Is aggressive intravenous fluid resuscitation beneficial in acute pancreatitis? A meta-analysis of randomized control trials and cohort studies

BACKGROUND There is conflincting evidence on the intravenous fluid(IVF)strategy for acute pancreatitis(AP).We perform a metaanalysis of the available evidence.AIM To investigate if aggressive IVF therapy in AP patients is beneficial to decrease mortality and improve outcomes.METHODS Metaanalysis of available randomized controlled trials and cohort studies comparing aggressive IVF vs non-aggressive IVF resuscitation.RESULTS There was no significant difference in mortality between the aggressive(n=1229)and non-aggressive IVF(n=1397)patients.Patients receiving aggressive IVF therapy had higher risk for acute kidney injury and acute respiratory distress syndrome.There also was no significant difference in the overall incidence of systemic inflammatory response syndrome,persistent organ failure,pancreatic necrosis when comparing both study groups.CONCLUSION Early aggressive IVF therapy did not improve mortality.Moreover,aggressive IVF therapy could potentially increase the risk for acute kidney injury and pulmonary edema leading to respiratory failure and mechanical ventilation.Studies are needed to investigate which subset of AP patients could benefit from aggressive IVF therapy.

Prognostic value of hemodynamic indices in patients with sepsis after fluid resuscitation

BACKGROUND Sepsis usually causes hemodynamic abnormalities.Hemodynamic index is one of the factors to identify the severity of sepsis and an important parameter to guide the procedure of fluid resuscitation.The present study investigated whether the assessment of hemodynamic indices can predict the outcomes of septic patients undergoing resuscitation therapy.AIM To evaluate the prognostic value of hemodynamic indices in patients with sepsis after fluid resuscitation.METHODS A retrospective study was conducted in 120 patients with sepsis at Hainan General Hospital/Hainan Affiliated Hospital of Hainan Medical University between October 2016 and October 2019.All patients were treated with sodium chloride combined with dextran glucose injection for fluid resuscitation.Patients’hemodynamic parameters were monitored,including heart rate(HR),cardiac index(CI),systemic vascular resistance index(SVRI),mean arterial pressure(MAP),central venous pressure(CVP),and central venous oxygen saturation.The prognostic value of hemodynamic indices was determined based on the prognosis status.RESULTS During fluid resuscitation,86 patients developed septic shock and 34 did not.Ninety-nine patients survived and 21 patients died at 28 d after the treatment.Heart rate,CI,mean arterial pressure,SVRI,and CVP were higher in patients with septic shock and patients who died from septic shock than in non-shock patients and patients who survived,and central venous oxygen saturation was lower in patients with shock and patients who died than in non-shock patients and thesurvivors (P < 0.05). When prognosis was considered as a dependent variable andhemodynamic parameters was considered as independent variables, the results ofa logistic regression analysis showed that CI, SVRI, and CVP were independentrisk factors for septic shock, and CI was an independent risk factor for 28-dmortality (P < 0.05).CONCLUSIONHemodynamic indices can be used to evaluate the prognosis of septic patientsafter fluid resuscitation.

The Influence of HIF-1α Expression on Apoptosis and Number of T Lymphocyte in Peyer’s Patches after Burn with Delayed Fluid Resuscitation in Rats at Plateau

