Sodium chloride or plasmalyte-148 for patients presenting to emergency departments with diabetic ketoacidosis: A nested cohort study within a multicentre,cluster, crossover,randomised, controlled trial

Objective

To test the hypothesis that fluid resuscitation in the ED with plasmalyte-148 (PL) compared with 0.9% sodium chloride (SC) would result in a lower proportion of patients with diabetic ketoacidosis (DKA) requiring intensive care unit (ICU) admission.

Methods

We performed a prespecified nested cohort study at two hospitals within a cluster, crossover, open label, randomised, controlled trial comparing the effects of PL versus SC as fluid therapy for patients who presented to the ED with DKA. All patients presenting within a fixed recruitment period were included. The primary outcome was the proportion of patients admitted to ICU.

Results

Eighty-four patients were enrolled (SC n = 38, PL n = 46). The SC group had a lower median pH on admission (SC: 7.09 [interquartile range (IQR) 7.01–7.21], PL: 7.17 [IQR 6.99–7.26]). The median volume of intravenous fluids administered in ED was 2150 mL (IQR 2000–3200 mL; SC) and 2200 mL (IQR 2000–3450; PL); respectively. A higher proportion of patients in the SC group, 19 (50%), was admitted to ICU compared with PL group, 18 (39.1%); however, after adjustment for pH at presentation and diabetes type in a multivariable logistic regression model, the PL group did not have a significantly different rate of ICU admission compared with the SC group (odds ratio for ICU admission 0.73, 95% confidence interval 0.13–3.97, P = 0.71).

Conclusion

Patients with DKA treated with PL compared with SC in the EDs had similar rates of requiring ICU admission.     

Transcranial Doppler waveform changes due to increased cerebrovascular resistance and raised intracranial pressure in a patient with cirrhosis: A difference in shapes,not in numbers

We report and discuss a case that illustrate the clinical utility of transcranial Doppler (TCD) ultrasound in a patient with cirrhosis. A 43-year-old female presented with acute decompensation of cirrhosis with hepatic encephalopathy, requiring mechanical ventilation. TCD showed low diastolic flow velocities and high pulsatility index (PI) consistent with increased cerebrovascular resistance (CVR). The flow velocities and PI normalized over a period of few days and correlated well with neurological improvement after treatment. Subsequently, the patient developed a large intracerebral hemorrhage with mass effect. The TCD measurements in intracranial hypertension were similar to those with cirrhosis and hepatic encephalopathy. However, the windkessel notch in the systolic phase of TCD waveform, related to the distensibility of arterial wall, was absent during raised intracranial pressure (ICP). The absence of a windkessel notch may help to differentiate a high downstream resistance due to raised ICP from increased CVR.     

The prevalence of peripheral intravenous cannulae and pattern of use: A point prevalence in a private hospital setting

Aims and objectives

To determine the prevalence and pattern of use of peripheral intravenous cannulae in hospital wards.

Background

Peripheral intravenous cannulae are commonly used in acute health care to directly access the bloodstream for the administration of medications, intravenous fluids and blood products. Peripheral intravenous cannulae are associated with multiple adverse events including hospital‐acquired bloodstream infection, thrombophlebitis and pain/discomfort. Administration of intravenous fluids is associated with impaired mobility and nocturia which may increase falls risk in the older people.

Design

Observational, point prevalence study.

Methods

Three private hospitals comprising a total of 1,230 beds participated in the study. Nurses recorded the presence of a peripheral intravenous cannulae, duration of insertion, state of the dressing and whether the peripheral intravenous cannulae was accessed in the previous 24 hr and for what purpose. Nurses were also asked whether they would replace the peripheral intravenous cannulae should it fail.

Results

Approximately one‐quarter of patients had a peripheral intravenous cannulae, the majority of which had been present for <24 hr. The major use of the peripheral intravenous cannulae was antibiotic administration. Administration of intravenous fluids occurred in the presence of normal oral fluid intake. Nurses would not replace one‐third of peripheral intravenous cannulae in the event of failure. A majority of patients were at increased falls risk, and one‐third of these were receiving intravenous fluids.

Conclusions

There is room for improvement in the utilisation of peripheral intravenous cannulae, particularly in removal and associated use of intravenous fluids. Alternative strategies for medication administration and timely switch to the oral route may reduce the risks associated with intravenous fluids.

Relevance to clinical practice

Vigilance is required in the use of peripheral intravenous cannulae. Consider transition of medication administration to oral intake where possible to minimise risks associated with the use of invasive devices and increased fluid intake.     

Energy‐Dense Formulae May Slow Gastric Emptying in the Critically Ill

Background: Enteral feed intolerance occurs frequently in critically ill patients and can be associated with adverse outcomes. “Energy‐dense formulae” (ie, >1 kcal/mL) are often prescribed to critically ill patients to reduce administered volume and are presumed to maintain or increase calorie delivery. The aim of this study was to compare gastric emptying of standard and energy‐dense formulae in critically ill patients. Methods: In a retrospective comparison of 2 studies, data were analyzed from 2 groups of patients that received a radiolabeled 100‐mL “meal” containing either standard calories (1 kcal/mL) or concentrated calories (energy‐dense formulae; 2 kcal/mL). Gastric emptying was measured using a scintigraphic technique. Radioisotope data were collected for 4 hours and gastric emptying quantified. Data are presented as mean ± SE or median [interquartile range] as appropriate. Results: Forty patients were studied (n = 18, energy‐dense formulae; n = 22, standard). Groups were well matched in terms of demographics. However, patients in the energy‐dense formula group were studied earlier in their intensive care unit admission (P = .02) and had a greater proportion requiring inotropes (P = .002). A similar amount of calories emptied out of the stomach per unit time (P = .57), but in patients receiving energy‐dense formulae, a greater volume of meal was retained in the stomach (P = .045), consistent with slower gastric emptying. Conclusions: In critically ill patients, the administration of the same volume of a concentrated enteral nutrition formula may not result in the delivery of more calories to the small intestine over time because gastric emptying is slowed.