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Shen J, Dai S, Tao X, Chen X, Xu L. Corrected flow time and respirophasic variation in blood flow peak velocity of radial artery predict fluid responsiveness in gynecological surgical patients with mechanical ventilation. BMC Anesthesiol 2022; 22:299. [PMID: 36123625 PMCID: PMC9484168 DOI: 10.1186/s12871-022-01837-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Accepted: 09/08/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Recent evidence suggests that ultrasound measurements of carotid and brachial artery corrected flow time (FTc) and respirophasic variation in blood flow peak velocity (ΔVpeak) are valuable for predicting fluid responsiveness in mechanical ventilated patients. We performed the study to reveal the performance of ultrasonic measurements of radial artery FTc and ΔVpeak for predicting fluid responsiveness in mechanical ventilated patients undergoing gynecological surgery. METHODS A total of eighty mechanical ventilated patients were enrolled. Radial artery FTc and ΔVpeak, and non-invasive pulse pressure variation (PPV) were measured before and after fluid challenge. Fluid responsiveness was defined as an increase in stroke volume index (SVI) of 15% or more after the fluid challenge. Multivariate logistic regression analyses and receiver operating characteristic (ROC) curve were used to screen multivariate predictors of fluid responsiveness and identify the predictive abilitie of non-invasive PPV, ΔVpeak and FTc on fluid responsiveness. RESULTS Forty-four (55%) patients were fluid responders. Multivariate logistic regression analysis showed that radial artery FTc, ΔVpeak, and non-invasive PPV were the independent predictors of fluid responsiveness, with odds ratios of 1.152 [95% confidence interval (CI) 1.045 to 1.270], 0.581 (95% CI 0.403 to 0.839), and 0.361 (95% CI, 0.193 to 0.676), respectively. The area under the ROC curve of fluid responsiveness predicted by FTC was 0.802 (95% CI, 0.706-0.898), and ΔVpeak was 0.812 (95% CI, 0.091-0.286), which were comparable with non-invasive PPV (0.846, 95%CI, 0.070-0.238). The optimal cut-off values of FTc for fluid responsiveness was 336.6 ms (sensitivity of 75.3%; specificity of 75.9%), ΔVpeak was 14.2% (sensitivity of 88.2%; specificity of 67.9%). The grey zone for FTc was 313.5-336.6 ms and included 40 (50%) of the patients, ΔVpeak was 12.2-16.5% and included 37(46%) of the patients. CONCLUSIONS Ultrasound measurement of radial artery FTc and ΔVpeak are the feasible and reliable methods for predicting fluid responsiveness in mechanically ventilated patients. TRIAL REGISTRATION The trial was registered at the Chinese Clinical Trial Registry (ChiCTR)(www.chictr.org), registration number ChiCTR2000040941.
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Affiliation(s)
- Jianjun Shen
- Department of Anesthesiology, the Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Shaobing Dai
- Department of Anesthesiology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Xia Tao
- Department of Ultrasound, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Xinzhong Chen
- Department of Anesthesiology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China
| | - Lili Xu
- Department of Anesthesiology, Women's Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang Province, China.
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Bakko F, Brown A, Lupi M, Maweni RM. Fluid and electrolyte management: increasing the knowledge of House Officers using an interactive eLearning tool. Ir J Med Sci 2022:10.1007/s11845-022-03074-y. [PMID: 35831766 DOI: 10.1007/s11845-022-03074-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 06/15/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Interactive case-based tutorials represent a well-established method of improving House Officer learning. There has been little research on how tutorials of this kind can be improved, and whether their use changes practice. AIM Our study aims to assess whether our eLearning tutorial on IV fluid and electrolyte prescribing improves the underlying knowledge base and confidence of participating House Officers, with regards to fluid and electrolyte balance physiology and prescribing. METHOD An interactive eLearning module with core information on fluid and electrolyte prescribing and associated cases with questions and answers was created and distributed to participating House Officers in the 2019-2020 cohort nationwide. Participants were asked to complete pre-eLearning and post-eLearning questionnaires as well as a feedback survey to assess the efficacy of the module. RESULTS Forty-nine House Officers completed the eLearning module and associated questionnaires. A majority of participants (69.3%) reported their previous teaching on fluid and electrolyte management as "very poor", "poor" or "mediocre". The average score for the pre-eLearning knowledge test was 75%, compared to a score of 97% for the post-eLearning knowledge test, resulting in a 22% increase in correct answers (p < 0.001). We found an increase of 53% in feeling "confident" or "very confident" in assessing and managing fluid requirements, and an increase of 57.1% in feeling "confident" or "very confident" in managing electrolyte requirements after undertaking the eLearning module. CONCLUSION An interactive eLearning tutorial with real-world applications provides an effective, low-cost intervention that can improve confidence and skill in prescribing IV fluids.
