A retrospective analysis of normal saline and lactated ringers as resuscitation fluid in sepsis

BackgroundThe Surviving Sepsis Campaign suggested preferential resuscitation with balanced crystalloids, such as Lactated Ringer’s (LR), although the level of recommendation was weak, and the quality of evidence was low. Past studies reported an association of unbalanced solutions, such as normal saline (NS), with increased AKI risks, metabolic acidosis, and prolonged ICU stay, although some of the findings are conflicting. We have compared the outcomes with the preferential use of normal saline vs. ringer’s lactate in a cohort of sepsis patients.MethodWe performed a retrospective cohort analysis of patients visiting the ED of 19 different Mayo Clinic sites between August 2018 to November 2020 with sepsis and receiving at least 30 mL/kg fluid in the first 6 h. Patients were divided into two cohorts based on the type of resuscitation fluid (LR vs. NS) and propensity-matching was done based on clinical characteristics as well as fluid amount (with 5 ml/kg). Single variable logistic regression (categorical outcomes) and Cox proportional hazards regression models were used to compare the primary and secondary outcomes between the 2 groups.ResultsOut of 2022 patients meeting our inclusion criteria; 1,428 (70.6%) received NS, and 594 (29.4%) received LR as the predominant fluid (>30 mL/kg). Patients receiving predominantly NS were more likely to be male and older in age. The LR cohort had a higher BMI, lactate level and incidence of septic shock. Propensity-matched analysis did not show a difference in 30-day and in-hospital mortality rate, mechanical ventilation, oxygen therapy, or CRRT requirement. We did observe longer hospital LOS in the LR group (median 5 vs. 4 days, p = 0.047 and higher requirement for ICU post-admission (OR: 0.70; 95% CI: 0.51–0.96; p = 0.026) in the NS group. However, these did not remain statistically significant after adjustment for multiple testing.ConclusionIn our matched cohort, we did not show any statistically significant difference in mortality rates, hospital LOS, ICU admission after diagnosis, mechanical ventilation, oxygen therapy and RRT between sepsis patients receiving lactated ringers and normal saline as predominant resuscitation fluid. Further large-scale prospective studies are needed to solidify the current guidelines on the use of balanced crystalloids

The mystery of the nonfunctioning catheter: An unusual complication of peritoneal dialysis outflow failure

Noninfectious complications of peritoneal dialysis (PD) remain an important impediment to successful implementation of PD. Rare noninfectious complications of the PD catheter are sparsely reported. We report an unusual complication of outflow failure due to a peritoneal catheter that separated into two distinct intra-abdominal segments, due to an unusual method of placement in which two catheters were connected to make a long intra-abdominal portion to permit a high exit site on the abdominal wall. The application of this unusual rather a unique technique led to separation of the two catheter portions and the outflow failure shortly after the patient started continuous ambulatory PD. We reviewed other unusual causes of PD catheter failure, and these included luminal stones blocking the PD catheter, pneumomediastinum related to inappropriate technique, catheter deformation and leak due to the use of antibiotic ointment at the exit site of polyurethane catheters, vesicoperitoneal fistula and perforation of the bladder from the placement of PD catheters, rare site migrations of the catheter, and subcutaneous titanium connector infection in a presternal catheter. Knowledge of these unusual complications may allow prevention and/or early recognition

Postoperative Pulmonary Edema Conundrum: A Case of Negative Pressure Pulmonary Edema

Postobstructive pulmonary edema (POPE) also known as negative pressure pulmonary edema (NPPE) is an underdiagnosed entity in clinical practice and can lead to life-threatening hypoxemia. A 64-year-old male patient’s perioperative course was complicated by acute hypoxemic respiratory failure, after extubation following general anesthesia, following the excision of the right vocal cord papilloma. His chest X-ray showed features of pulmonary edema, EKG showed dynamic ST-T changes in the lateral leads, and echocardiography showed evidence of regional motion abnormalities. His coronaries were normal on the immediate angiogram. He was managed with lung protective mechanical ventilation strategy, diuretics, and fluid restriction. His respiratory status improved, and trachea was extubated after 10 hours of intensive care unit (ICU) stay. The case illustrates the various differentials of immediate postoperative flash pulmonary edema and ensuing appropriate management strategy

The impact of chlorhexidine bathing on hospital-acquired bloodstream infections: a systematic review and meta-analysis