Objective: To research the expression of hypoxia inducible factor-1 alpha (HIF-1 alpha) on the apoptosis and number of T lymphocyte in Peyer’s patches after severe burn on plateau in rats. Methods: Wistar rats (n = 130) were subjected to deep thickness burn injury (30% TBSA, III degree), at two different altitudes. 60 of them were given delayed fluid resuscitation (DFR, n = 30 at each altitude) 6 h after burn at different altitude;60 of them were carried out immediate fluid resuscitation (IFR, n = 30 at each altitude);10 rats were subjected to 37°C warm water as sham burn (SG, n = 10). The Peyer’s patches were harvested from the ileum of rats at different time point after burn respectively. The expression of HIF-1 alpha, CD3(+) and the apoptosis and number of T lymphocyte in Peyer’s patches were detected by tissue microarray technology and immunohistochemistry. Results: The apoptosis was higher in DFR group than that in IFR group. The increase in HIF-1 alpha expression was observed mainly on cell nucleus in T lymphocytes. The expression levels of HIF-1 alpha in Peyer’s patches were much higher in DFR group and IFR group than those in SG, and they were higher at high altitude (3848 metres) than those at lower altitude (1517 metres), and also higher in DFR group compared with IFR group (all P < 0.05). The expression levels of CD3+ in Peyer’s patches were much lower in DFR group and IFR group than those in sham group, and the lowest value appeared at 12 hours after burn (all P < 0.05). Conclusion: High expression of HIF-1 alpha may induce the apoptosis of T lymphocytes in Peyer’s patches after severe burn with delayed fluid resuscitation in rats at plateau.

Aggressive versus controlled fluid resuscitation in acute pancreatitis: A systematic review and meta-analysis of randomized controlled trials

Background:Early fluid resuscitation is one of the fundamental treatments for acute pancreatitis(AP),but there is no consensus on the optimal fluid rate.This systematic review and meta-analysis aimed to compare the efficacy and safety of aggressive vs.controlled fluid resuscitation(CFR)in AP.Methods:The Cochrane Central Register of Controlled Trials(CENTRAL),MEDLINE,Embase,and Web of Science databases were searched up to September 30,2022,for randomized controlled trials(RCTs)comparing aggressive with controlled rates of early fluid resuscitation in AP patients without organ failure on admission.The following keywords were used in the search strategy:"pancreatitis,""fluid therapy,""fluid resuscitation,"and"randomized controlled trial."There was no language restriction.The Grading of Recommendations Assessment,Development and Evaluation(GRADE)framework was used to assess the certainty of evidence.Trial sequential analysis(TSA)was used to control the risk of random errors and assess the conclusions.Results:A total of five RCTs,involving 481 participants,were included in this study.For primary outcomes,there was no significant difference in the development of severe AP(relative risk[RR]:1.87,95%confidence interval[CI]0.95-3.68;P=0.07;n=437;moderate quality of evidence)or hypovolemia(RR:0.98,95%CI:0.32-2.97;P=0.97;n=437;moderate quality of evidence)between the aggressive and CFR groups.A significantly higher risk of fluid overload(RR:3.25,95%CI:1.53-6.93;P<0.01;n=249;low quality of evidence)was observed in the aggressive fluid resuscitation(AFR)group than the controlled group.Additionally,the risk of intensive care unit admission(P=0.02)and the length of hospital stay(P<0.01)as partial secondary outcomes were higher in the AFR group.TSA suggested that more studies were required to draw precise conclusions.Conclusion:For AP patients without organ failure on admission,CFR may be superior to AFR with respect to both efficacy and safety outcomes.Registration:PROSPERO;https://www.crd.york.ac.uk/PROSPERO/;CRD 42022363945.

Impact of initial fluid resuscitation volume on clinical outcomes in patientswith heart failure and septic shock

Background:Fluid resuscitation is a key treatment for sepsis,but limited data exists in patients with existing heartfailure(HF)and septic shock.The objective of this study was to determine the impact of initial fluid resuscitationvolume on outcomes in HF patients with reduced or mildly reduced left ventricular ejection fraction(LVEF)withseptic shock.Methods:This multicenter,retrospective,cohort study included patients with known HF(LVEF≤50%)presentingwith septic shock.Patients were divided into two groups based on the volume of fluid resuscitation in the first 6 h;<30 mL/kg or≥30 mL/kg.The primary outcome was a composite of in-hospital mortality or renal replacementtherapy(RRT)within 7 days.Secondary outcomes included acute kidney injury(AKI),initiation of mechanicalventilation,and length of stay(LOS).All related data were collected and compared between the two groups.A generalized logistic mixed model was used to assess the association between fluid groups and the primaryoutcome while adjusting for baseline LVEF,Acute Physiology and Chronic Health Evaluation(APACHE)II score,inappropriate empiric antibiotics,and receipt of corticosteroids.Results:One hundred and fifty-four patients were included(93 patients in<30 mL/kg group and 61 patientsin≥30 mL/kg group).The median weight-based volume in the first 6 h was 17.7(12.2–23.0)mL/kg in the<30 mL/kg group vs.40.5(34.2–53.1)mL/kg in the≥30 mL/kg group(P<0.01).No statistical difference was detected in the composite of in-hospital mortality or RRT between the<30 mL/kg group compared to the≥30 mL/kggroup(55.9%vs.45.9%,P=0.25),respectively.The<30 mL/kg group had a higher incidence of AKI,mechanicalventilation,and longer hospital LOS.Conclusions:In patients with known reduced or mildly reduced LVEF presenting with septic shock,no differencewas detected for in-hospital mortality or RRT in patients who received≥30 mL/kg of resuscitation fluid comparedto less fluid,although this study was underpowered to detect a difference.Importantly,≥30 mL/kg fluid did notresult in a higher need for mechanical ventilation.

