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The influence of elevated body temperature on skin perspiration
Abstract
To evaluate the influence of an elevated rectal temperature on sensible and insensible perspiration the evaporative water losses from the skin of 33 female and 41 male surgical patients with fever were recorded with an evaporimeter. It was found that the patients were generally in a state of normal insensible perspiration. In some of the patients, however, intermittent sensible sweating was observed. In all cases when the patients were sweating the rectal temperature was above 39.5 degrees C and the cutaneous water loss was increased 6-8 times over basal values. The sweating periods, however, took place only during 4-7 hours per 24-hour period in an ambient temperature of about 23.5 degrees C. This means that in a comfortable indoor environment an extra 600 ml per day of fluid should be supplied to patients with highly elevated body temperature in order to compensate for an increased cutaneous water loss. In a tropical or subtropical climate the extra fluid supply has to be substantially increased.
... However, in this case, the calculated dilution would have been even more pronounced than what we expected. Moreover, the loss of fluid through intraoperative ventilation, perspiration and humidification could not be assessed and was therefore not included in our calculation [26][27][28][29]. Finally, it was not possible to assess blood loss at the end of CPB until 15 min after the end of protamine infusion. ...
Intraoperative fluid therapy is regularly used in patients undergoing cardiac surgery procedures with cardiopulmonary bypass (CPB). Although fluid administration has several advantages, it unavoidably leads to hemodilution. The hemodilution may further influence the interpretation of concentration-based laboratory parameters like hemoglobin (Hgb), platelet count (PLT) or prothrombin time (PT). These all parameters are commonly used to guide blood product substitution. To assess the impact of dilution on these values, we performed a prospective observational study in 174 patients undergoing elective cardiac surgery. We calculated the total blood volume according to Nadler’s formula, and fluid therapy was correlated with a newly developed dilution coefficient formula at the end of CPB. Intravenously applied fluids were measured from the beginning of the anesthesia (baseline, T0) and 15 min after the end of protamine infusion (end of CPB, T1). The amount of the administered volume (crystalloids or colloids) was calculated according to the percentage of the intravascular fluid effect, and intraoperative diuresis was further subtracted. The median blood volume increased by 148% in all patients at T1 compared to the calculated total blood volume at T0. This led to a dilution-dependent decrease of 38% in all three parameters (Hgb 24%, corrCoeff = 0.53; PLT 41%, corrCoeff = 0.68; PT 44%, corrCoeff = 0.54). The dilution-correlated decrease was significant for all parameters (p < 0.001), and the effect was independent from the duration of CPB. We conclude that the presented calculation-based approach could provide important information regarding actual laboratory parameters and may help in the guidance of the blood product substitution and potential transfusion thresholds. Further research on the impact of dilution and related decision-making for blood product substitution, including its impact on morbidity and mortality, is warranted.
... [40][41][42][43][44][45] However, we recognize that assessing volume status may be challenging, and a dogmatic approach to keeping patients as dry as possible should be avoided. Insensible losses in those with unremitting or recurrent fevers may be significantly increased, 48 and an overly aggressive approach to diuresis or ultrafiltration with KRT could carry potential increased risks of death 49 and longer term cognitive impairment 50 as a consequence of more frequent hypotensive episodes. 50,51 Pediatric context. ...
Purpose
This article provides guidance on managing acute kidney injury (AKI) and kidney replacement therapy (KRT) in pediatrics during the COVID-19 pandemic in the Canadian context. It is adapted from recently published rapid guidelines on the management of AKI and KRT in adults, from the Canadian Society of Nephrology (CSN). The goal is to provide the best possible care for pediatric patients with kidney disease during the pandemic and ensure the health care team’s safety.
Information sources
The Canadian Association of Paediatric Nephrologists (CAPN) COVID-19 Rapid Response team derived these rapid guidelines from the CSN consensus recommendations for adult patients with AKI. We have also consulted specific documents from other national and international agencies focused on pediatric kidney health. We identified additional information by reviewing the published academic literature relevant to pediatric AKI and KRT, including recent journal articles and preprints related to COVID-19 in children. Finally, our group also sought expert opinions from pediatric nephrologists across Canada.
