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A neglected topic for way too long, the interest in fluid therapy seems to be quickly rising as the medical community is making a shift from looking at fluids as a mere method of stabilization towards the appreciation of its relevant side effects. Many questions remain to be answered indeed: Is the upgrade from saline 0.9% to balanced crystalloids worth the extra cost? Does HES still have a place in the OR? Do we have to fill the gap left by HES on ICU with crystalloids, other colloids or even albumin? Is it really impossible to avoid fluid overload by using only crystalloids? Is there still a definitive place for human albumin? How do we treat and monitor specific patient populations, like patients with trauma, liver failure, brain edema and right heart failure among others? How do we avoid a one-size-fits-all regimen in perioperative goal-directed therapy? What with the fluids beyond resuscitation? And what do the authors of the big fluid trials do in real life themselves? The 9th International Fluid Academy Day will again be a 1 day concise meeting on all aspects of fluid managament and hemodynamic monitoring in the critically ill. Date: October 26th 2019, 8:00 - 18:00 21. #ifad2019 how to guide deresuscitation (malbrain)

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Copyright © 2018 by Elsevier Inc. All rights reserved. Pagana: Mosby’s Manual of Diagnostic and Laboratory Tests, 6th Edition Esophageal Reflux Case Studies A 45-year-old woman complained of heartburn and frequent regurgitation of “sour” material into her mouth. Often while sleeping, she would be awakened by a severe cough. The results of her physical examination were negative. Studies Results Routine laboratory studies Negative Barium swallow (BS), p. 941 Hiatal hernia Esophageal function studies (EFS), p. 624 Lower esophageal sphincter (LES) pressure 4 mm Hg (normal: 10–20 mm Hg) Acid reflux Positive in all positions (normal: negative) Acid clearing Cleared to pH 5 after 20 swallows (normal: <10 swallows) Swallowing waves Normal amplitude and normal progression Bernstein test Positive for pain (normal: negative) Esophagogastroduodenoscopy (EGD), p. 547 Reddened, hyperemic, esophageal mucosa Gastric scan, p. 743 Reflux of gastric contents to the lungs Swallowing function, p. 1014 No aspiration during swallowing Diagnostic Analysis The barium swallow indicated a hiatal hernia. Although many patients with a hiatal hernia have no reflux, this patient’s symptoms of reflux necessitated esophageal function studies. She was found to have a hypotensive LES pressure along with severe acid reflux into her esophagus. The abnormal acid clearing and the positive Bernstein test result indicated esophagitis caused by severe reflux. The esophagitis was directly visualized during esophagoscopy. Her coughing and shortness of breath at night were caused by aspiration of gastric contents while sleeping. This was demonstrated by the gastric nuclear scan. When awake, she did not aspirate, as evident during the swallowing function study. The patient was prescribed esomeprazole (Nexium). She was told to avoid the use of tobacco and caffeine. Her diet was limited to small, frequent, bland feedings. She was instructed to sleep with the head of her bed elevated at night. Because she had only minimal relief of her symptoms after 6 weeks of medical management, she underwent a laparoscopic surgical antireflux procedure. She had no further symptoms. Critical Thinking Questions 1. Why would the patient be instructed to avoid tobacco and caffeine? 2. Why did the physician recommend 6 weeks of medical management? Case Studies Copyright © 2018 by Elsevier Inc. All rights reserved. 2 3. How do antacid medication work in patients with gastroesophageal reflux? 4. What would you approach the situation, if your patient decided not to take the medication and asked you for an alternative medicine approach? Copyright © 2018 by Elsevier Inc. All rights reserved. Pagana: Mosby’s Manual of Diagnostic and Laboratory Tests, 6th Edition Adolescent With Diabetes Mellitus (DM) Case Studies The patient, a 16-year-old high-school football player, was brought to the emergency.Copyright © 2018 by Elsevier Inc. All rights reserved. Pag.docx

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