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Affiliation(s)
- Freya Bakko
- Imperial College Healthcare NHS Trust, London, UK.
| | - Annabel Brown
- London North West University Healthcare NHS Trust, London, United Kingdom
| | - Micol Lupi
- Chelsea and Westminster NHS Foundation Trust, London, United Kingdom.,Imperial College London, London, United Kingdom
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Kaptein MJ, Kaptein EM. Inferior Vena Cava Collapsibility Index: Clinical Validation and Application for Assessment of Relative Intravascular Volume. Adv Chronic Kidney Dis 2021; 28:218-226. [PMID: 34906306 DOI: 10.1053/j.ackd.2021.02.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/21/2021] [Accepted: 02/02/2021] [Indexed: 12/23/2022]
Abstract
Accurate assessment of relative intravascular volume is critical to guide volume management of patients with acute or chronic kidney disorders, particularly those with complex comorbidities requiring hospitalization or intensive care. Inferior vena cava (IVC) diameter variability with respiration measured by ultrasound provides a dynamic noninvasive point-of-care estimate of relative intravascular volume. We present details of image acquisition, interpretation, and clinical scenarios to which IVC ultrasound can be applied. The variation in IVC diameter over the respiratory or ventilatory cycle is greater in patients who are volume responsive than those who are not volume responsive. When 2 recent prospective studies of spontaneously breathing patients (n = 214) are added to a prior meta-analysis of 181 patients, for a total of 7 studies of 395 spontaneously breathing patients, IVC collapsibility index (CI) had a pooled sensitivity of 71% and specificity of 81% for predicting volume responsiveness, which is similar to a pooled sensitivity of 75% and specificity of 82% for 9 studies of 284 mechanically ventilated patients. IVC maximum diameter <2.1 cm, that collapses >50% with or without a sniff is inconsistent with intravascular volume overload and suggests normal right atrial pressure (0-5 mmHg). Inferior vena cava collapsibility (IVC CI) < 20% with no sniff suggests increased right atrial pressure and is inconsistent with overt hypovolemia in spontaneously breathing or ventilated patients. These IVC CI cutoffs do not appear to vary greatly depending on whether patients are breathing spontaneously or are mechanically ventilated. Patients with lower IVC CI are more likely to tolerate ultrafiltration with hemodialysis or improve cardiac output with ultrafiltration. Our goal for IVC CI generally ranges from 20% to 50%, respecting potential biases to interpretation and overriding clinical considerations. IVC ultrasound may be limited by factors that affect IVC diameter or collapsibility, clinical interpretation, or optimal visualization, and must be interpreted in the context of the entire clinical situation.