Update on the strategy for intravenous fluid treatment in acute pancreatitis

Fluid therapy/resuscitation is mandatory in acute pancreatitis due to the pathophysiology of fluid loss as a consequence of the inflammatory process.For many years,without clear evidence,early and aggressive fluid resuscitation with crystalloid solutions(normal saline solution or Ringer lactate solution)was recommended.Recently,many randomized control trials and meta-analyses on fluid therapy have revealed that high fluid rate infusion is associated with increased mortality and severe adverse events compared to those resulting from moderate fluid rates,and this has triggered a paradigm shift in fluid management strategies.Meanwhile,there is evidence to show that Ringer lactate solution is superior to normal saline solutions in this context.The purpose of this review is to provide an update on the strategies for intravenous fluid treatment in acute pancreatitis,including the type,optimal amount,rate of infusion,and monitoring guides.Recommendations from recent guidelines are critically evaluated for this review in order to reach the authors'recommendations based on the available evidence.

Bioelectrical impedance analysis-guided fluid management promotes primary fascial closure after open abdomen:a randomized controlled trial

Background:Fluid overload(FO)after resuscitation is frequent and contributes to adverse outcomes among postinjury open abdomen(OA)patients.Bioelectrical impedance analysis(BIA)is a promising tool for monitoring fluid status and FO.Therefore,we sought to investigate the efficacy of BIA-directed fluid resuscitation among OA patients.Methods:A pragmatic,prospective,randomized,observer-blind,single-center trial was performed for all trauma patients requiring OA between January 2013 and December 2017 to a national referral center.A total of 140 postinjury OA patients were randomly assigned in a 1:1 ratio to receive either a BIA-directed fluid resuscitation(defined as BIA)protocol that included fluid administration with monitoring of hemodynamic parameters and different degrees of interventions to achieve a negative fluid balance targeting the hydration level(HL)measured by BIA or a traditional fluid resuscitation(TRD)in which clinicians determined the fluid resuscitation regimen according to traditional parameters during 30 d of intensive care unit(ICU)management.The primary outcome was the 30-day primary fascial closure(PFC)rate.The secondary outcomes included the time to PFC,postoperative 7-day cumulative fluid balance(CFB)and adverse events within 30 d after OA.The Kaplan–Meier method and the log-rank test were utilized for PFC after OA.A generalized linear regression model for the time to PFC and CFB was built.Results:A total of 134 patients completed the trial(BIA,n=66;TRD,n=68).The BIA patients were significantly more likely to achieve PFC than the TRD patients(83.33%vs.55.88%,P<0.001).In the BIA group,the time to PFC occurred earlier than that of the TRD group by an average of 3.66 d(P<0.001).Additionally,the BIA group showed a lower postoperative 7-day CFB by an average of 6632.80 ml(P<0.001)and fewer complications.Conclusions:Among postinjury OA patients in the ICU,the use of BIA-guided fluid resuscitation resulted in a higher PFC rate and fewer severe complications than the traditional fluid resuscitation strategy.

