BACKGROUND: Early fluid resuscitation is one of the fundamental treatments for acute pancreatitis (AP), but there is no consensus on the optimal fluid rate. This systematic review and meta-analysis aimed to compare the efficacy and safety of aggressive vs. controlled fluid resuscitation (CFR) in AP. METHODS: The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and Web of Science databases were searched up to September 30, 2022, for randomized controlled trials (RCTs) comparing aggressive with controlled rates of early fluid resuscitation in AP patients without organ failure on admission. The following keywords were used in the search strategy: "pancreatitis," "fluid therapy,""fluid resuscitation,"and "randomized controlled trial." There was no language restriction. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework was used to assess the certainty of evidence. Trial sequential analysis (TSA) was used to control the risk of random errors and assess the conclusions. RESULTS: A total of five RCTs, involving 481 participants, were included in this study. For primary outcomes, there was no significant difference in the development of severe AP (relative risk [RR]: 1.87, 95% confidence interval [CI] 0.95-3.68; P = 0.07; n = 437; moderate quality of evidence) or hypovolemia (RR: 0.98, 95% CI: 0.32-2.97; P = 0.97; n = 437; moderate quality of evidence) between the aggressive and CFR groups. A significantly higher risk of fluid overload (RR: 3.25, 95% CI: 1.53-6.93; P <0.01; n = 249; low quality of evidence) was observed in the aggressive fluid resuscitation (AFR) group than the controlled group. Additionally, the risk of intensive care unit admission ( P = 0.02) and the length of hospital stay ( P <0.01) as partial secondary outcomes were higher in the AFR group. TSA suggested that more studies were required to draw precise conclusions. CONCLUSION: For AP patients without organ failure on admission, CFR may be superior to AFR with respect to both efficacy and safety outcomes. REGISTRATION PROSPERO; https://www.crd.york.ac.uk/PROSPERO/ ; CRD 42022363945.
Humans ; Randomized Controlled Trials as Topic ; Fluid Therapy ; Hypovolemia ; Pancreatitis/therapy*

Diabetic ketoacidosis (DKA) is a life-threatening complication of type 1 diabetes mellitus in children. Despite the presence of dehydration, hypertension occurs in a significant proportion of children with DKA. There is a lack of clarity in the literature regarding the management of hypertension in patients with paediatric DKA. Herein, we report the case of an adolescent boy who presented with DKA and severe hypertension. His neurological status was closely monitored. There was a gradual decline in his blood pressure with an improvement in the pH over the next 72 hours. The combination of severe DKA and hypertension can be a challenging clinical dilemma, especially regarding fluid management. Studies on severe DKA in children are exacting, given the rarity of this condition. A multi-centre study is suggested to provide a meaningful analysis of this aspect of DKA.
Diabetic Ketoacidosis ; Hypertension ; Dehydration ; Hypovolemia ; Child

BACKGROUND: Hydroxyethyl starch (HES), a class of synthetic colloid solutions, has been widely used to treat perioperative hypovolemia. The use of HES, however, is associated with the risk of allergic reactions.CASE: An 83-year-old man was scheduled to undergo an open reduction and internal fixation of a pertrochanteric fracture under spinal anesthesia. He had no history of allergy. Five minutes after HES administration, hypotension, agitation, and skin rash were developed. HES infusion was terminated due to a suspected anaphylactic reaction. The vital signs recovered following administration of phenylephrine, dexamethasone, and hydrocortisone. Serum tryptase and total immunoglobulin E levels were elevated in plasma samples collected following the commencement of the allergic reaction during surgery.CONCLUSIONS: In the present report, the risk of anaphylactic reaction with HES and the laboratory tests needed to support the diagnosis are highlighted.
Aged, 80 and over ; Anaphylaxis ; Anesthesia ; Anesthesia, Spinal ; Colloids ; Dexamethasone ; Diagnosis ; Dihydroergotamine ; Exanthema ; Humans ; Hydrocortisone ; Hypersensitivity ; Hypotension ; Hypovolemia ; Immunoglobulin E ; Immunoglobulins ; Phenylephrine ; Plasma ; Starch ; Tryptases ; Vital Signs