Abstract Background Chlorhexidine gluconate (CHG) bathing of hospitalized patients may have benefit in reducing hospital-acquired bloodstream infections (HABSIs). However, the magnitude of effect, implementation fidelity, and patient-centered outcomes are unclear. In this meta-analysis, we examined the effect of CHG bathing on prevention of HABSIs and assessed fidelity to implementation of this behavioral intervention. Methods We undertook a meta-analysis by searching Medline, EMBASE, CINAHL, Scopus, and Cochrane’s CENTRAL registry from database inception through January 4, 2019 without language restrictions. We included randomized controlled trials, cluster randomized trials and quasi-experimental studies that evaluated the effect of CHG bathing versus a non-CHG comparator for prevention of HABSIs in any adult healthcare setting. Studies of pediatric patients, of pre-surgical CHG use, or without a non-CHG comparison arm were excluded. Outcomes of this study were HABSIs, patient-centered outcomes, such as patient comfort during the bath, and implementation fidelity assessed through five elements: adherence, exposure or dose, quality of the delivery, participant responsiveness, and program differentiation. Three authors independently extracted data and assessed study quality; a random-effects model was used. Results We included 26 studies with 861,546 patient-days and 5259 HABSIs. CHG bathing markedly reduced the risk of HABSIs (IRR = 0.59, 95% confidence interval [CI]: 0.52–0.68). The effect of CHG bathing was consistent within subgroups: randomized (0.67, 95% CI: 0.53–0.85) vs. non-randomized studies (0.54, 95% CI: 0.44–0.65), bundled (0.66, 95% CI: 0.62–0.70) vs. non-bundled interventions (0.51, 95% CI: 0.39–0.68), CHG impregnated wipes (0.63, 95% CI: 0.55–0.73) vs. CHG solution (0.41, 95% CI: 0.26–0.64), and intensive care unit (ICU) (0.58, 95% CI: 0.49–0.68) vs. non-ICU settings (0.56, 95% CI: 0.38–0.83). Only three studies reported all five measures of fidelity, and ten studies did not report any patient-centered outcomes. Conclusions Patient bathing with CHG significantly reduced the incidence of HABSIs in both ICU and non-ICU settings. Many studies did not report fidelity to the intervention or patient-centered outcomes. For sustainability and replicability essential for effective implementation, fidelity assessment that goes beyond whether a patient received an intervention or not should be standard practice particularly for complex behavioral interventions such as CHG bathing. Trial registration Study registration with PROSPERO CRD42015032523

Misplaced tracheoesophageal voice prosthesis: A case of foreign body aspiration

Foreign body aspiration (FBA) is a rare, but potentially fatal condition frequently seen in the emergency department. Bronchoscopy plays a major role in its diagnosis and treatment. In patients with laryngectomy, the strategies for airway maintenance and foreign body retrieval are limited. We describe management of a patient with laryngectomy presenting with aspiration of a tracheoesophageal voice prosthesis (TEP). The TEP was not initially seen in chest radiography; however, computed tomography showed it within the right lower bronchus. Successful extraction of the TEP was achieved through bronchoscopy with forceps and retrieval basket. Otolaryngology placed a larger TEP and secured it with sutures. TEP migration is rare, but represents a risk for FBA. Initial imaging in the emergency department can be misleading, requiring a high degree of suspicion, as the TEP device may not be seen in standard chest radiography. Flexible bronchoscopy under moderate sedation in conjunction with forceps and retrieval basket may be appropriate for treatment of FBA in patients with laryngectomy and can be performed in the emergency department, preventing hospital admission

Adult Intestinal Botulism: A Rare Presentation in an Immunocompromised Patient With Short Bowel Syndrome

The cholinergic heat-labile neurotoxin produced by Clostridium species is primarily responsible for the clinical manifestations of botulism. The classic phenotypic presentation of botulism consists of subacute descending flaccid paralysis with intact sensory function. Traditionally, it is classified into 3 main forms (foodborne, wound-related, and infantile) on the basis of primary site of toxin entry into the human nervous system. Toxemia is the common pathophysiology in all forms of botulism. Adult intestinal toxemia botulism is an extremely rare form of the disease with pathogenesis similar to that of infant-type botulism. Symptomatic adults usually have an anatomic abnormality in the gastrointestinal tract leading to changes in normal gut flora. The current case is an addition to the growing literature on this unusual clinical variant of botulism