Intravenous fluid management of trauma patients is fraught with complex decisions that are often complicated by coagulopathy and blood loss. This review discusses the fluid management in trauma patients from the perspective of the developing world. In addition, the article describes an approach to specific circumstances in trauma fluid decision‐making and provides recommendations for the resource‐limited environment.

Background: General pathophysiological mechanisms regarding associations between fluid administration and intra-abdominal hypertension (IAH) are evident, but specific effects of type, amount, and timing of fluids are less clear. Objectives: This review aims to summarize current knowledge on associations between fluid administration and intra-abdominal pressure (IAP) and fluid management in patients at risk of intra-abdominal hypertension and abdominal compartment syndrome (ACS). Methods: We performed a structured literature search from 1950 until May 2021 to identify evidence of associations between fluid management and intra-abdominal pressure not limited to any specific study or patient population. Findings were summarized based on the following information: general concepts of fluid management, physiology of fluid movement in patients with intra-abdominal hypertension, and data on associations between fluid administration and IAH. Results: We identified three randomized controlled trials (RCTs), 38 prospective observational studies, 29 retrospective studies, 18 case reports in adults, two observational studies and 10 case reports in children, and three animal studies that addressed associations between fluid administration and IAH. Associations between fluid resuscitation and IAH were confirmed in most studies. Fluid resuscitation contributes to the development of IAH. However, patients with IAH receive more fluids to manage the effect of IAH on other organ systems, thereby causing a vicious cycle. Timing and approach to de-resuscitation are of utmost importance, but clear indicators to guide this decision-making process are lacking. In selected cases, only surgical decompression of the abdomen can stop deterioration and prevent further morbidity and mortality. Conclusions: Current evidence confirms an association between fluid resuscitation and secondary IAH, but optimal fluid management strategies for patients with IAH remain controversial.

Background: The spectrum of illness and long-term outcome of critically ill patients admitted to intensive care units (ICUs) in South Africa remains largely unknown. Objectives: This study was designed to provide data on ICU outcomes and disease burden in public sector ICUs in KwaZulu-Natal. The primary objective was to describe 30-day mortality of all patients admitted to participating sites. Secondary objectives included clinical demographics and spectrum of illness amongst these patients, and testing a template to demonstrate feasibility of such data collection. Methods: 30DOS was a multicentre, prospective, observational cohort study conducted over 30 days. An a priori decision was made to report study results separately for adults and paediatric patients. This article reports the results for adult patients. The complete 30-DOS study included 11 ICUs in six hospitals. All adult patients admitted to study ICUs were included. Patients were followed up telephonically by a research assistant. Data on patient demographics, preadmission functional scoring, injury severity scoring, co-morbidities, admission diagnosis/es, organ support, and outcome were collected. Results: A total of 228 adults were included. The majority of admissions (73.7%) occurred on an emergency basis, with 68.4% occurring in the postoperative period. Approximately half were for non-communicable disease (49.6%), followed by trauma (29.0%) and infectious disease (21.5%). There were a total of 59 (25.9%) deaths within the first 30 days after admission. In-ICU mortality was 19.7%. There were 12 (5.3%) in-hospital deaths following discharge and two (0.9%) out-of-hospital deaths. Thirty-day survival was known for 174 (76.3%) admissions with a 33.9% mortality rate. Conclusion: Overall in-ICU mortality was 19.7% with a large trauma burden in a young population. Thirty-day mortality was 33.9%. Information pertaining to patient demographics and spectrum of illness provided novel information to further the understanding of the demand placed on critical care resources within South Africa.