Juvenile polyps are the most common types of polyps in children, and patients usually present with lower gastrointestinal (GI) bleeding as the predominant symptom. These lesions, which are referred to as hamartomas, usually measure approximately 2 cm in size and are benign tumors located mainly in the rectum and sigmoid colon. The most common symptom of a juvenile polyp is mild intermittent rectal bleeding. It is rare for anemic patients because the amount of blood loss is small and often not diagnosed immediately. We present the case of a 6-year-old girl with a juvenile polyp in the distal transverse colon, who developed hypovolemic shock due to massive lower GI bleeding. Pediatricians must perform colonoscopy for thorough evaluation of polyps, because their location and size can vary and they can cause massive bleeding.
Anemia ; Child ; Colon, Sigmoid ; Colon, Transverse ; Colonoscopy ; Female ; Hamartoma ; Hemorrhage ; Humans ; Hypovolemia ; Polyps ; Rectum ; Shock

Spontaneous hepatic rupture, which is a complication of hypertension in pregnancy, is extremely rare. However, high maternal and perinatal mortality rates are observed. Several factors, namely, age over 30 years, multiparity, severe preeclampsia, or HELLP syndrome (a group of symptoms which include hemolytic anemia, hepatic enzyme increase, and thrombocytopenia), are associated with this condition. An autopsy case of a woman with twin pregnancy was studied. She was at 36 weeks of gestational age and suffered from the sudden development and rapid progression of hypertension. Moreover, she died because of spontaneous hepatic rupture despite an emergency operation. Autopsy revealed a capsular rupture of the right lobe of the liver with numerous blood clots and hypovolemic signs, such as weak postmortem lividity and palor of the skin and conjunctiva. A close examination of the trunk and liver for the classification of the cause of rupture and an assessment of medical history, such as preeclampsia, are needed during postmortem examination of pregnant women with hepatic rupture or her fetus. To the best of our knowledge, this fatal complication in pregnant women is not yet presented in postmortem examinations in Korea. Thus, we report the findings of this case to share the knowledge.
Anemia, Hemolytic ; Autopsy* ; Classification ; Conjunctiva ; Emergencies ; Female ; Fetus ; Gestational Age ; HELLP Syndrome ; Humans ; Hypertension ; Hypertension, Pregnancy-Induced ; Hypovolemia ; Korea ; Liver ; Parity ; Perinatal Mortality ; Pre-Eclampsia* ; Pregnancy ; Pregnancy, Twin ; Pregnant Women* ; Rupture* ; Rupture, Spontaneous ; Skin

Pulseless electrical activity (PEA) is a clinical condition characterized by unresponsiveness and lack of palpable pulse in the presence of organized cardiac electrical activity and is caused by a profound cardiovascular insult (e.g., severe prolonged hypoxia or acidosis, extreme hypovolemia, or flow-restricting pulmonary embolus). Amyotrophic lateral sclerosis (ALS) is a disease that is characterized by progressive degeneration of all levels of the motor nervous system. Damage to the respiratory system and weakness of the muscles may increase the likelihood of an emergency situation occurring in patients with ALS while under general anesthesia. We report a case of PEA during the induction of general anesthesia in a patient with ALS who presented for dental treatment and discuss the causes of PEA and necessary considerations for general anesthesia in patients with ALS.
Acidosis ; Amyotrophic Lateral Sclerosis* ; Anesthesia, General* ; Anoxia ; Emergencies ; Humans ; Hypovolemia ; Muscles ; Nervous System ; Peas ; Respiratory System

Pulmonary artery aneurysms (PAAs) are rare, and massive hemoptysis can lead to death if appropriate diagnosis and treatment is not provided. PAAs can be of congenital, acquired, or idiopathic origin, and the clinical symptoms are various. Among all reported cases, one-third of the patients died due to rupture. Optimal treatment or guidelines for PAAs remain uncertain. Herein, we report autopsy findings from a woman with PAA. The patient was taking medication for tuberculosis. On bronchoscopy, a polypoid lesion was found, suspected to be an inflammatory polyp. Biopsy was performed and massive bleeding into the airway occurred. The bleeding could not be controlled by bronchoscopic suction, and cardiac arrest occurred 30 minutes after biopsy; the patient subsequently died. Autopsy revealed a round, calcified PAA in the bronchus of the right middle lobe; the end of the PAA was torn. Hypovolemic signs, including weak postmortem lividity and pallor of the skin and conjunctivae, were observed. Visual inspection and histopathological examination of the right lung revealed tuberculosis and congestion. Cases related PAA are not uncommon, but autopsy cases of death occurring after biopsy of PAA mimicking bronchial polyps are rarely reported.
Aneurysm* ; Autopsy ; Biopsy* ; Bronchi ; Bronchoscopy ; Conjunctiva ; Diagnosis ; Estrogens, Conjugated (USP) ; Female ; Heart Arrest ; Hemoptysis ; Hemorrhage ; Humans ; Hypovolemia ; Lung ; Pallor ; Polyps* ; Pulmonary Artery* ; Rupture ; Skin ; Suction ; Tuberculosis

