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Nikravan S, Bughrara N, Klick J, Lanspa MJ, Rapoport L, Díaz-Gomez J. An Echocardiographic Approach for the Management of Shock: The Subcostal to Apical, Respiratory to Parasternal-Cardiac to Respiratory, Aortic to Stomach Protocol. Semin Ultrasound CT MR 2024; 45:74-83. [PMID: 38065314 DOI: 10.1053/j.sult.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/13/2024]
Abstract
Point of care ultrasound has become an integral part of critical care medicine, particularly for recognizing shock etiologies and guiding management. Most of the current ultrasonography guided shock protocols have been tailored towards a qualitative assessment of patients on presentation with shock. Unfortunately, the evolving nature of shock, particularly in the face of resuscitation and physiologic changes, demands a more sophisticated approach. This manuscript serves to present a comprehensive algorithm called the transthoracic Subcostal To Apical, Respiratory to paraSternal and transesophageal Cardiac to Respiratory, Aortic to StomacH ultrasonographic evaluations for the assessment of shock. This protocol is better suited for the critically ill patient in its ability to move beyond pattern recognition and focus on monitoring shock states from their presentation through their evolution. Not only is importance placed on the sequence of the exam, but also the identification of signs of chronic disease, the early incorporation of pulmonary evaluation, and the role for transesophageal imaging in critically ill patients with difficult surface imaging. Given the broad capabilities of bedside ultrasound, the Subcostal To Apical, Respiratory to paraSternal-Cardiac to Respiratory, Aortic to StomacH protocol serves as a multifaceted algorithm allowing for a nuanced and dynamic approach for the resuscitation of critically ill patients in shock.
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Affiliation(s)
| | | | - John Klick
- University of Vermont Medical Center, Burlington, VT
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White KC, Nasser A, Gatton ML, Laupland KB. Current management of fluid balance in critically ill patients with acute kidney injury: A scoping review. CRIT CARE RESUSC 2023; 25:126-135. [PMID: 37876369 PMCID: PMC10581269 DOI: 10.1016/j.ccrj.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Abstract
Objective The overall objective of this scoping review is to assess the extent of the literature related to the fluid management of critically ill patients with acute kidney injury (AKI). Introduction AKI is common in critically ill patients where fluid therapy is a mainstay of treatment. An association between fluid balance (FB) and adverse patient-centred outcomes in critically ill patients with AKI regardless of severity has been demonstrated. The evidence for the prospective intervention of FB and its impact on outcomes is unknown. Inclusion criteria All studies investigating FB in patients with AKI admitted to an intensive care unit were included. Literature not related to FB in the critically ill patient with AKI population was excluded. Methods We searched MEDLINE, EMBASE, and CINAHL from January 1st, 2012, onwards. We included primary research studies, experimental and observational, recruiting adult participants admitted to an intensive care unit who had an AKI. We extracted data on study and patient characteristics, as well as FB, renal-based outcomes, and patient-centred outcomes. Two reviewers independently screened citations for eligible studies and performed data extraction. Results Of the 13,767 studies reviewed, 22 met the inclusion criteria. Two studies examined manipulation of fluid input, 18 studies assessed enhancing fluid removal, and two studies applied a restrictive fluid protocol. Sixteen studies examined patients receiving renal replacement therapy, five studies included non-renal replacement therapy patients, and one study included both. Current evidence is broad with varied approaches to managing fluid input and fluid removal. The studies did not demonstrate a consensus approach for any aspect of the fluid management of critically ill patients. There was a limited application of a restrictive fluid protocol with no conclusions possible. Conclusions The current body of evidence for the management of FB in critically ill patients with AKI is limited in nature. The current quality of evidence is unable to guide current clinical practice. The key outcome of this review is to highlight areas for future research.