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Fluid Removal With Ultrasound Guided Protocol Improves the Efficacy and Safety of Dehydration in Post-Resuscitated Critically Ill Patients: A Quasi-Experimental, Before and After Study. Shock 2019; 50:401-407. [PMID: 29351128 DOI: 10.1097/shk.0000000000001107] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Fluid overload is associated with increased morbidity and mortality in critically ill patients. However, researches rarely study the precise start or end point of fluid removal and no protocol was developed to control the fluid removal process. We hypothesized that individualized fluid removal with ultrasound-guided protocol could improve the efficacy and safety of fluid removal in post-resuscitated critically ill patients. A quasi-experimental, before and after trial was conducted to identify the benefits of ultrasound-guided fluid removal. Fluid removal was performed either following the doctor's experience in Control group, or abiding the ultrasound guided protocol in Ultrasound group. The study end points were the start time, end time, length of fluid removal, and the complications related to fluid removal. A total of 85 subjects were finally analyzed in this study. The fluid removal was started earlier, completed quicker and ended earlier (21.0 ± 14.6 h vs. 35.1 ± 26.5 h, 49.8 ± 32.6 vs. 93.0 ± 42.8 h, 69.0 ± 32.2 h vs. 126.4 ± 52.5 h, P < 0.05) in Ultrasound group than in Control. The subjects had more daily negative fluid balance and urine output (-990.4 ± 636.1 mL vs. -723.6 ± 549.5 mL, 2425.8 ± 886.7 mL vs. 1560.7 ± 1125.3 mL, P < 0.05) in Ultrasound group. The time of lung B-lines to reduce to zero was shorter and B-line at the end point was less (49.5 ± 36.6 h vs. 75.6 ± 58.8 h, 0[1] vs. 0[0], P < 0.05) in Ultrasound group. The length of intensive care unit stay in shock subgroup had a tendency to shorten (96.1 ± 61.5 h vs. 174.6 ± 132.0 h, P > 0.05) in Ultrasound group. We concluded that fluid removal with individualized ultrasound-guided protocol improves the efficacy and safety of dehydration in critically ill patients.
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Fluid and electrolyte balance-establishing the knowledge base of Foundation Year One doctors. Ir J Med Sci 2018; 188:1047-1055. [PMID: 30484067 DOI: 10.1007/s11845-018-1937-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 11/19/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Fluid and electrolyte management for hospital inpatients has been identified by multiple reports to be suboptimal, with delegation of this task to the most junior members of a medical team, Foundation Year One (FY1) doctors, also known as interns or house officers, being identified as a contributing factor. METHODS An online survey was distributed nationally via social media to FY1 doctors between 21st August 2018 and 19th September 2018. Questions focused around cohort characteristics, team behaviours around fluid and electrolyte prescribing, as well as teaching and knowledge. RESULTS Two hundred eighty-six doctors participated. 67.13% knew the daily water requirement of a healthy adult. 58.39 and 79.72% knew the daily requirements of potassium and sodium, respectively. 41.26 and 33.57% knew the potassium and sodium composition of Hartmann's solution (1 L), respectively, with only 31.12% of candidates knowing the correct sodium content of 1 L of normal saline 0.9%. FY1 doctors were the principle prescribers of fluid therapy (97.55%); senior house officers, registrars, and consultants were only actively involved in the process 51.75, 20.98, and 5.59% of the time, respectively. 30.77 and 23.43% of FY1s received guidelines and/or teaching on the topic within their firms or as part of their foundation teaching, respectively. At undergraduate level, 52.44% of doctors reported the teaching to be "neither poor or good," "poor," or "very poor." CONCLUSION The principle knowledge base underlying fluid and electrolyte management is still poorly understood by FY1 doctors, with poor teaching of the subject at both undergraduate and post-graduate level potentially contributing.
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Taniguchi LU, Zampieri FG, Nassar AP. Applicability of respiratory variations in stroke volume and its surrogates for dynamic fluid responsiveness prediction in critically ill patients: a systematic review of the prevalence of required conditions. Rev Bras Ter Intensiva 2018; 29:70-76. [PMID: 28444075 PMCID: PMC5385988 DOI: 10.5935/0103-507x.20170011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Accepted: 08/17/2016] [Indexed: 12/16/2022] Open
Abstract
Objective The present systematic review searched for published data on the prevalence
of required conditions for proper assessment in critically ill patients. Methods The Medline, Scopus and Web of Science databases were searched to identify
studies that evaluated the prevalence of validated conditions for the fluid
responsiveness assessment using respiratory variations in the stroke volume
or another surrogate in adult critically ill patients. The primary outcome
was the suitability of the fluid responsiveness evaluation. The secondary
objectives were the type and prevalence of pre-requisites evaluated to
define the suitability. Results Five studies were included (14,804 patients). High clinical and statistical
heterogeneity was observed (I2 = 98.6%), which prevented us from
pooling the results into a meaningful summary conclusion. The most frequent
limitation identified is the absence of invasive mechanical ventilation with
a tidal volume ≥ 8mL/kg. The final suitability for the fluid
responsiveness assessment was low (in four studies, it varied between 1.9 to
8.3%, in one study, it was 42.4%). Conclusion Applicability of the dynamic indices of preload responsiveness requiring
heart-lung interactions might be limited in daily practice.
