Guidelines for the choice of intravenous fluids for vascular filling in critically ill patients, 2021

Treatment of Acute Circulatory Failure Based on Carbon Dioxide-Oxygen (CO2-O2) Derived Indices: The Lactel Randomized Multicenter Study

BACKGROUND

Acute circulatory failure is critical in patients in the ICU. Indices derived from oxygen and CO2 metabolism (CO2-O2-derived indices) including the central venous-to-arterial CO2 difference and central venous-to-arterial CO2 difference/arteriovenous oxygen content ratio are markers for global metabolic demand and tissue hypoxia.

RESEARCH QUESTION

Does a resuscitation strategy using CO2-O2-derived indices improve tissular hypoperfusion compared with standard care?

STUDY DESIGN AND METHODS

We conducted a randomized, prospective, multicenter, single-anonymized study in 3 ICUs. Patients aged ≥ 18 years with acute circulatory failure and arterial blood lactate levels ≥ 3 mM were included. Patients were randomized to receive either a CO2-O2-derived algorithm-based treatment or standard clinical practice. The primary outcome was lactate clearance > 10% within 2 hours. Secondary outcomes included Sepsis-Related Organ Failure Assessment score and mortality.

RESULTS

Of the 179 patients enrolled (90 control patients and 89 treatment patients), there was no significant difference in achieving a lactate clearance > 10% at 2 hours between the control (50%) and interventional groups (43.8%) (P = .497). At t2 hours, the median change in lactate levels in the control group was -10.53% (-29.27 to 5.68), whereas in the interventional group, it was -2.70% (-22.58 to 19.1; P = .096). Secondary outcomes did not differ between groups in Sepsis-Related Organ Failure Assessment scores (6 [3 to 9] vs 7 [4 to 10]; P = .719), ICU and hospital length of stay (4.5 days [2.0 to 10.8] vs 5.0 days [2.0 to10.0]; P = .963 and 11 days [3.0 to 27.0] vs 10 days [3.0 to 21.0]; P = .493), or 28-day mortality (44.9% vs 33.3%, P = .150).

INTERPRETATION

Our results indicate that algorithm-based resuscitation using CO2-O2-derived indices did not improve lactate clearance or clinical outcomes compared with standard care. Further research is needed to identify specific patient subgroups who may benefit from this approach.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov; No.: NCT05032521; URL: www.

CLINICALTRIALS

gov.

Machine Learning-Based Prediction of Early Complications Following Surgery for Intestinal Obstruction: Multicenter Retrospective Study

BACKGROUND

Early complications increase in-hospital stay and mortality after intestinal obstruction surgery. It is important to identify the risk of postoperative early complications for patients with intestinal obstruction at a sufficiently early stage, which would allow preemptive individualized enhanced therapy to be conducted to improve the prognosis of patients with intestinal obstruction. A risk predictive model based on machine learning is helpful for early diagnosis and timely intervention.

OBJECTIVE

This study aimed to construct an online risk calculator for early postoperative complications in patients after intestinal obstruction surgery based on machine learning algorithms.

METHODS

A total of 396 patients undergoing intestinal obstruction surgery from April 2013 to April 2021 at an independent medical center were enrolled as the training cohort. Overall, 7 machine learning methods were used to establish prediction models, with their performance appraised via the area under the receiver operating characteristic curve (AUROC), accuracy, sensitivity, specificity, and F1-score. The best model was validated through 2 independent medical centers, a publicly available perioperative dataset the Informative Surgical Patient dataset for Innovative Research Environment (INSPIRE), and a mixed cohort consisting of the above 3 datasets, involving 50, 66, 48, and 164 cases, respectively. Shapley Additive Explanations were measured to identify risk factors.

RESULTS

The incidence of postoperative complications in the training cohort was 47.44% (176/371), while the incidences in 4 external validation cohorts were 34% (17/50), 56.06% (37/66), 52.08% (25/48), and 48.17% (79/164), respectively. Postoperative complications were associated with 8-item features: Physiological Severity Score for the Enumeration of Mortality and Morbidity (POSSUM physiological score), the amount of colloid infusion, shock index before anesthesia induction, ASA (American Society of Anesthesiologists) classification, the percentage of neutrophils, shock index at the end of surgery, age, and total protein. The random forest model showed the best overall performance, with an AUROC of 0.788 (95% CI 0.709-0.869), accuracy of 0.756, sensitivity of 0.695, specificity of 0.810, and F1-score of 0.727 in the training cohort. The random forest model also achieved a comparable AUROC of 0.755 (95% CI 0.652-0.839) in validation cohort 1, a greater AUROC of 0.817 (95% CI 0.695-0.913) in validation cohort 2, a similar AUROC of 0.786 (95% CI 0.628-0.902) in validation cohort 3, and the comparable AUROC of 0.720 (95% CI 0.671-0.768) in validation cohort 4. We visualized the random forest model and created a web-based online risk calculator.

