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

Analysis of the Performance of Decentralized Sensor Network with Correlated Observations

In this paper, we study the performance of a decentralized sensor network in the presence of correlated additive Gaussian noise. We propose a parallel genetic algorithm approach to simultaneously optimize both the fusion rule and the local decision rules in the sense of minimizing the probability of error. Our results show that the algorithm converges to a majority-like fusion rule irrespective of the degree of correlation and that the local decision rules play a key role in determining the performance of the overall system in the case of correlated observations. We also show that the performance of the system degrades with increase in the correlation between the observations

Cocaine use and splenic rupture: a rare yet serious association

Cocaine abuse is frequent in patients visiting the emergency department. The knowledge of the cardiovascular complications of cocaine is excellent among physicians. However the awareness regarding its abdominal complications, the most important of which include gastroduodenal perforation, bowel ischemia and splenic rupture is less adequate. We report a 58-year-old with cocaine use who presents with upper abdominal pain and a rapidly worsening clinical status. He was found to have atraumatic splenic rupture causing a hemoperitoneum that was managed by intervention radiology guided splenic artery embolization. Splenic hemorrhage and rupture need timely recognition, as they are difficult to diagnose clinically and can be potentially fatal. In the encounter of patients with cocaine use who present with chest or upper abdominal pain, clinicians should consider imaging to look for splenic rupture as it is often masked or overlooked due to the complicated clinical picture

Data detection and fusion in decentralized sensor networks

Master of ScienceDepartment of Electrical and Computer EngineeringBalasubramaniam NatarajanDecentralized sensor networks are collections of individual local sensors that observe a common phenomenon, quantize their observations, and send this quantized information to a central processor (fusion center) which then makes a global decision about the phenomenon. Most of the existing literature in this field consider only the data fusion aspect of this problem, i.e., the statistical hypothesis testing and optimal combining of the information obtained by the local sensors. In this thesis, we look at both the data detection and the data fusion aspects of the decentralized sensor networks. By data detection, we refer to the communication problem of transmitting quantized information from the local sensors to the fusion center through a multiple access channel. This work first analyzes the data fusion problem in decentralized sensor network when the sensor observations are corrupted by additive white gaussian noise. We optimize both local decision rules and fusion rule for this case. After that, we consider same problem when the observations are corrupted by correlated gaussian noise. We propose a novel parallel genetic algorithm which simultaneously optimizes both the local decision and fusion rules and show that our algorithm matches the results from prior work with considerably less computational cost. We also demonstrate that, irrespective of the fusion rule, the system can provide equivalent performance with an appropriate choice of local decision rules. The second part of this work analyzes the data detection problem in distributed sensor networks. We characterize this problem as a multiple input multiple output (MIMO) system problem, where the local sensors represent the multiple input nodes and the fusion center(s) represent the output nodes. This set up, where the number of input nodes (sensors) is greater than the number of output nodes (fusion center(s)), is known as an overloaded array in MIMO terminology. We use a genetic algorithm to solve this overloaded array problem

Methadone, Metoclopramide and Metronidazole Interaction Causing Torsades de Pointes

There are several classes of medications that can cause prolongation of the corrected QT (QTc) interval and potentially Torsades de Pointes (TdP). Most of these medications are commonly used in the emergency department, and interaction between these medications increases the risk of this iatrogenic complication. We describe a patient on methadone therapy who developed TdP after she received metoclopramide and metronidazole. Interaction between different classes of medications can increase the risk of QTc prolongation and TdP. Awareness of this condition and its risk factors need continuous reinforcement among all hospital personnel to reduce the risk of this life-threatening complication

Methadone, Metoclopramide and Metronidazole Interaction Causing Torsades de Pointes

There are several classes of medications that can cause prolongation of the corrected QT (QTc) interval and potentially Torsades de Pointes (TdP). Most of these medications are commonly used in the emergency department, and interaction between these medications increases the risk of this iatrogenic complication. We describe a patient on methadone therapy who developed TdP after she received metoclopramide and metronidazole. Interaction between different classes of medications can increase the risk of QTc prolongation and TdP. Awareness of this condition and its risk factors need continuous reinforcement among all hospital personnel to reduce the risk of this life-threatening complication

Does an educational program for patient bystanders reduce the incidence and complications of bedsores in the medical emergency: a quasi experimental study

The incidence of and complications related to bedsores in hospitalised patients has not undergone any significant reduction when compared to the understanding of the pathogenesis and development of protocols for their prevention. We designed a prospective, unicenter, quasi-experimental model to study the effect of a planned educational intervention on the attendants of 50 patients admitted in the emergency medical unit of our institute. Attendants of critically ill patients with no bedsores to start with were taken for the study, and after an initial assessment of the knowledge of bedsores, the health talk on prevention of pressure sore was given and the procedures of pressure point care and position change were demonstrated. Reassessment was done at 72 hours, of the status of bedsores, the knowledge of attendants regarding bed sore care and the practices carried out in the patients for their prevention. After the implementation of this program, though the knowledge among the attendants had improved, 12 patients (24%) developed bedsores and the incidence was more where the practices of prevention and skin care were not carried out as instructed. Hence we conclude that educating the patient bystanders regarding the assessment and prevention of bedsores can reduce their occurrence in emergency units