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Affiliation(s)
- Kyle C. White
- Intensive Care Unit, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
- Faculty of Health, Queensland University of Technology (QUT), Brisbane, Queensland, Australia
- Intensive Care Unit, Queen Elizabeth II Jubilee Hospital, Coopers Plains, Queensland, Australia
| | - Ahmad Nasser
- Intensive Care Unit, Queen Elizabeth II Jubilee Hospital, Coopers Plains, Queensland, Australia
- Faculty of Medicine, University of Queensland, Herston, Queensland, Australia
| | - Michelle L. Gatton
- Faculty of Health, Queensland University of Technology (QUT), Brisbane, Queensland, Australia
| | - Kevin B. Laupland
- Faculty of Health, Queensland University of Technology (QUT), Brisbane, Queensland, Australia
- Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
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Messmer AS, Dill T, Müller M, Pfortmueller CA. Active fluid de-resuscitation in critically ill patients with septic shock: A systematic review and meta-analysis. Eur J Intern Med 2023; 109:89-96. [PMID: 36635127 DOI: 10.1016/j.ejim.2023.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 01/01/2023] [Accepted: 01/05/2023] [Indexed: 01/12/2023]
Abstract
PURPOSE To evaluate the impact of active fluid de-resuscitation on mortality in critically ill patients with septic shock. METHODS A systematic search was performed on PubMed, EmBase, and the Cochrane Library databases. Trials investigating active fluid de-resuscitation and reporting data on mortality in patients with septic shock were eligible. The primary objective was the impact of active de-resuscitation in patients with septic shock on short-term mortality. Secondary outcomes were whether de-resuscitation lead to a fluid separation, and the impact of de-resuscitation on patient-centred outcomes. RESULTS Thirteen trials (8,030 patients) were included in the systematic review, whereof 5 randomised-controlled trials (RCTs) were included in the meta-analysis. None of the RCTs showed a reduction in mortality with active de-resuscitation measures (relative risk (RR) 1.12 [95%-CI 0.84 - 1.48]). Fluid separation was achieved by two RCTs. Evidence from non-randomised trials suggests a mortality benefit with de-resuscitation strategies and indicates a trend towards a more negative fluid balance. Patient-centred outcomes were not influenced in the RCTs, and only one non-randomised trial revealed an impact on the duration of mechanical ventilation and renal replacement requirement (RRT). CONCLUSION We found no evidence for superiority of active fluid de-resuscitation compared to usual care regarding mortality, fluid balance or patient-centred outcomes in patients with septic shock. Current evidence is limited by the lack of high-quality RCTs in patients with septic shock, the small sample sizes and the heterogeneity of the applied de-resuscitation techniques. In addition, validity of the majority of RCTs is compromised by their inability to achieve fluid separation.
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Affiliation(s)
- Anna S Messmer
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Tatjana Dill
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Martin Müller
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Carmen A Pfortmueller
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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Sepsis-associated acute kidney injury: consensus report of the 28th Acute Disease Quality Initiative workgroup. Nat Rev Nephrol 2023; 19:401-417. [PMID: 36823168 DOI: 10.1038/s41581-023-00683-3] [Citation(s) in RCA: 58] [Impact Index Per Article: 58.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2023] [Indexed: 02/25/2023]
Abstract
Sepsis-associated acute kidney injury (SA-AKI) is common in critically ill patients and is strongly associated with adverse outcomes, including an increased risk of chronic kidney disease, cardiovascular events and death. The pathophysiology of SA-AKI remains elusive, although microcirculatory dysfunction, cellular metabolic reprogramming and dysregulated inflammatory responses have been implicated in preclinical studies. SA-AKI is best defined as the occurrence of AKI within 7 days of sepsis onset (diagnosed according to Kidney Disease Improving Global Outcome criteria and Sepsis 3 criteria, respectively). Improving outcomes in SA-AKI is challenging, as patients can present with either clinical or subclinical AKI. Early identification of patients at risk of AKI, or at risk of progressing to severe and/or persistent AKI, is crucial to the timely initiation of adequate supportive measures, including limiting further insults to the kidney. Accordingly, the discovery of biomarkers associated with AKI that can aid in early diagnosis is an area of intensive investigation. Additionally, high-quality evidence on best-practice care of patients with AKI, sepsis and SA-AKI has continued to accrue. Although specific therapeutic options are limited, several clinical trials have evaluated the use of care bundles and extracorporeal techniques as potential therapeutic approaches. Here we provide graded recommendations for managing SA-AKI and highlight priorities for future research.
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Ruste M, Sghaier R, Chesnel D, Didier L, Fellahi JL, Jacquet-Lagrèze M. Perfusion-based deresuscitation during continuous renal replacement therapy: A before-after pilot study (The early dry Cohort). J Crit Care 2022; 72:154169. [PMID: 36201978 DOI: 10.1016/j.jcrc.2022.154169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 09/15/2022] [Accepted: 09/25/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Active fluid removal has been suggested to improve prognosis following the resolution of acute circulatory failure. We have implemented a routine care protocol to guide fluid removal during continuous renal replacement therapy (CRRT). We designed a before-after pilot study to evaluate the impact of this deresuscitation strategy on the fluid balance. METHODS Consecutive ICU patients suffering from fluid overload and undergoing CRRT for acute kidney injury underwent a perfusion-based deresuscitation protocol combining a restrictive intake, net ultrafiltration (UFnet) of 2 mL/kg/h, and monitoring of perfusion (early dry group, N = 42) and were compared to a historical group managed according to usual practices (control group, N = 45). The primary outcome was the cumulative fluid balance at day 5 or at discharge. RESULTS Adjusted cumulative fluid balance was significantly lower in the early dry group (median [IQR]: -7784 [-11,833 to -2933] mL) compared to the control group (-3492 [-9935 to -1736] mL; p = 0.04). The difference was mainly driven by a greater daily UFnet (31 [22-46] mL/kg/day vs. 24 [15-32] mL/kg/day; p = 0.01). There was no significant difference between both groups regarding hemodynamic tolerance. CONCLUSION Our perfusion-based deresuscitation protocol achieved a greater negative cumulative fluid balance compared to standard practices and was hemodynamically well tolerated.
