and specificity analysis of the IJV/CCA CSA during inspiration after fluid correction to predict a central venous pressure (CVP) of 8 - 12 cmH2O showed that at a ratio of 2.56, the highest sensitivity was 56.5%, and the specificity was 83.3%; at a ratio of 2.58, the highest sensitivity was 65.2% and the specificity was 75%. During expiration, specificity after fluid correction was 56.62%; at a ratio of 2.62, the highest sensitivity was 52.2%, and the specificity was 67%; and at a ratio of 2.65, the sensitivity was 56.5%, and the specificity was 50%. Conclusions: The assessment of the IJV/CCA CSA ratio alongside ultrasonography could be a non-invasive tool for the evaluation of intravascular volume status in spontaneously breathing adult patients after major surgeries.