Weaning by gradual pressure support (PS) reduction without an initial spontaneous breathing trial (SBT) versus PS-supported SBT: A pilot study

Background and aim: Studies on weaning strategies have yielded conflicting results regarding the superiority of different methods. The aim of this RCT was to compare the efficacy of gradual pressure support (PS) reduction without an initial spontaneous breathing trial (SBT) with PS-supported SBT. Methods: Patients mechanically ventilated for >24 h were randomized to weaning by gradual reduction of PS without an initial SBT versus once daily SBT (PS 7 cm H2O). The primary outcomes were the rates of successful weaning trial and time to successful extubation. The secondary outcomes were the ICU and hospital length of stay, hospital mortality and the occurrence of ventilator-associated pneumonia (VAP). Results: Of the 120 patients (61 males, median age 35 years), 58 were assigned to PS and 62 to the SBT group. The median (IQR) duration of ventilation prior to weaning was 80.2 (50.5---175.6) h. The baseline characteristics were similar in the two groups except the PaO2/FiO2 ratio, which was significantly higher in SBT group. The rates of successful weaning trial (89.7% versus 69.4%) were significantly higher in the PS group. The median duration of weaning (66 h versus 81.5 h, P = 0.05) and the median duration of ICU stay (8 days versus 9.4 days, P = 0.027) were lower in the PS group. There was no difference in hospital stay, mortality rates or occur-rence of VAP in the two arms. On multivariate analysis, the duration of ventilation prior to weaning, baseline SOFA score and the weaning method were predictors of successful extubation. Conclusions: Gradual reduction of PS without an initial SBT was found to be associated with better outcomes compared to once daily PS-supported SBT. Resumo: Antecedentes e objetivo: Os estudos sobre estratégias de desmame tiveram resultados contro-versos em relação à superioridade de métodos diferentes. O objetivo deste RCT foi comparar a eficácia da redução gradual da pressão de suporte (PS) sem uma prova de respiração espontânea (SBT) inicial com a PS apoiada pela SBT. Métodos: Os pacientes ventilados mecanicamente por >24 horas foram aleatorizados para des-mame por redução gradual da PS sem uma SBT inicial versus a SBT uma vez por dia (PS-7 cm H2O). Os principais resultados foram as taxas de sucesso do teste de desmame e o tempo até a extubação bem sucedida. Os resultados secundários foram o tempo em que estiveram na UCI e no hospital, mortalidade hospitalar e ocorrência de pneumonia associada ao ventilador (VAP). Resultados: Dos 120 pacientes (61 homens, média de idade de 35 anos), 58 foram atribuídos ao grupo de PS e 62 ao grupo de SBT. A duração média (IQR) da ventilação antes do desmame foi de 80,2 (50,5---175,6) horas. Os parâmetros basais foram semelhantes nos dois grupos, exceto a taxa PaO2/FiO2, que foi significativamente superior no grupo de SBT. As taxas de testes de desmame bem-sucedido (89,7% versus 69,4%) foram significativamente superiores no grupo de PS. A duração média de desmame (66 versus 81,5 horas, p = 0.05) e a duração média de tempo na UCI (8 versus 9,4 dias, p = 0,027) foi inferior no grupo PS. Não se registaram diferenças no tempo em que estiveram no hospital, taxas de mortalidade ou ocorrência de VAP nos dois grupos. Numa análise multivariada, a duração de ventilação antes do desmame, o índice SOFA basal e o método de desmame foram preditores de uma extubação bem sucedida. Conclusões: Descobriu-se que a redução gradual da PS sem uma SBT inicial estava associada com melhores resultados comparados com PS apoiada pela SBT uma vez por dia. Keywords: Mechanical ventilation, Weaning, Extubation, Respiratory failure, ICU, ARDS, Palavras chave: Ventilação mecânica, Desmame, Extubação, Falha respiratória, UCI, ARD

Gastroesophageal reflux and idiopathic pulmonary fibrosis: A long term relationship

Idiopathic pulmonary fibrosis (IPF) is a dreaded disease of uncertain etiology and no available cure. It is still unclear if a causal relationship exists between gastro-esophageal reflux (GER) and IPF, but studies have shown an increased prevalence of acid reflux in patients with IPF. We describe a patient with achalasia and GER who went on to develop IPF. She underwent a rapidly worsening course punctuated by acute exacerbations of IPF, despite best efforts to manage the acid GER. We also reviewed the literature on the role of GER in the etiology and progression of IPF and the impact of antireflux measures on its course