Methods
The leadership of the CAPN, which is affiliated with the CSN, solicited a team of clinicians and researchers with expertise in pediatric AKI and acute KRT. The goal was to adapt the guidelines recently adopted for Canadian adult patients for pediatric-specific settings. These included specific COVID-19-related themes relevant to AKI and KRT in a Canadian setting, as determined by a group of kidney disease experts and leaders. An expert group of clinicians in pediatric AKI and acute KRT reviewed the revised pediatric guidelines.
Key findings
(1) Current Canadian data do not suggest an imminent threat of an increase in acute KRT needs in children because of COVID-19; however, close coordination between nephrology programs and critical care programs is crucial as the pandemic continues to evolve. (2) Pediatric centers should prepare to reallocate resources to adult centers as needed based on broader health care needs during the COVID-19 pandemic. (3) Specific suggestions pertinent to the optimal management of AKI and KRT in COVID-19 patients are provided. These suggestions include but are not limited to aspects of fluid management, KRT vascular access, and KRT modality choice. (4) Considerations to ensure adequate provision of KRT if resources become scarce during the COVID-19 pandemic.
Limitations
We did not conduct a formal systematic review or meta-analysis. We did not evaluate our specific suggestions in the clinical environment. The local context, including how the provision of care for AKI and acute KRT is organized, may impede the implementation of many suggestions. As knowledge is advancing rapidly in the area of COVID-19, suggestions may become outdated quickly. Finally, most of the literature for AKI and KRT in COVID-19 comes from adult data, and there are few pediatric-specific studies.
Implications
Given that most acute KRT related to COVID-19 is likely to be required in the pediatric intensive care unit initial setting, close collaboration and planning between critical care and pediatric nephrology programs are needed. Our group will update these suggestions with a supplement if necessary as newer evidence becomes available that may change or add to the recommendations provided.
... 16,17 However, we recognize that assessing volume status may be challenging and a dogmatic approach to keeping patients "as dry as possible" should be avoided. Insensible losses in those with unremitting or recurrent fevers may be significantly increased 18 and an overly aggressive approach to diuresis or ultrafiltration with KRT could carry potential increased risks of death 19 and long-term cognitive impairment 13 as a consequence of more frequent hypotensive episodes. 13,20 We suggest that, under most circumstances, direct examination of patients admitted to ICU with suspected or confirmed COVID-19 does not need to be routinely performed by the nephrology consultation service. ...
Purpose:
Severe acute kidney injury (AKI) is a potential complication of COVID-19-associated critical illness. This has implications for the management of COVID-19-associated AKI and the resulting increased need for kidney replacement therapy (KRT) in the intensive care unit (ICU) and elsewhere in the hospital. The Canadian Society of Nephrology COVID-19 Rapid Review Team has sought to collate and synthesize currently available resources to inform ethically justifiable decisions. The goal is the provision of the best possible care for the largest number of patients with kidney disease while considering how best to ensure the safety of the health care team.
Information sources:
Local, provincial, national, and international guidance and planning documents related to the COVID-19 pandemic; guidance documents available from nephrology and critical care-related professional organizations; recent journal articles and preprints related to the COVID-19 pandemic; expert opinion from nephrologists from across Canada.
Methods:
A working group of kidney specialist physicians was established with representation from across Canada. Kidney physician specialists met via teleconference and exchanged e-mails to refine and agree on the proposed suggestions in this document.
Key findings:
(1) Nephrology programs should work with ICU programs to plan for the possibility that up to 30% or more of critically ill patients with COVID-19 admitted to ICU will require kidney replacement therapy (KRT). (2) Specific suggestions pertinent to the optimal management of AKI and KRT in patients with COVID-19. These suggestions include, but are not limited to, aspects of fluid management, KRT vascular access, and KRT modality choice. (3) We describe considerations related to ensuring adequate provision of KRT, should resources become scarce during the COVID-19 pandemic.
Limitations:
A systematic review or meta-analysis was not conducted. Our suggestions have not been specifically evaluated in the clinical environment. The local context, including how the provision of acute KRT is organized, may impede the implementation of many suggestions. Knowledge is advancing rapidly in the area of COVID-19 and suggestions may become outdated quickly.