CONCLUSIONS

We have developed and validated a generalizable random forest model to predict postoperative early complications in patients undergoing intestinal obstruction surgery, enabling clinicians to screen high-risk patients and implement early individualized interventions. An online risk calculator for early postoperative complications was developed to make the random forest model accessible to clinicians around the world.

2024 Systematic Review of Evidence-Based Guidelines for Prehospital Care

OBJECTIVES

Evidence-based guidelines (EBGs) are widely recognized as valuable tools to aggregate and translate scientific knowledge into clinical care. High-quality EBGs can also serve as important components of dissemination and implementation efforts focused on educating emergency medical services (EMS) clinicians about current evidence-based prehospital clinical care practices and operations. We aimed to perform the third biennial systematic review of prehospital EBGs to identify and assess the quality of prehospital EBGs published since 2021.

METHODS

We systematically searched Ovid Medline and EMBASE from January 1, 2021, to June 6, 2023, for publications relevant to prehospital care, based on an organized review of the literature, and focused on providing recommendations for clinical care or operations. Included guidelines were appraised using the National Academy of Medicine (NAM) criteria for high-quality guidelines and scored using the Appraisal of Guidelines for Research and Evaluation (AGREE) II Tool.

RESULTS

We identified 33 new guidelines addressing clinical and operational topics of EMS medicine. The most addressed EMS core content areas were time-life critical conditions (n = 17, 51.5%), special clinical considerations (n = 15, 45%), and injury (n = 12, 36%). Seven (21%) guidelines included all elements of the National Academy of Medicine (NAM) criteria for high-quality guidelines, including the full reporting of a systematic review of the evidence. Guideline appraisals by the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool demonstrated modest compliance to reporting recommendations and similar overall quality compared to previously identified guidelines (mean overall domain score 67%, SD 12%), with Domain 5 ("Applicability") scoring the lowest of the six AGREE II domains (mean score of 53%, SD 13%).

CONCLUSIONS

This updated systematic review identified and appraised recent guidelines addressing prehospital care and identifies important targets for education of EMS personnel. Continued opportunities exist for prehospital guideline developers to include comprehensive evidence-based reporting into guideline development to facilitate widespread implementation of high-quality EBGs in EMS systems and incorporate the best available scientific evidence into initial education and continued competency activities.

Albumin in Normovolemic Fluid Management for Severe Traumatic Brain Injury: Controversies and Research Gaps

Traumatic brain injury (TBI) is a significant public health issue characterized by high mortality rates and long-term complications. This commentary examines the controversial role of the use of albumin in the fluid management of patients with severe TBI. Despite its physiological benefits, the clinical use of albumin remains controversial due to the fact that various studies have yielded mixed results. Serum albumin is important for maintaining normovolemia, primarily through its contribution to colloid osmotic pressure, which helps to retain fluid in the circulatory system. This review highlights the existing evidence, examines inconsistencies in guideline recommendations, and suggests future research directions to clarify the efficacy and safety of the use of albumin in maintaining normovolemia in patients with TBI. The review also discusses the potential benefits of small-volume resuscitation strategies for the management of acute kidney injury in TBI patients, drawing parallels with the management of septic acute kidney injury. The need for further well-designed randomized controlled trials and ethical considerations in studies regarding the use of hyperoncotic albumin in TBI management is emphasized.

Prospective randomized double-blind study to evaluate the superiority of Vasopressin versus Norepinephrine in the management of the patient at renal risk undergoing cardiac surgery with cardiopulmonary bypass (NOVACC trial)

BACKGROUND

Cardiac surgery-associated acute kidney injury (CS-AKI) affects up to 30% of patients, increasing morbidity and healthcare costs. This condition results from complex factors like ischemia-reperfusion injury and renal hemodynamic changes, often exacerbated by surgical procedures. Norepinephrine, commonly used in cardiac surgeries, may heighten the risk of CS-AKI. In contrast, vasopressin, a noncatecholaminergic agent, shows potential in preserving renal function by favorably affecting renal hemodynamic. Preliminary findings, suggest vasopressin could reduce the incidence of CS-AKI compared to norepinephrine. Additionally, vasopressin is linked to a lower incidence of postoperative atrial fibrillation, another factor contributing to longer hospital stays and higher costs. This study hypothesizes that vasopressin could effectively reduce CS-AKI occurrence and severity by optimizing renal perfusion during cardiac surgeries.