Introduction: Increased intra-abdominal pressure (IAP) has an important impact on morbidity and mortality in critically ill patients. The SERENNO Sentinel system (Serenno Medical, Yokne’am Illit, Israel) is a novel device that allows automatic and continuous IAP measurements. Aims: Pre-clinical validation in a bench model study comparing the new device with the gold standard method and two other continuous IAP measurement devices. Methods: IAP measurement with the novel SERENNO device (IAP_SER) was compared with the gold standard IAP_H2O (water column height) and two other automatic and continuous IAP measurement devices: IAP_CiM measured via the CiMON device (Pulsion Medical Systems, Munich, Germany) and IAP_SPIE measured using the Spiegelberg device (Spiegelberg, Hamburg, Germany), which previously received the CE mark for clinical applications. The IAP measurement was performed six times (n = 6) at each pressure value (between 0 and 35 mmHg) with different methods and the height of the water column in a bench-top phantom was used as the reference IAP for further interpretations. In addition to the quadruple comparisons, intra- and inter-observer variability of IAP measurements were also calculated. Correlation studies and Bland and Altman’s analyses were performed in addition to the concordance study. Results: The CiMON and Spiegelberg devices showed a greater dynamic range and standard deviation when recording IAP_CiM and IAP_SPIE compared with IAP_SER. In general, the maximum and minimum values of IAP recorded with each device (at each level of IAP_H2O) were significantly different from each other. However, the average values were in very good agreement. The highest correlation was observed between IAP_SER and IAP_H2O, and IAP_SER and IAP_SPIE (R = 0.99, p = 0.001 for both comparisons and intra- and inter-observer measurements). Although the CiMON and SERENNO systems were in very good agreement with each other, a slightly smaller correlation coefficient was found between them (R = 0.95, p = 0.001, and R = 0.96, p = 0.001 for intra- and inter-observer measurements, respectively). When compared to the gold standard (IAP_H2O), Bland and Altman’s analysis showed a mean difference of +0.44, −0.25, and −0.04 mmHg for the intra-observer measurements and +0.18, −0.75, and −0.58 mmHg for the inter-observer measurements for IAP_SER, IAP_CiM, and IAP_SPIE, respectively. IAP_SER showed a small positive bias (overestimation), while IAP_CiM and IAP_SPIE showed a negative bias (underestimation) when compared to IAP_H2O. Further statistical analysis showed a concordance coefficient of 100% with an excellent ability of the SERENNO system in tracking IAP_H2O changes. Conclusions: Pre-clinical validation of a new IAP monitoring device (SERENNO) showed very promising results when compared with the gold standard and other continuous techniques; however, clinical trials should be followed as the next stage of the validation process. Based on the actual research guidelines, the SERENNO system can be used interchangeably with the gold standard.

Introduction: Intra-abdominal pressure (IAP) has been recognized as an important vital sign in critically ill patients. Due to the high prevalence and incidence of intra-abdominal hypertension in surgical (trauma, burns, cardiac) and medical (sepsis, liver cirrhosis, acute kidney injury) patients, continuous IAP (CIAP) monitoring has been proposed. This research was aimed at validating a new CIAP monitoring device, the TraumaGuard from Sentinel Medical Technologies, against the gold standard (height of a water column) in an in vitro setting and performing a comparative analysis among different CIAP measurement technologies (including two intra-gastric and two intra-bladder measurement devices). A technical and clinical guideline addressing the strengths and weaknesses of each device is provided as well. Methods: Five different CIAP measurement devices (two intra-gastric and three intra-vesical), including the former CiMON, Spiegelberg, Serenno, TraumaGuard, and Accuryn, were validated against the gold standard water column pressure in a bench-top abdominal phantom. The impacts of body temperature and bladder fill volume (for the intra-vesical methods) were evaluated for each system. Subsequently, 48 h of continuous monitoring (n = 2880) on top of intermittent IAP (n = 300) readings were captured for each device. Using Pearson’s and Lin’s correlations, concordance, and Bland and Altman analyses, the accuracy, precision, percentage error, correlation and concordance coefficients, bias, and limits of agreement were calculated for all the different devices. We also performed error grid analysis on the CIAP measurements to provide an overview of the involved risk level due to wrong IAP measurements and calculated the area under the curve and time above a certain IAP threshold. Lastly, the robustness of each system in tracking the dynamic variations of the raw IAP signal due to respirations and heartbeats was evaluated as well. Results: The TraumaGuard was the only technology able to measure the IAP with an empty artificial bladder. No important temperature dependency was observed for the investigated devices except for the Spiegelberg, which displayed higher IAP values when the temperature was increased, but this could be adjusted through recalibration. All the studied devices showed excellent ability for IAP monitoring, although the intra-vesical IAP measurements seem more reliable. In general, the TraumaGuard, Accuryn, and Serenno showed better accuracy compared to intra-gastric measurement devices. On average, biases of +0.71, +0.93, +0.29, +0.25, and −0.06 mm Hg were observed for the CiMON, Spiegelberg, Serenno, TraumaGuard, and Accuryn, respectively. All of the equipment showed percentage errors smaller than 25%. Regarding the correlation and concordance coefficients, the Serenno and TraumaGuard showed the best results (R² = 0.98, p = 0.001, concordance coefficient of 99.5%). Error grid analysis based on the Abdominal Compartment Society guidelines showed a very low associated risk level of inappropriate treatment strategies due to erroneous IAP measurements. Regarding the dynamic tracings of the raw IAP signal, all the systems can track respiratory variations and derived parameters; however, the CiMON was slightly superior compared to the other technologies. Conclusions: According to the research guidelines of the Abdominal Compartment Society (WSACS), this in vitro study shows that the TraumaGuard can be used interchangeably with the gold standard for measuring continuous IAP, even in an empty artificial bladder. Confirmation studies with the TraumaGuard in animals and humans are warranted to further validate these findings.