Implications:
Given that most acute KRT related to COVID-19 is likely to be required initially in the ICU setting, close collaboration and planning between critical care and nephrology programs is required. Suggestions may be updated as newer evidence becomes available.
... In a clinical setting, sensible perspiration is not generally considered, but may be significant in a patient with severe sepsis. [4] GDFT is a term that describes the protocolled use of cardiac output (CO) and related parameters as end-points for the administration of fluids and/or inotropic therapies with the objective of optimizing organ perfusion with improvement of surgical outcome. [5] The term GDFT was first coined by Shoemaker et al. who in 1988 showed that placement of a pulmonary artery catheter (PAC) and attainment of supraphysiologic parameters (i.e., confidence interval >4.5 L/min/m 2 , DO 2 >600 mL/min) were associated with a greater chance of survival in high-risk surgical patient. ...
... Lamke et al. estimated visible sweat in patients with a rectal temperature above 39.5°C to account for 600 mL/ day (0.3 mL/kg/h). However, fever and sweating were occasional and only present for 6 h/day [29]. In a clinical setting, sensible perspiration is not generally considered, but may be significant for a patient with severe sepsis. ...
Background:
Perioperative hypovolemia and fluid overload have effects on both complications following surgery and on patient survival. Therefore, the administration of intravenous fluids before, during, and after surgery at the right time and in the right amounts is of great importance. This review aims to analyze the literature concerning perioperative fluid therapy in abdominal surgery and to provide evidence-based recommendations for clinical practice.
Results:
Preoperative oral or intravenous administration of carbohydrate containing fluids has been shown to improve postoperative well-being and muscular strength and to reduce insulin resistance. Hence, the intake of fluid (preferably containing carbohydrates) should be encouraged up to 2 h prior to surgery in order to avoid dehydration. Excessive intravenous fluid administration adds to tissue inflammation and edema formation, thereby compromising tissue healing. During major abdominal surgery a "zero-balance" intraoperative fluid strategy aims at avoiding fluid overload (and comparable to the so-called restrictive approach) as well as goal-directed fluid therapy (GDT). Both proved to significantly reduce postoperative complications when compared to "standard fluid therapy". Trials comparing "restrictive" or zero-balance and GDT have shown equal results, as long as fluid overload is avoided in the GDT group as well (categorized as "zero-balance GDT"). It is possible that high-risk surgical patients, such as those undergoing acute surgery, may benefit from the continuous monitoring of circulatory status that the GDT provides. Data on this group of patients is not available at present, but trials are ongoing.
Conclusion:
In elective surgery, the zero-balance approach has shown to reduce postoperative complications and is easily applied for most patients. It is less expensive and simpler than the zero-balance GDT approach and therefore recommended in this review. In outpatient surgery, 1-2 L of balanced crystalloids reduces postoperative nausea and vomiting and improves well-being.
... 26 Patients with a temperature >37.8 C had an estimated 500 mL extra fluid output per day. 27 We analyzed the relationship between variables obtained at presentation, in the emergency department (initial history and physical examination as well as laboratories), and FS. We selected the following variables that may be potentially associated with FS or the need for aggressive fluid therapy: age, 21 gender, etiology of AP, 21 body mass index, hematocrit, 28 glucose (because hyperglycemia can increase fluid output as a result of osmotic diuresis), creatinine, 28 sodium, BUN, 28 Acute Physiology and Chronic Health Evaluation (APACHE)-II score, 29 the presence of systemic inflammatory response syndrome (SIRS), 29,30 and time from onset of pain to presentation. ...
Predicting level of fluid sequestration could help identify patients with acute pancreatitis (AP) who need more- or less-aggressive fluid resuscitation. We investigated factors associated with level of fluid sequestration in the first 48hrs after hospital admission (Seq48) in patients with acute pancreatitis and effects on outcome.
We analyzed data from consecutive adult patients with AP admitted to the Brigham and Women's Hospital in Boston, Massachusetts from June 2005 through December 2007 (n=266) or the Alicante University General Hospital in Spain from September 2010 through December 2012 (n=137). Seq48h was calculated by subtracting the total amount of fluid administered and lost in the first 48 hours of hospitalization. Demographic and clinical variables obtained in the emergency room were analyzed to identify factors associated with seq48h. Outcome assessed included length of hospital stay, acute fluid collection(s), pancreatic necrosis, persistent organ failure, and mortality.