STUDY DESIGN

The NOVACC trial (NCT05568160) is a multicenter, randomized, double blinded superiority-controlled trial testing the superiority of vasopressin over norepinephrine in patients scheduled for cardiac surgery with cardiopulmonary bypass (CPB). The primary composite end point is the occurrence of acute kidney injury and death. The secondary end points are neurological, cardiologic, digestive, and vasopressor related complications at day 7, day 30, day 90, hospital and intensive care unit lengths of stay, medico-economic costs at day 90.

CONCLUSION

The NOVACC trial will assess the effectiveness of vasopressin in cardiac surgery with CPB in reducing acute kidney injury, mortality, and medical costs.

CLINICAL TRIAL REGISTRATION

NCT05568160.

Precision fluid and vasoactive drug therapy for critically ill patients

There are several clinical practice guidelines concerning the use of fluid and vasoactive drug therapies in critically ill adult patients, but the recommendations in these guidelines are often based on low-quality evidence. Further, some were compiled prior to the publication of landmark clinical trials, particularly in the comparison of balanced crystalloid and normal saline. An important consideration in the treatment of critically ill patients is the application of precision medicine to provide the most effective care to groups of patients most likely to benefit from the therapy. Although not currently widely integrated into these practice guidelines, the utility of precision medicine in critical illness is a recognized research priority for fluid and vasoactive therapy management. The purpose of this narrative review was to illustrate the evaluation and challenges of providing precision fluid and vasoactive therapies to adult critically ill patients. The review includes a discussion of important investigations published after the release of currently available clinical practice guidelines to provide insight into how recommendations and research priorities may change future guidelines and bedside care for critically ill patients.

Protocol Study for the Evaluation of Non-Opioid Balanced General Anaesthesia in Cardiac Surgery with Cardiopulmonary Bypass: A Randomised, Controlled, Multicentric Superiority Trial (OFACAR Study)

Opioid-free anaesthesia (OFA) is general anaesthesia based on the use of several non-opioid molecules that aim to have an analgesic effect, decrease the sympathetic response, decrease hormonal stress, and decrease the inflammatory response during surgery. Although this approach to anaesthesia is regularly used in clinical practice, it remains a novel approach. The literature on this anaesthesia modality finds a number of positive effects on cardiac, respiratory, and cognitive function but no randomised study evaluated these effects during cardiac surgery where there is a high incidence of postoperative complications. The main aim of the study is to compare OFA vs. standard balanced opioid general anaesthesia on the incidence of postoperative complications and the length of stay in intensive care and hospital. OFACAR is a multicentric, randomised, controlled, superiority, single-blind, two parallel-arm clinical trial in patients undergoing cardiac surgery with cardiopulmonary bypass. We compared a balanced general anaesthesia without opioids (OFA group) vs. a balanced opioid general anaesthesia with sufentanil (control group). One hundred and sixty patients will be enrolled in each treatment group. The primary endpoint is a composite one which corresponds to the occurrence of at least one of the postoperative complications, defined according to European standards within 30 days after surgery. Recruitment started in September 2019, and data collection is expected to end in November 2024.

Septic shock in obstetrics: guidelines of the All-Russian public organization “Federation of Anesthesiologists and Reanimatologists”

The article reflects the main provisions of the clinical guidelines on septic shock in obstetrics, approved by the All-Russian public organization “Federation of Anesthesiologists-Resuscitators” in 2022. The relevance of the problem is associated with high mortality and morbidity rates from sepsis and septic shock in obstetrics. The main issues of etiology, pathogenesis, clinical picture, methods of laboratory and instrumental diagnostics, features of using the qSOFA, SOFA, MOEWS, SOS, MEWC, IMEWS scales for sepsis verification are consistently presented. The article presents the starting intensive therapy (the first 6–12 hours) of the treatment of septic shock in obstetrics, taking into account the characteristics of the pregnant woman's body. The strategy of prescribing vasopressors (norepinephrine, phenylephrine, epinephrine), inotropic drugs (dobutamine) is described, antibiotics and optimal antibiotic therapy regimens, features of infusion and adjuvant therapy are presented. The issues of surgical treatment of the focus of infection and indications for hysterectomy, as well as the organization of medical care and rehabilitation of patients with sepsis and septic shock were discussed. The basic principles of prevention of sepsis and septic shock in obstetrics are described. The criteria for the quality of medical care for patients with septic shock and the algorithms of doctor's actions in the diagnosis and intensive care of patients with septic shock in obstetrics are presented.

