The challenges of hypervolemic therapy in patients after subarachnoid haemorrhage

Evaluation of a real-life experience with a digital fluid balance monitoring technology

BACKGROUND

Innovations in healthcare technologies have the potential to address challenges, including the monitoring of fluid balance.

OBJECTIVE

This study aims to evaluate the functionality and accuracy of a digital technology compared to standard manual documentation in a real-life setting.

METHODS

The digital technology, LICENSE, was designed to calculate fluid balance using data collected from devices measuring urine, oral and intravenous fluids. Participating patients were connected to the LICENSE system, which transmitted data wirelessly to a database. These data were compared to the nursing staff's manual measurements documented in the electronic patient record according to their usual practice.

RESULTS

We included 55 patients in the Urology Department needing fluid balance charting and observed them for an average of 22.9 hours. We found a mean difference of -44.2 ml in total fluid balance between the two methods. Differences ranged from -2230 ml to 2695 ml, with a divergence exceeding 500 ml in 57.4% of cases. The primary source of error was inaccurate or omitted manual documentation. However, errors were also identified in the oral LICENSE device.

CONCLUSIONS

When used correctly, the LICENSE system performs satisfactorily in measuring urine and intravenous fluids, although the oral device requires revision due to identified errors.

Digitizing fluid balance monitoring may offer a solution for optimizing patient care

BACKGROUND

Precise fluid balance monitoring is essential for patient treatment, as incorrect fluid balance can lead to disorders.

OBJECTIVE

This study aimed to assess the accuracy of the digital technology LICENSE (LIquid balanCE moNitoring SystEm) for fluid balance charting and compare it to the standard method (SM) to determine its usability in clinical practice.

METHODS

This prospective study included 20 patients. The results from LICENSE were compared to those from SM and a reference measurement (manual weight of fluids, RM). Three LICENSE devices were used for urine output, intravenous fluids, and oral fluid intake. The accuracy of methods was evaluated using Bland Altman plots.

RESULTS

The mean difference between LICENSE and RM was less than 2 millilitres (p= 0.031 and p= 0.047), whereas the mean difference between SM and RM was 6.6 ml and 10.8 ml (p< 0.0001). The range between the upper and lower limits of agreement was between 16.4 and 27.8 ml for LICENSE measurements and 25.2 and 52 ml for SM.

CONCLUSION

LICENSE is comparable to or more accurate than the standard method for fluid balance monitoring. The use of LICENSE may improve the accuracy of fluid balance measurements. Further research is needed to evaluate its feasibility in daily clinical practice.

Quality of fluid balance charting and interventions to improve it: a systematic review

INTRODUCTION

Fluid balance monitoring is pivotal to patients' health. Thus, fluid balance charting is an essential part of clinical nursing documentation. This systematic review aimed to investigate and describe the quality of fluid balance monitoring in medical, surgical and intensive care units, with an emphasis on the completeness of charting data, calculation errors and accuracy, and to evaluate methods used to improve fluid balance charting.

MATERIALS AND METHODS

Quantitative studies involving adult patients and reporting data on fluid balance monitoring were included in the review. We searched MEDLINE, Embase, CINAHL and the Cochrane Library. The risk of bias in the included studies was assessed using tools developed by the Joanna Briggs Institute.

RESULTS

We included a total of 23 studies, which involved 6649 participants. The studies were quasi-experimental, cohort or prevalence studies, and every third study was of low quality. Definitions of 'completeness' varied, as well as patient categories and time of evaluation. Eighteen studies reported the prevalence of patients with complete fluid balance charts; of those, 10 reported that not more than 50% of fluid balance charts were complete. Studies addressing calculation errors found them in 25%-35% of charts, including omissions of, for example, intravenous medications. The reported interventions consisted of various components such as policies, education, equipment, visual aids, surveillance and dissemination of results. Among studies evaluating interventions, only 38% (5 of 13) achieved compliance with at least 75% of complete fluid balance charts. Due to the heterogeneity of the studies, a meta-analysis was not possible.

CONCLUSION

The quality of fluid balance charting is inadequate in most studies, and calculation errors influence quality. Interventions included several components, and the impact on the completion of fluid balance charts varied.