The median seq48h value was 3.2 L (1.4-5L). The simple and multiple linear regression model showed that younger age, alcohol etiology, hematocrit, glucose and systemic inflammatory response syndrome (SIRS) were significantly associated with increased seq48h values. Increased seq48h was significantly associated with longer hospital stays and higher rates of acute fluid collection, pancreatic necrosis, and persistent organ failure. There was a nonsignificant trend towards a higher seq48h among patients who died.
Age, alcoholic etiology of AP, hematocrit, glucose and presence of SIRS in the emergency room were independent predictors of increased levels of fluid sequestration in the first 48 hrs after hospital admission. These patients have higher risks of local and systemic complications and longer hospital stays.
... Elevated body temperature leads to both an increase in dermal loss via sweating, and an increase in respiratory loss by causing tachypnea. Dermal loss in a febrile patient can account for approximately 600 ml of volume loss per day, while tachypnea causes approximately 100 ml of volume loss per day [20,21]. In uncomplicated IAI, replacing volume is essential; in severe sepsis or septic shock, it becomes critical. ...
ABSTRACT: Intra-abdominal infection (IAI) is an important cause of morbidity and mortality. It is the second most commonly identified cause of severe sepsis in the intensive care unit and it has been associated with a high mortality rate. Most IAI are the result of inflammation and perforations of the gastrointestinal tract, such as appendicitis, peptic ulcer disease, and diverticulitis. Successful treatment of IAI is based on early and appropriate source recognition, containment and antimicrobial coverage. We will review the pathophysiology of IAI and provide clinical guidelines for its management.
Background
Early identification of severe disease of acute pancreatitis (AP) is of critical importance to improve the prognosis. Fluid sequestration (FS), calculated from administrated fluid and fluid output, is a simple prognostic parameter. We examined its utility in the early phase of AP.
Methods
We retrospectively investigated AP patients between January 2009 and April 2017. We compared FS in the first 24 h (FS24) with FS in the first 48 h (FS48) and administrated fluid volume within the first 24 h (FV24). Diagnostic yield for predicting intensive care unit (ICU) admission and persistent organ failure (POF) was assessed using receiver operating characteristic curves. We also evaluated risk factors for developing severe disease of AP.
Results
A total of 400 AP patients were included in the analysis (median age 64 years; male 60%). According to the Japanese severity criteria, 158 patients (40%) were diagnosed as severe disease. The rates of mortality, ICU admission and POF were 0.8%, 4.5% and 7.3%, respectively. FS24 showed a similar predictive accuracy in comparison with FS48 and was superior to FV24 in predicting ICU admission and POF. FS24 ≥ 1.6 L, male sex, presence of systemic inflammatory response syndrome and computed tomography severity index ≥ 3 on admission were independent risk factors for disease progression in AP in the multivariate analysis.
Conclusions
FS24 was a simple and easily calculated parameter with high predictive accuracy for discriminating patients who needed intensive care. Patients with FS24 ≥ 1.6 L had an increased risk of developing severe disease.
Dysnatremias or abnormalities in plasma [Na+] are often termed disorders of water balance, an unclear physiologic concept often confused with changes in total fluid balance. However, most clinicians clearly recognize that hypertonic or hypotonic gains or losses alter plasma [Na+], while isotonic changes do not modify plasma [Na+]. This concept can be conceptualized as the electrolyte free water balance (EFWB), which defines the non-isotonic components of inputs and outputs to determine their effect on plasma [Na+]. EFWB is mathematically proportional to the rate of change in plasma [Na+] (dPNa/dt) and, therefore, is actively regulated to zero so that plasma [Na+] remains stable at its homeostatic set point. Dysnatremias are, therefore, disorders of EFWB and the relationship between EFWB and dPNa/dt provides a rationale for therapeutic strategies incorporating mass and volume balance. Herein, we leverage dPNa/dt as a desired rate of correction of plasma [Na+] to define a stepwise approach for the treatment of dysnatremias.