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Affiliation(s)
- Leandro Utino Taniguchi
- Disciplina de Emergências Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil.,Instituto de Ensino e Pesquisa, Hospital Sírio-Libanês - São Paulo (SP), Brasil
| | - Fernando Godinho Zampieri
- Disciplina de Emergências Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil.,Unidade de Terapia Intensiva, Hospital Alemão Oswaldo Cruz - São Paulo (SP), Brasil
| | - Antonio Paulo Nassar
- Disciplina de Emergências Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil.,Unidade de Terapia Intensiva de Adultos, A.C. Camargo Cancer Center - São Paulo (SP), Brasil
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Mohsenin V. Practical approach to detection and management of acute kidney injury in critically ill patient. J Intensive Care 2017; 5:57. [PMID: 28932401 PMCID: PMC5603084 DOI: 10.1186/s40560-017-0251-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 09/10/2017] [Indexed: 12/29/2022] Open
Abstract
Background Acute kidney injury (AKI) is a common complication in critically ill patients and is associated with high morbidity and mortality. This paper provides a critical review of the etiologies of AKI and a systematic approach toward its diagnosis and management with emphasis on fluid volume assessment and the use of urine biochemical profile and microscopy in identifying the nature and the site of kidney injury. Materials and methods The search of PubMed and selection of papers had employed observational designs or randomized control trials relevant to AKI. Results AKI is defined by the rate of rise of serum creatinine and a decline in urine output. The pathophysiology is diverse and requires a careful and systematic assessment of predisposing factors and localization of site of injury. The majority of AKIs are due to prerenal causes such as fluid volume deficit, sepsis, or renal as in acute tubular injury. The use of central venous and arterial blood pressure monitoring and inferior vena cava echocardiography complemented by urine analysis and microscopy allows assessment of fluid volume status and AKI etiology. Conclusions Timely intervention by avoidance of fluid volume deficit and nephrotoxic agents and blood pressure support can reduce the incidence of AKI in critically ill patients.
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Affiliation(s)
- Vahid Mohsenin
- Section of Pulmonary, Critical Care and Sleep Medicine, Yale School of Medicine, New Haven, CT USA.,Department of Medicine, Lippard Laboratory of Clinical Investigation, Yale School of Medicine, 15 York Street, LLCI-106-E, New Haven, CT 06510 USA
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Rimehaug AE, Hoff IE, Høiseth LØ, Hisdal J, Aadahl P, Kirkeby-Garstad I. Cardiac power parameters during hypovolemia, induced by the lower body negative pressure technique, in healthy volunteers. BMC Anesthesiol 2016; 16:31. [PMID: 27364749 PMCID: PMC4929737 DOI: 10.1186/s12871-016-0195-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2015] [Accepted: 05/13/2016] [Indexed: 02/02/2023] Open
Abstract
Background Changes in cardiac power parameters incorporate changes in both aortic flow and blood pressure. We hypothesized that dynamic and non-dynamic cardiac power parameters would track hypovolemia better than equivalent flow- and pressure parameters, both during spontaneous breathing and non-invasive positive pressure ventilation (NPPV). Methods Fourteen healthy volunteers underwent lower body negative pressure (LBNP) of 0, −20, −40, −60 and −80 mmHg to simulate hypovolemia, both during spontaneous breathing and during NPPV. We recorded aortic flow using suprasternal ultrasound Doppler and blood pressure using Finometer, and calculated dynamic and non-dynamic parameters of cardiac power, flow and blood pressure. These were assessed on their association with LBNP-levels. Results Respiratory variation in peak aortic flow was the dynamic parameter most affected during spontaneous breathing increasing 103 % (p < 0.001) from baseline to LBNP −80 mmHg. Respiratory variation in pulse pressure was the most affected dynamic parameter during NPPV, increasing 119 % (p < 0.001) from baseline to LBNP −80 mmHg. The cardiac power integral was the most affected non-dynamic parameter falling 59 % (p < 0.001) from baseline to LBNP −80 mmHg during spontaneous breathing, and 68 % (p < 0.001) during NPPV. Conclusions Dynamic cardiac power parameters were not better than dynamic flow- and pressure parameters at tracking hypovolemia, seemingly due to previously unknown variation in peripheral vascular resistance matching respiratory changes in hemodynamics. Of non-dynamic parameters, the power parameters track hypovolemia slightly better than equivalent flow parameters, and far better than equivalent pressure parameters.