Effect of continuous infusion of hypertonic saline solution on survival of patients with brain injury: a systematic review and meta-analysis

BACKGROUND

The objective was to determine the effects of continuous infusion of hypertonic saline solutions on outcomes of patients with brain injury.

METHODS

Preferred Reported Items for Systemic Reviews and Meta-Analysis guidelines were followed. We searched the MEDLINE and COCHRANE clinical trials register (through December 2021) and reference lists of articles. We included all clinical trials conducted in brain-injured patients hospitalized in intensive care units evaluating continuous infusion of hypertonic saline solution (osmolarity above 308 mOsm/L). Two reviewers extracted data that were checked by two others. The primary outcome was the in-hospital mortality rate. The main secondary outcomes were the rates of intracranial hypertension, an unfavorable neurological outcome at day 90, and adverse events.

RESULTS

We identified 23 clinical trials reporting the use of continuous infusion of hypertonic saline solution in brain-injured patients. The primary outcome was available in 10 studies (n = 1883 patients). The odds ratio (OR) for in-hospital death with the intervention was 0.68 (95% confidence interval (CI), 0.54-0.85, I² = 0%). In the subgroup of studies including only traumatic brain-injured patients (7 studies, n = 1521 patients), the OR for the primary outcome was 0.74 (95%CI 0.57-0.95) with the intervention. The OR for intracranial hypertension and unfavorable neurological outcome at day 90 were 0.66 (95%CI 0.49-0.88, I² = 42%, n = 787 patients) and 0.61 (95%CI 0.46-0.81, I² = 15%, n = 956 patients), respectively. Regarding safety, the OR of acute kidney injury and severe hypernatremia were 0.82 (95%CI 0.47-1.44, I² = 0%) and 3.38 (95%CI 2.16-5.27, I² = 24%).

CONCLUSIONS

Continuous hypertonic saline solution infusion reduced in-hospital mortality without increasing the risk of unfavorable neurological outcome at day 90 in brain-injured patients hospitalized in intensive care units. Given the inclusion of observational and heterogeneous studies, further randomized studies are needed before developing recommendations for implementation at the bedside.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021221367. Registered 13 May 2021.

Progress in the management of acute colchicine poisoning in adults

Colchicine is a tricyclic, lipid-soluble alkaloid which has long been used to treat gout and many immunological diseases. Due to its narrow therapeutic window and long half-life of elimination, colchicine overdose occurs occasionally. Unfortunately, some patients lost their lives because of colchicine overdose or suicide. Acute colchicine poisoning can lead to original gastrointestinal disorders, shock, progressive multiple organ failure, and myelosuppression. Although many researchers in the world performed lots of research, there are currently no specific antidotes for colchicine poisoning. Meanwhile, there are no management guidelines to treat patients with acute colchicine poisoning until now. Herein, we systematically elaborate on the clinical features and progress in the management of acute colchicine poisoning in adults according to the previous literature. This paper will provide some valuable and available information for clinicians.

Intravenous fluid therapy in perioperative and critical care setting-Knowledge test and practice: An international cross-sectional survey

PURPOSE

In the absence of recent international recommendations supported by scientific societies like Anesthesiology or Intensive Care Medicine, healthcare professionals (HCP) knowledge on IV fluid is expected to vary. We undertook a cross-sectional survey, aiming to assess prescription patterns and test the knowledge of HCP for IV fluid use in the operating room (OR) and intensive care unit (ICU).

METHODS

An online international cross-sectional survey was conducted between October 20, 2019, and November 27, 2021. The survey included multiple-choice questions on demographics, practice patterns and knowledge of IV fluids, and a hemodynamically unstable patient assessment.

RESULTS

1045 HCP, from 97 countries responded to the survey. Nearly three-quarters reported the non-existence of internal hospital or ICU-based guidelines on IV fluids. The respondents' mean score on the knowledge assessment questions was 46.4 ± 14.4. The cumulative mean scores were significantly higher among those supervising trainees (p = 0.02), specialists (p < 0.001) and those working in high-income (p < 0.001) countries. Overall performance of respondents on the knowledge testing for IV fluid was unsatisfactory with only 6.5% respondents performed above average.

CONCLUSION

There is a wide difference in the knowledge and prescription of IV fluids among the HCP surveyed. These findings reflect the urgent need for education on IV fluids.