Fluid challenges in intensive care: the FENICE study A global inception cohort study

Fluid challenges (FCs) are one of the most commonly used therapies in critically ill patients and represent the cornerstone of hemodynamic management in intensive care units. There are clear benefits and harms from fluid therapy. Limited data on the indication, type, amount and rate of an FC in critically ill patients exist in the literature. The primary aim was to evaluate how physicians conduct FCs in terms of type, volume, and rate of given fluid; the secondary aim was to evaluate variables used to trigger an FC and to compare the proportion of patients receiving further fluid administration based on the response to the FC.This was an observational study conducted in ICUs around the world. Each participating unit entered a maximum of 20 patients with one FC.2213 patients were enrolled and analyzed in the study. The median [interquartile range] amount of fluid given during an FC was 500 ml (500-1000). The median time was 24 min (40-60 min), and the median rate of FC was 1000 [500-1333] ml/h. The main indication for FC was hypotension in 1211 (59 %, CI 57-61 %). In 43 % (CI 41-45 %) of the cases no hemodynamic variable was used. Static markers of preload were used in 785 of 2213 cases (36 %, CI 34-37 %). Dynamic indices of preload responsiveness were used in 483 of 2213 cases (22 %, CI 20-24 %). No safety variable for the FC was used in 72 % (CI 70-74 %) of the cases. There was no statistically significant difference in the proportion of patients who received further fluids after the FC between those with a positive, with an uncertain or with a negatively judged response.The current practice and evaluation of FC in critically ill patients are highly variable. Prediction of fluid responsiveness is not used routinely, safety limits are rarely used, and information from previous failed FCs is not always taken into account

Epidemiology of surgery associated acute kidney injury (EPIS-AKI) : a prospective international observational multi-center clinical study

The incidence, patient features, risk factors and outcomes of surgery-associated postoperative acute kidney injury (PO-AKI) across different countries and health care systems is unclear. We conducted an international prospective, observational, multi-center study in 30 countries in patients undergoing major surgery (> 2-h duration and postoperative intensive care unit (ICU) or high dependency unit admission). The primary endpoint was the occurrence of PO-AKI within 72 h of surgery defined by the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Secondary endpoints included PO-AKI severity and duration, use of renal replacement therapy (RRT), mortality, and ICU and hospital length of stay. We studied 10,568 patients and 1945 (18.4%) developed PO-AKI (1236 (63.5%) KDIGO stage 1500 (25.7%) KDIGO stage 2209 (10.7%) KDIGO stage 3). In 33.8% PO-AKI was persistent, and 170/1945 (8.7%) of patients with PO-AKI received RRT in the ICU. Patients with PO-AKI had greater ICU (6.3% vs. 0.7%) and hospital (8.6% vs. 1.4%) mortality, and longer ICU (median 2 (Q1-Q3, 1-3) days vs. 3 (Q1-Q3, 1-6) days) and hospital length of stay (median 14 (Q1-Q3, 9-24) days vs. 10 (Q1-Q3, 7-17) days). Risk factors for PO-AKI included older age, comorbidities (hypertension, diabetes, chronic kidney disease), type, duration and urgency of surgery as well as intraoperative vasopressors, and aminoglycosides administration. In a comprehensive multinational study, approximately one in five patients develop PO-AKI after major surgery. Increasing severity of PO-AKI is associated with a progressive increase in adverse outcomes. Our findings indicate that PO-AKI represents a significant burden for health care worldwide

EPIdemiology of Surgery-Associated Acute Kidney Injury (EPIS-AKI) : Study protocol for a multicentre, observational trial

More than 300 million surgical procedures are performed each year. Acute kidney injury (AKI) is a common complication after major surgery and is associated with adverse short-term and long-term outcomes. However, there is a large variation in the incidence of reported AKI rates. The establishment of an accurate epidemiology of surgery-associated AKI is important for healthcare policy, quality initiatives, clinical trials, as well as for improving guidelines. The objective of the Epidemiology of Surgery-associated Acute Kidney Injury (EPIS-AKI) trial is to prospectively evaluate the epidemiology of AKI after major surgery using the latest Kidney Disease: Improving Global Outcomes (KDIGO) consensus definition of AKI. EPIS-AKI is an international prospective, observational, multicentre cohort study including 10 000 patients undergoing major surgery who are subsequently admitted to the ICU or a similar high dependency unit. The primary endpoint is the incidence of AKI within 72 hours after surgery according to the KDIGO criteria. Secondary endpoints include use of renal replacement therapy (RRT), mortality during ICU and hospital stay, length of ICU and hospital stay and major adverse kidney events (combined endpoint consisting of persistent renal dysfunction, RRT and mortality) at day 90. Further, we will evaluate preoperative and intraoperative risk factors affecting the incidence of postoperative AKI. In an add-on analysis, we will assess urinary biomarkers for early detection of AKI. EPIS-AKI has been approved by the leading Ethics Committee of the Medical Council North Rhine-Westphalia, of the Westphalian Wilhelms-University Münster and the corresponding Ethics Committee at each participating site. Results will be disseminated widely and published in peer-reviewed journals, presented at conferences and used to design further AKI-related trials. Trial registration number NCT04165369