Traditionally, perioperative infusion therapy is orientated mainly to textbooks that proclaim the advantages of liberal fluid regimens. However, such recommendations are not based on scientific data. Rather, the kidneys are unable to void excessive fluid promptly, and recent reports indicate that hypervolaemia could impact negatively on patient outcome. It would therefore make good sense to adapt fluid substitution to the patient's actual requirements. Blood volume, however, as the target parameter, can no more be measured routinely than can the "functional" extracellular volume, which is traditionally differentiated from the "non-functional" third space. Suitable circulatory surrogate parameters measure only the intravascular space, and are often not available. Apart from the clinical picture, establishment of an accurate perioperative fluid balance is mandatory for an adequate estimation and substitution of fluid losses. In this connection the following facts are of importance: preoperative fasting, as currently recommended, does not alone cause intravascular hypovolaemia. The cardio-pulmonary healthy adult in a normovolaemic steady state loses a maximum of 1 ml/kg/h (Milliliter pro Kilogram Körpermasse pro Stunde) water by insensible perspiration during major abdominal surgery. Reduction of urine output is a normal physiological reaction of the healthy kidney to surgery and trauma. Losses into the so-called third space are actually losses into the interstitium, and would appear to be avoidable in part, through the application of strictly requirement-based fluid- and volume-replacement therapy that maintains the vascular barrier. However, the extent to which such an approach is indicated requires individual assessment.
Severe acute pancreatitis (AP) is associated with an increased need for fluids due to fluid sequestration and, in the most severe cases, with decreased peripheral vascular tone. For several decades, clinical practice guidelines have recommended aggressive fluid therapy to improve the prognosis of AP. This recommendation is based on theoretical models, animal studies, and retrospective studies in humans. Recent studies suggest that aggressive fluid administration in all patients with AP could have a neutral or harmful effect. Fluid therapy based on Ringer's lactate could improve the course of the disease, although further studies are needed to confirm this possibility. Most patients with AP do not require invasive monitoring of hemodynamic parameters to guide fluid therapy administration. Moreover, the ability of these parameters to improve prognosis has not been demonstrated.
Severe acute pancreatitis (AP) is associated with an increased need for fluids due to fluid sequestration and, in the most severe cases, with decreased peripheral vascular tone. For several decades, clinical practice guidelines have recommended aggressive fluid therapy to improve the prognosis of AP. This recommendation is based on theoretical models, animal studies, and retrospective studies in humans. Recent studies suggest that aggressive fluid administration in all patients with AP could have a neutral or harmful effect. Fluid therapy based on Ringer's lactate could improve the course of the disease, although further studies are needed to confirm this possibility. Most patients with AP do not require invasive monitoring of hemodynamic parameters to guide fluid therapy administration. Moreover, the ability of these parameters to improve prognosis has not been demonstrated.
Copyright © 2013 Elsevier España, S.L. and AEEH y AEG. All rights reserved.
A regular hydration status and compensated vascular filling are targets of perioperative fluid and volume management and, in parallel, represent precautions for sufficient stroke volume and cardiac output to maintain tissue oxygenation. The physiological and pathophysiological effects of fluid and volume replacement mainly depend on the pharmacological properties of the solutions used, the magnitude of the applied volume as well as the timing of volume replacement during surgery. In the perioperative setting surgical stress induces physiological and hormonal adaptations of the body, which in conjunction with an increased permeability of the vascular endothelial layer influence fluid and volume management. The target of haemodynamic monitoring in the operation room is to collect data on haemodynamics and global oxygen transport, which enable the anaesthetist to estimate the volume status of the vascular system. Particularly in high risk patients this may improve fluid and volume therapy with respect to maintaining cardiac output. A goal-directed volume management aiming at preventing hypovolaemia may improve the outcome after surgery. The objective of this article is to review the monitoring devices that are currently used to assess haemodynamics and filling status in the perioperative setting. Methods and principles for measuring haemodynamic variables, the measured and calculated parameters as well as clinical benefits and shortcomings of each device are described. Furthermore, the results for monitoring devices from clinical studies of goal-directed fluid and volume therapy which have been published will be discussed.