Controversies in the management of acute pancreatitis:An update

This review summarized the current controversies in the management of acute pancreatitis(AP).The controversies in management range from issues involving fluid resuscitation,nutrition,the role of antibiotics and antifungals,which analgesic to use,role of anticoagulation and intervention for complications in AP.The interventions vary from percutaneous drainage,endoscopy or surgery.Active research and emerging data are helping to formulate better guidelines.The available evidence favors crystalloids,although the choice and type of fluid resuscitation is an area of dynamic research.The nutrition aspect does not have controversy as of now as early enteral feeding is preferred most often than not.The empirical use of antibiotics and antifungals are gray zones,and more data is needed for conclusive guidelines.The choice of analgesic is being studied,and the recommendations are still evolving.The position of using anticoagulation is still awaiting consensus.The role of intervention is well established,although the modality is constantly changing and favoring endoscopy or percutaneous drainage rather than surgery.It is evident that more multicenter randomized controlled trials are required for establishing the standard of care in these crucial management issues of AP to improve the morbidity and mortality worldwide.

Resuscitation fluids as drugs:targeting the endothelial glycocalyx

Fluid resuscitation is an essential intervention in critically ill patients,and its ultimate goal is to restore tissue perfusion.Critical illnesses are often accompanied by glycocalyx degradation caused by inflammatory reactions,hypoperfusion,shock,and so forth,leading to disturbed microcirculatory perfusion and organ dysfunction.Therefore,maintaining or even restoring the glycocalyx integrity may be of high priority in the therapeutic strategy.Like drugs,however,different resuscitation fluids may have beneficial or harmful effects on the integrity of the glycocalyx.The purpose of this article is to review the effects of different resuscitation fluids on the glycocalyx.Many animal studies have shown that normal saline might be associated with glycocalyx degradation,but clinical studies have not confirmed this finding.Hydroxyethyl starch(HES),rather than other synthetic colloids,may restore the glycocalyx.However,the use of HES also leads to serious adverse events such as acute kidney injury and bleeding tendencies.Some studies have suggested that albumin may restore the glycocalyx,whereas others have suggested that balanced crystalloids might aggravate glycocalyx degradation.Notably,most studies did not correct the effects of the infusion rate or fluid volume;therefore,the results of using balanced crystalloids remain unclear.Moreover,mainly animal studies have suggested that plasma may protect and restore glycocalyx integrity,and this still requires confirmation by high-quality clinical studies.

New perspectives of volemic resuscitation in polytrauma patients:a review

Nowadays,fluid resuscitation of multiple trauma patients is still a challenging therapy.Existing therapies for volume replacement in severe haemorrhagic shock can lead to adverse reactions that may be fatal for the patient.Patients presenting with multiple trauma often develop hemorrhagic shock,which triggers a series of metabolic,physiological and cellular dysfunction.These disorders combined,lead to complications that significantly decrease survival rate in this subset of patients.Volume and electrolyte resuscitation is chal enging due to many factors that overlap.Poor management can lead to post-resuscitation systemic inflammation causing multiple organ failure and ultimately death.In literature,there is no exact formula for this purpose,and opinions are divided.This paper presents a review of modern techniques and current studies regarding the management of fluid resuscitation in trauma patients with hemorrhagic shock.According to the literature and from clinical experience,al aspects regarding post-resuscitation period need to be considered.Also,for every case in particular,emergency therapy management needs to be rigorously respected considering al physiological,biochemical and biological parameters.

Dose-related effects of norepinephrine on early-stage endotoxemic shock in a swine model