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Affiliation(s)
- Martin Ruste
- Service d'anesthésie-réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, 59, Boulevard Pinel, 69677 Bron Cedex, France; Faculté de médecine Lyon Est, Université Claude Bernard Lyon 1, 8, Avenue Rockefeller, 69373 Lyon, Cedex 08, France.
| | - Raouf Sghaier
- Service d'anesthésie-réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, 59, Boulevard Pinel, 69677 Bron Cedex, France
| | - Delphine Chesnel
- Service d'anesthésie-réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, 59, Boulevard Pinel, 69677 Bron Cedex, France; Faculté de médecine Lyon Sud, Université Claude Bernard Lyon 1, 165, chemin du Petit Revoyet, 69921 Oullins, France
| | - Léa Didier
- Service d'anesthésie-réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, 59, Boulevard Pinel, 69677 Bron Cedex, France; Faculté de médecine Lyon Est, Université Claude Bernard Lyon 1, 8, Avenue Rockefeller, 69373 Lyon, Cedex 08, France
| | - Jean-Luc Fellahi
- Service d'anesthésie-réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, 59, Boulevard Pinel, 69677 Bron Cedex, France; Faculté de médecine Lyon Est, Université Claude Bernard Lyon 1, 8, Avenue Rockefeller, 69373 Lyon, Cedex 08, France; Laboratoire CarMeN, Inserm UMR 1060, Université Claude Bernard Lyon 1, Lyon, France
| | - Matthias Jacquet-Lagrèze
- Service d'anesthésie-réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, 59, Boulevard Pinel, 69677 Bron Cedex, France; Faculté de médecine Lyon Est, Université Claude Bernard Lyon 1, 8, Avenue Rockefeller, 69373 Lyon, Cedex 08, France; Laboratoire CarMeN, Inserm UMR 1060, Université Claude Bernard Lyon 1, Lyon, France
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Wichmann S, Barbateskovic M, Liang N, Itenov TS, Berthelsen RE, Lindschou J, Perner A, Gluud C, Bestle MH. Loop diuretics in adult intensive care patients with fluid overload: a systematic review of randomised clinical trials with meta-analysis and trial sequential analysis. Ann Intensive Care 2022; 12:52. [PMID: 35696008 PMCID: PMC9192894 DOI: 10.1186/s13613-022-01024-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 05/12/2022] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Fluid overload is a risk factor for organ dysfunction and death in intensive care unit (ICU) patients, but no guidelines exist for its management. We systematically reviewed benefits and harms of a single loop diuretic, the predominant treatment used for fluid overload in these patients. METHODS We conducted a systematic review with meta-analysis and Trial Sequential Analysis (TSA) of a single loop diuretic vs. other interventions reported in randomised clinical trials, adhering to our published protocol, the Cochrane Handbook, and PRISMA statement. We assessed the risks of bias with the ROB2-tool and certainty of evidence with GRADE. This study was registered in the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42020184799). RESULTS We included 10 trials (804 participants), all at overall high risk of bias. For loop diuretics vs. placebo/no intervention, we found no difference in all-cause mortality (relative risk (RR) 0.72, 95% confidence interval (CI) 0.49-1.06; 4 trials; 359 participants; I2 = 0%; TSA-adjusted CI 0.15-3.48; very low certainty of evidence). Fewer serious adverse events were registered in the group treated with loop diuretics (RR 0.81, 95% CI 0.66-0.99; 6 trials; 476 participants; I2 = 0%; very low certainty of evidence), though contested by TSA (TSA-adjusted CI 0.55-1.20). CONCLUSIONS The evidence is very uncertain about the effect of loop diuretics on mortality and serious adverse events in adult ICU patients with fluid overload. Loop diuretics may reduce the occurrence of these outcomes, but large randomised placebo-controlled trials at low risk of bias are needed.