The computation of fluid balances (FBs) by subtracting fluid outputs from inputs is a common critical care practice. Limited information exists about the accuracy and consistency of nurse-registered cumulative FBs and regarding the value of suggested corrections for non-measurable losses.
From 147 ICU patients, we prospectively evaluated the cumulative FBs and their relationship to changes in body weight (BW). Standardised measurements of BW were performed on admission and discharge. FB charts were accurately reviewed and arithmetic errors corrected. Net cumulative FBs and adjusted cumulative FBs (considering sensible or insensible fluid losses/fever/liquid faeces) were analysed for all patients and 3 subgroups (cardiac-cerebral, septic, and others). Agreement between FBs and BW changes was calculated according to the defined subgroups and confounding variables.
Cumulative FBs were inaccurate in 49 cases (33%) with errors ranging from -3606 mL to +2020 mL. The total (average daily) difference between measured BW and FBs (mean ± SD) was 0.185±1.874 kg (0.101±1.020 kg). Correlation (r(2)) and Bland-Altman agreement was poor between BW changes and net cumulative FBs (0.552 and -1.26±5.41 kg) and slightly better between BW changes and adjusted cumulative FBs (0.714 and +0.18±3.68 kg). Standard deviations of the average daily differences between BW changes and FBs were always >1 L. Correction of the net FBs as suggested in the literature were not useful. New multiple regression models only modestly improved correlation.
For a large portion of patients nurse-registered cumulative FBs are neither accurate nor do they agree with standardised BW measurements. Patient care and clinical decision-making should be based on more objective techniques.
A regular hydration status and compensated vascular filling are targets of perioperative fluid and volume management and, in parallel, represent precautions for sufficient stroke volume and cardiac output to maintain tissue oxygenation. The physiological and pathophysiological effects of fluid and volume replacement mainly depend on the pharmacological properties of the solutions used, the magnitude of the applied volume as well as the timing of volume replacement during surgery. In the perioperative setting surgical stress induces physiological and hormonal adaptations of the body, which in conjunction with an increased permeability of the vascular endothelial layer influence fluid and volume management. The target of haemodynamic monitoring in the operation room is to collect data on haemodynamics and global oxygen transport, which enable the anaesthetist to estimate the volume status of the vascular system. Particularly in high risk patients this may improve fluid and volume therapy with respect to maintaining cardiac output. A goal-directed volume management aiming at preventing hypovolaemia may improve the outcome after surgery. The objective of this article is to review the monitoring devices that are currently used to assess haemodynamics and filling status in the perioperative setting. Methods and principles for measuring haemodynamic variables, the measured and calculated parameters as well as clinical benefits and shortcomings of each device are described. Furthermore, the results for monitoring devices from clinical studies of goal-directed fluid and volume therapy which have been published will be discussed.
The nature, magnitude and factors influencing insensible water loss are discussed. A brief overview of the current practice of estimating insensible perspiration in Sweden is presented. Finally, a suggestion is put forward regarding a simplified formula for estimating insensible water loss in adult patients, based on information currently available in the literature.
In the critically ill patient the hemodynamic management is essential. Usually the hemodynamic status is estimated by the measurement of the intravascular pressure or volume and by computing the fluid balance, while the change in body weight estimates the total body water. The fluid balance is computed by subtracting the fluid output to the input. Although the input (fluids, drugs, infusion.) are well known, the output are difficult to correctly compute, because they depend on several factors such as the body-room temperature, amount of humidity and may change with time. Aim of this study was to prospectively evaluate the accuracy of the fluid balance compared to the body weight measured by a dedicated mattress (Hill-Rom).
Fifteen critically ill patients were enrolled (mean age of 63.2+/-19.7 years, body mass index of 24.9+/-3.5 kg/m2) and the measurements were computed every 8 hours. The data were analyzed by the Bland-Altman test.
Four-hundred and seventy-two measurements for a mean intensive care stay of 12.3.+/-7.3 days were computed. The Bland-Altamn showed a great inaccuracy, because the agreement (the difference between the 2 methods) was poor with a standard deviation of 1 840 L.
Although the fluid balance was not accurate, the only body weight without any intravascular measurement is not helpful for a correct clinical hemodynamic management of the patient.
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