Background The benefits of early use of norepinephrine in endotoxemic shock remain unknown.We aimed to elucidate the effects of different doses of norepinephrine in early-stage endotoxemic shock using a clinically relevant large animal model.Methods Vasodilatory shock was induced by endotoxin bolus in 30 Bama suckling pigs.Treatment included fluid resuscitation and administration of different doses of norepinephrine,to induce return to baseline mean arterial pressure(MAP).Fluid management,hemodynamic,microcirculation,inflammation,and organ function variables were monitored.All animals were supported for 6 h after endotoxemic shock.Results Infused fluid volume decreased with increasing norepinephrine dose.Return to baseline MAP was achieved more frequently with doses of 0.8µg/kg/min and 1.6µg/kg/min(P<0.01).At the end of the shock resuscitation period,cardiac index was higher in pigs treated with 0.8µg/kg/min norepinephrine(P<0.01),while systemic vascular resistance was higher in those receiving 0.4µg/kg/min(P<0.01).Extravascular lung water level and degree of organ edema were higher in animals administered no or 0.2µg/kg/min norepinephrine(P<0.01),while the percentage of perfused small vessel density(PSVD)was higher in those receiving 0.8µg/kg/min(P<0.05)and serum lactate was higher in the groups administered no and 1.6µg/kg/min norepinephrine(P<0.01).Conclusions The impact of norepinephrine on the macro-and micro-circulation in early-stage endotoxemic shock is dose-dependent,with very low and very high doses resulting in detrimental effects.Only an appropriate norepinephrine dose was associated with improved tissue perfusion and organ function.

液体复苏对失血性休克所致肠道炎症反应及细菌移位的影响

The therapeutic strategies of hemorrhagic shock mainly include bleeding control and fluid resuscitation. However, current resuscitation fluids may further aggravate the inflammation of low intestine and bacterial translocation that causes organ dysfunction. This review discusses the possible mechanisms about the inflammation of lower intestine and bacterial translocation, and the effect of different fluids resuscitation on the inflammation of low intestine and bacterial translocation. However, it still has not perfectly fluid resuscitation used in hemorrhagic shock nowadays.

Severe burn injury in late pregnancy:a case report and literature review

The management of serious burn injuries during pregnancy is an unsolved clinical problem because of the low incidence of this disease.Although it has been documented that the effect of burns on fetal and maternal survival is detrimental,there have been conflicting reports among the different burn centers regarding the mortality of burned pregnant women and the management of burn patients during pregnancy.We report a case of severe burn in late pregnancy treated at our burn center.Additionally,we searched and summarized the literature concerning the management of pregnant patients to provide useful information for their treatment.

Advantage of surgical intensive care unit(SICU)predominant by cardiothoracic surgeons in multiple trauma management in a primary hospital

Purpose It is a challenge for the primary hospitals to manage multiple trauma patients.In this article,we explored the advantage of establishing a surgical intensive care unit(SICU)predominant by cardiothoracic surgeons in the early management of multiple trauma.Methods This was a retrospective study and patients with multiple trauma in our hospital were collected and divided into two groups,based on time period and treat modes:group A(retrospective observation group)where patients were treated with the traditional treatment mode from January 2017 to December 2017 and group B(study group)where patients were treated in the SICU predominant by cardiothoracic surgeons from January 2018 to December 2018.Clinical data including demographics,injury severity score(ISS),causes of injury,time intervals from reception to entering SICU or operating room and mortality three days after injuries were collected.Data were analyzed by SPSS 20.0 software.Categorical variables were presented as number and/or frequency and continuous variables as mean±SD.Results Altogether 406 patients were included in this study,including 217 patients in group A and 189 patients in group B.General data between the two groups revealed no significant difference:mean age(years)(35.51±12.97 vs.33.62±13.61,p=0.631),gender distribution(mean/female,130/87 vs.116/73,p=0.589)and ISS(15.92±7.95 vs.16.16±6.89,p=0.698).Fall from height were the dominant mechanism of injury,with 135 cases in group A(71.4%)and 121 cases in group B(55.8%),followed by traffic accidents.Injury mechanism showed no significant differences between two groups(p=1.256).Introduction of the SICU significantly improved the care of trauma patients,regarding speed and mortality.Time intervals between reception and entering SICU or operating room was(108.23±6.72)min and(45.67±7.96)min in group A and B,respectively(p=0.001).Mortality three days after injuries was 13.89%and 5.53%in group A and B,respectively(p=0.005).Conclusion Establishing a SICU predominant by cardiothoracic surgeons can reduce the early mortality rates in multiple trauma patients.