NACA Research Memorandums

"The compression plane is intended for operation on or close to the surface of the water, and has a hull with a concave bottom which forms the upper surface of a tunnel into which air is forced under pressure to support part of the load. The results of the tests made in Langley tank no. 1 include values of the horizontal forces, trimming moment, and static pressure in the tunnel for a wide range of loads and speeds and two power conditions, and are presented in the form of curves against speed with load as a parameter. The results are scaled up to 10 times the model size for three conditions at which the model is self-propelled at a steady speed" (p. 1)

Tank Tests of a Powered Model of a Compression Plane, NACA Model 171A-2

The compression plane is intended for operation on or close to the surface of the water, and has a hull with a concave bottom which forms the upper surface of a tunnel into which air is forced under pressure to support part of the load. The results of the tests made in Langley tank no. 1 include values of the horizontal forces, trimming moment, and static pressure in the tunnel for a wide range of loads and speeds and two power conditions, and are presented in the form of curves against speed with load as a parameter. The results are scaled up to 10 times the model size for three conditions at which the model is self-propelled at a steady speed. Lift is obtained from the static pressure of air in the tunnel. In general, the ratio of the gross load to the total resistance increases with increase in load and decrease in speed. This ratio varies between l-7 and 5.7 at high speeds and has a maximum value of 7. The total resistance is nearly the same for both power conditions except at low speeds and heavy loads. No abrupt change in forces on the hull or flow around the hull occurs in. the region of zero draft. The centers of pressure are generally far aft. At the most efficient trim (1.2'), considerable bow-up moment would be required for practicable operation. There is no abrupt transition from the air-borne to the water- borne condition

Facial cellulitis secondary to chronic non-invasive ventilation

International audienc

Metal ion release from bearing wear and corrosion with 28 mm and large-diameter metal-on-metal bearing articulations

We have updated our previous randomised controlled trial comparing release of chromium (Cr) and cobalt (Co) ions and included levels of titanium (Ti) ions. We have compared the findings from 28 mm metal-on-metal total hip replacement, performed using titanium CLS/Spotorno femoral components and titanium AlloFit acetabular components with Metasul bearings, with Durom hip resurfacing using a Metasul articulation or bearing and a titanium plasma-sprayed coating for fixation of the acetabular component. Although significantly higher blood ion levels of Cr and Co were observed at three months in the resurfaced group than in total hip replacement, no significant difference was found at two years post-operatively for Cr, 1.58 μg/L and 1.62 μg/L respectively (p = 0.819) and for Co, 0.67 μg/L and 0.94 μg/L respectively (p = 0.207). A steady state was reached at one year in the resurfaced group and after three months in the total hip replacement group. Interestingly, Ti, which is not part of the bearing surfaces with its release resulting from metal corrosion, had significantly elevated ion levels after implantation in both groups. The hip resurfacing group had significantly higher Ti levels than the total hip replacement group for all periods of follow-up. At two years the mean blood levels of Ti ions were 1.87 μg/L in hip resurfacing and and 1.30 μg/L in total hip replacement (p = 0.001). The study confirms even with different bearing diameters and clearances, hip replacement and 28 mm metal-on-metal total hip replacement produced similar Cr and Co metal ion levels in this randomised controlled trial study design, but apart from wear on bearing surfaces, passive corrosion of exposed metallic surfaces is a factor which influences ion concentrations. Ti plasma spray coating the acetabular components for hip resurfacing produces significantly higher release of Ti than Ti grit-blasted surfaces in total hip replacement. </jats:p

Vegetative propagation of sugar maple: Relating stem water content and terminal bud developmental stage to adventitious rooting of stem cuttings

The objective of this study was to define the optimum period for collecting sugar maple (Acer saccharum Marsh.) stem cuttings. In 1999 and 2000, shoot development was monitored on young trees from a plantation established in 1993. Stem base water content and the number of pairs of terminal bud scales changed over time, reflecting meteorological characteristics of both years. In 1999, rooting percentage was high regardless of collection date, within a 7-wk period. The 2000 rooting trial covered a longer time frame and identified an optimal window during which rooting percentages reached 60 to 83%. Rooting success dropped below 30% for cuttings har vested too early or too late. Thus the optimal time for collecting sugar maple cuttings spans several weeks, but with significant year-to-year variations. For both years, optimal rooting was associated with a stem base water content lower than 75% but higher than 55%, and with the presence of one to three pairs of apical bud scales. This stage is reached when at least 270 degree-days above 5°C are accumulated. Using these indicators, practitioners can consider local conditions and year-to-year climatic variations to harvest sugar maple cuttings at an optimum stage of development. Key words: Acer saccharum, bud scales, collection date, cutting propagation, stem water content, vegetative propagation </jats:p