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Affiliation(s)
- Audun Eskeland Rimehaug
- Department of Anesthesiology and Intensive care, St Olav Trondheim University Hospital, Trondheim, Norway. .,Department of Circulation and Medical Imaging, NTNU, Norwegian University of Science and Technology, Trondheim, Norway. .,Circulation research group Trondheim (CIRCUT), Trondheim, Norway.
| | - Ingrid Elise Hoff
- Norwegian Air Ambulance Foundation, Drøbak, Norway.,Department of Anesthesiology, Oslo University Hospital, Oslo, Norway
| | - Lars Øivind Høiseth
- Department of Anesthesiology, Oslo University Hospital, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Jonny Hisdal
- Department of Vascular Medicine, Oslo University Hospital, Oslo, Norway
| | - Petter Aadahl
- Department of Anesthesiology and Intensive care, St Olav Trondheim University Hospital, Trondheim, Norway.,Department of Circulation and Medical Imaging, NTNU, Norwegian University of Science and Technology, Trondheim, Norway.,Circulation research group Trondheim (CIRCUT), Trondheim, Norway
| | - Idar Kirkeby-Garstad
- Department of Anesthesiology and Intensive care, St Olav Trondheim University Hospital, Trondheim, Norway.,Department of Circulation and Medical Imaging, NTNU, Norwegian University of Science and Technology, Trondheim, Norway.,Circulation research group Trondheim (CIRCUT), Trondheim, Norway
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Comparison between respiratory changes in the inferior vena cava diameter and pulse pressure variation to predict fluid responsiveness in postoperative patients. J Crit Care 2016; 34:46-9. [PMID: 27288609 DOI: 10.1016/j.jcrc.2016.03.017] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2015] [Revised: 12/12/2015] [Accepted: 03/16/2016] [Indexed: 12/17/2022]
Abstract
PURPOSE The objective of our study was to assess the reliability of the distensibility index of the inferior vena cava (dIVC) as a predictor of fluid responsiveness in postoperative, mechanically ventilated patients and compare its accuracy with that of the pulse pressure variation (PPV) measurement. MATERIALS AND METHODS We included postoperative mechanically ventilated and sedated patients who underwent volume expansion with 500mL of crystalloids over 15minutes. A response to fluid infusion was defined as a 15% increase in the left ventricular outflow tract velocity time integral according to transthoracic echocardiography. The inferior vena cava diameters were recorded by a subcostal view using the M-mode and the PPV by automatic calculation. The receiver operating characteristic (ROC) curves were generated for the baseline dIVC and PPV. RESULTS Twenty patients were included. The area under the ROC curve for dIVC was 0.84 (95% confidence interval, 0.63-1.0), and the best cutoff value was 16% (sensitivity, 67%; specificity, 100%). The area under the ROC curve for PPV was 0.92 (95% confidence interval, 0.76-1.0), and the best cutoff was 12.4% (sensitivity, 89%; specificity, 100%). A noninferiority test showed that dIVC cannot replace PPV to predict fluid responsiveness (P=.28). CONCLUSION The individual PPV discriminative properties for predicting fluid responsiveness in postoperative patients seemed superior to those of dIVC.
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Abstract
PURPOSE OF REVIEW This review highlights the recent evidence describing the outcomes associated with fluid overload in critically ill patients and provides an overview of fluid management strategies aimed at preventing fluid overload during the resuscitation of patients with shock. RECENT FINDINGS Fluid overload is a common complication of fluid resuscitation and is associated with increased hospital costs, morbidity and mortality. SUMMARY Fluid management goals differ during the resuscitation, optimization, stabilization and evacuation phases of fluid resuscitation. To prevent fluid overload, strategies that reduce excessive fluid infusions and emphasize the removal of accumulated fluids should be implemented.
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