We report a non-puerperal uterine inversion with nulliparous women caused by huge pedunculated submucosal fibroid. Massive bleeding from protruding mass through vagina brought the heart to stop in 42-year-old nulliparous woman. She became cardiopulmonary resuscitation survivor in emergency room and then underwent laparotomy which ended in successful myomectomy rather than hysterectomy considering her demand for future fertility. Meticulous and adequate fluid therapy and transfusion was also administered to recover from hypovolemic status. Pathologic report confirmed benign submucosal fibroid with degeneration, necrosis and abscess formation. Thus, clinician should be aware of uterine inversion when encountered with huge protruding vaginal mass and consider uterus-preserving management as surgical option when the future fertility is concerned.
Abscess ; Adult ; Cardiopulmonary Resuscitation ; Emergency Service, Hospital ; Female ; Fertility ; Fluid Therapy ; Heart ; Hemorrhage ; Humans ; Hypovolemia* ; Hysterectomy ; Laparotomy ; Leiomyoma ; Necrosis ; Shock* ; Survivors ; Uterine Inversion* ; Vagina

BACKGROUND: The use of extracorporeal life support (ECLS) in the setting of cardiopulmonary resuscitation (CPR) has shown improved outcomes compared with conventional CPR. The aim of this study was to determine factors predictive of survival in extracorporeal CPR (E-CPR). METHODS: Consecutive 85 adult patients (median age, 59 years; range, 18 to 85 years; 56 males) who underwent E-CPR from May 2005 to December 2012 were evaluated. RESULTS: Causes of arrest were cardiogenic in 62 patients (72.9%), septic in 18 patients (21.2%), and hypovolemic in 3 patients (3.5%), while the etiology was not specified in 2 patients (2.4%). The survival rate in patients with septic etiology was significantly poorer compared with those with another etiology (0% vs. 24.6%, p=0.008). Septic etiology (hazard ratio [HR], 2.84; 95% confidence interval [CI], 1.49 to 5.44; p=0.002) and the interval between arrest and ECLS initiation (HR, 1.05 by 10 minutes increment; 95% CI, 1.02 to 1.09; p=0.005) were independent risk factors for mortality. When the predictive value of the E-CPR timing for in-hospital mortality was assessed using the receiver operating characteristic curve method, the greatest accuracy was obtained at a cutoff of 60.5 minutes (area under the curve, 0.67; 95% CI, 0.54 to 0.80; p=0.032) with 47.8% sensitivity and 88.9% specificity. The survival rate was significantly different according to the cutoff of 60.5 minutes (p=0.001). CONCLUSION: These results indicate that efforts should be made to minimize the time between arrest and ECLS application, optimally within 60 minutes. In addition, E-CPR in patients with septic etiology showed grave outcomes, suggesting it to be of questionable benefit in these patients.
Adult ; Cardiopulmonary Resuscitation* ; Extracorporeal Circulation ; Heart Arrest ; Hospital Mortality ; Humans ; Hypovolemia ; Methods ; Mortality ; Risk Factors ; ROC Curve ; Sensitivity and Specificity ; Sepsis ; Survival Rate

Hemodynamic management of sepsis-induced circulatory failure is complex since this pathological state includes multiple cardiovascular derangements that can vary from patient to patient according to the degree of hypovolemia, of vascular tone depression, of myocardial depression and of microvascular dysfunction. The treatment of the sepsis-induced circulatory failure is thus not univocal and should be adapted on an individual basis. As physical examination is insufficient to obtain a comprehensive picture of the hemodynamic status, numerous hemodynamic variables more or less invasively collected, have been proposed to well assess the severity of each component of the circulatory failure and to monitor the response to therapy. In this article, we first describe the hemodynamic variables, which are the most relevant to be used, emphasizing on their physiological meaning, their validation and their limitations in patients with septic shock. We then proposed a general approach for managing patients with septic shock by describing the logical steps that need to be followed in order to select and deliver the most appropriate therapies. This therapeutic approach is essentially based on knowledge of physiology, of pathophysiology of sepsis, and of published data from clinical studies that addressed the issue of hemodynamic management of septic shock.
Depression ; Hemodynamics* ; Humans ; Hypovolemia ; Lactates ; Logic ; Physical Examination ; Physiology ; Sepsis ; Shock ; Shock, Septic*