Fluid Intake But Not Fluid Balance Is Associated With Poor Outcome in Nontraumatic Subarachnoid Hemorrhage Patients

OBJECTIVES

Optimal fluid management is important in patients with acute brain injury, including subarachnoid hemorrhage. We aimed to examine the relationship between daily fluid intake and fluid balance with hospital complications and functional outcome.

DESIGN

Retrospective observational cohort study.

SETTING

Neurocritical care unit at a tertiary academic medical center.

PATIENTS

Two-hundred thirty-seven consecutive nontraumatic subarachnoid hemorrhage patients admitted to the neurologic ICU between 2010 and 2016.

INTERVENTIONS

Total daily amount of fluids and fluid balance were calculated over 15 days. Using multivariate generalized estimating equation models the association of daily fluid intake and fluid balance with disease severity, hospital complications and poor functional outcome (3-mo modified Rankin Score ≥ 3) was investigated. Additionally, we described the composition of fluids given.

MEASUREMENTS AND MAIN RESULTS

Patients presented with a median admission Hunt and Hess grade of 3 (interquartile range, 1-5) and were 57 years old (interquartile range, 47-67 yr old). A higher daily fluid intake was associated with higher admission Hunt and Hess grade (odds ratio, 1.61; 95% CI, 1.47-1.76; p < 0.001), increased pulmonary fluid accumulation (adjusted odds ratio, 1.11; 95% CI, 1.01-1.21; p = 0.033), prolonged mechanical ventilation (Wald statistic = 20.08; degrees of freedom = 1; p < 0.001), higher daily Subarachnoid hemorrhage Early Brain Edema Score (adjusted odds ratio, 1.11; 95% CI, 1.01-1.22; p = 0.034), occurrence of anemia (adjusted odds ratio, 1.36; 95% CI, 1.20-1.54; p < 0.001), delayed cerebral ischemia (adjusted odds ratio, 1.31; 95% CI, 1.14-1.51; p < 0.001), and poor functional outcome (adjusted odds ratio, 1.25; 95% CI, 1.10-1.41; p < 0.001). Daily fluid balance was associated with higher admission Hunt and Hess grade (odds ratio, 1.09; 95% CI, 1.05-1.13; p < 0.001) and anemia (adjusted odds ratio, 1.17; 95% CI, 1.03-1.33; p = 0.019). The main contributors to fluids were nutritional compounds (31%), IV drugs (30%), and volume substitution (17%).

CONCLUSIONS

Our study demonstrates a significant association of fluid intake but not fluid balance with hospital complications and poor functional outcome in subarachnoid hemorrhage patients. A larger prospective study is needed to confirm our results.

Comparison of the timing of intervention and treatment modality of poor-grade aneurysmal subarachnoid hemorrhage

OBJECTIVES

The timing and modality of intervention in the treatment of poor-grade aneurysmal subarachnoid haemorrhage (aSAH) has not been defined. The purpose of the study is to analyse whether early treatment and type of intervention influence the clinical outcomes of poor-grade aSAH patients.

MATERIAL AND METHODS

Patients with poor-grade aSAH were retrieved. Demographics, Fisher grade, radiological characteristics and clinical outcomes were recorded. Outcomes were compared using the modified Rankin Scale (mRS), for groups treated early within 24 hours of aSAH or later and by clipping or endovascular therapy. Multivariate multiple regression model and logistic regression were used to assess factors affecting outcomes at discharge in mRS and length of stay.

RESULTS

The study was conducted on 79 patients. 47 (59%) were treated by clipping, 38 (48%) received intervention within 24 hours of aSAH. Patients treated <24h had significantly lower mortality (n = 5; 13% vs. n = 14; 37%; p < .023), higher rate of 0-3 mRS (n = 22;58% vs. n = 9; 22%; p < .039) and were younger (49.5 ± 6.1 vs. 65.8 ± 7.4 years; p < .038). There were no significant differences in mRS between clipping and endovascular therapy. Predictors of length of stay were ICH, MLS, endovascular therapy, location in posterior circulation, Fisher grade and time to intervention <24h. Early intervention, <24h significantly influenced the favourable results in mRS (0-3); (OR 4,14; Cl95% 3.82-4.35). Posterior circulation aneurysms, midline shift and intracerebral hematoma were correlated with poor outcomes.

CONCLUSIONS

Early treatment, within 24 h, of poor-grade aSAH confirmed better clinical outcome compared to later aneurysm securement. There was no significant difference between clipping and endovascular treatment.