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Affiliation(s)
- Sine Wichmann
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Dyrehavevej 29, 3400, Hillerød, Denmark.
| | - Marija Barbateskovic
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital-Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Ning Liang
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, 16 Nanxiaojie, Dongzhimen, Beijing, 100700, China
| | - Theis Skovsgaard Itenov
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Dyrehavevej 29, 3400, Hillerød, Denmark
| | - Rasmus Ehrenfried Berthelsen
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Dyrehavevej 29, 3400, Hillerød, Denmark
| | - Jane Lindschou
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital-Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital-Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Campusvej 55, 5230, Odense, Denmark
| | - Morten Heiberg Bestle
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Dyrehavevej 29, 3400, Hillerød, Denmark
- Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen, Denmark
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Restrictive fluid management versus usual care in acute kidney injury (REVERSE-AKI): a pilot randomized controlled feasibility trial. Intensive Care Med 2021; 47:665-673. [PMID: 33961058 PMCID: PMC8195764 DOI: 10.1007/s00134-021-06401-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 04/01/2021] [Indexed: 12/21/2022]
Abstract
Purpose We compared a restrictive fluid management strategy to usual care among critically ill patients with acute kidney injury (AKI) who had received initial fluid resuscitation. Methods This multicenter feasibility trial randomized 100 AKI patients 1:1 in seven ICUs in Europe and Australia. Restrictive fluid management included targeting negative or neutral daily fluid balance by minimizing fluid input and/or enhancing urine output with diuretics administered at the discretion of the clinician. Fluid boluses were administered as clinically indicated. The primary endpoint was cumulative fluid balance 72 h from randomization. Results Mean (SD) cumulative fluid balance at 72 h from randomization was − 1080 mL (2003 mL) in the restrictive fluid management arm and 61 mL (3131 mL) in the usual care arm, mean difference (95% CI) − 1148 mL (− 2200 to − 96) mL, P = 0.033. Median [IQR] duration of AKI was 2 [1–3] and 3 [2–7] days, respectively (median difference − 1.0 [− 3.0 to 0.0], P = 0.071). Altogether, 6 out of 46 (13%) patients in the restrictive fluid management arm and 15 out of 50 (30%) in the usual care arm received renal replacement therapy (RR 0.42; 95% CI 0.16–0.91), P = 0.043. Cumulative fluid balance at 24 h and 7 days was lower in the restrictive fluid management arm. The dose of diuretics was not different between the groups. Adverse events occurred more frequently in the usual care arm. Conclusions In critically ill patients with AKI, a restrictive fluid management regimen resulted in lower cumulative fluid balance and less adverse events compared to usual care. Larger trials of this intervention are justified. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-021-06401-6.
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Cinotti R, Lascarrou JB, Azais MA, Colin G, Quenot JP, Mahé PJ, Roquilly A, Gaultier A, Asehnoune K, Reignier J. Diuretics decrease fluid balance in patients on invasive mechanical ventilation: the randomized-controlled single blind, IRIHS study. Crit Care 2021; 25:98. [PMID: 33691730 PMCID: PMC7943707 DOI: 10.1186/s13054-021-03509-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 02/16/2021] [Indexed: 01/09/2023] Open
Abstract
Background Fluid overload has been associated with increased morbidity and mortality in critically ill patients. The goal of this study was to assess the efficacy and safety of a diuretic strategy to overcome positive fluid balance in patients on invasive mechanical ventilation.
Methods Design: Multicenter, single-blind, randomized-controlled study. Patients were randomized into a diuretic (furosemide) or a control group. Patients were eligible in case of fluid overload defined as in-ICU weight increase ≥ 3%, invasive mechanical ventilation (FiO2 ≤ 60% and PEEP ≤ 10 cm H2O on inclusion) and hemodynamic stabilization. The primary outcome was fluid balance, defined as weight variation from reference weight to successful extubation. The main secondary outcome was the safety of diuretic. Results 171 patients were randomized. After 5 exclusions, 166 patients were included in the analysis: 77 in the diuretic and 89 in the control group. Fluid balance was 1.4 [− 2.5 to 4.5] kg in the diuretic and 6.4 [0.5–11.2] kg in the control group (p < 0.001). In the multiple imputation analysis, fluid balance was significantly decreased in the diuretic group (mean difference = − 4.8 95% CI [− 7.3 to − 2.5], p < 0.001). Eleven (14%) patients died in the diuretic group and 16 (18%) patients in the control group (p = 0.5). There was a worsening of Acute Kidney Injury in 67 (75.3%) patients of the control group versus 46 (59.7%) patients in the diuretic group (p = 0.03). Conclusions In this multicenter randomized-controlled study, protocolized diuretic therapy reduced fluid accumulation in patients receiving mechanical ventilation and was well tolerated with a favorable safety profile. Trial registration NCT 02345681, Registered January 26 2015, Prospectively registered, https://clinicaltrials.gov/ct2/show/NCT02345681?term=02345681&draw=2&rank=1. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03509-5.
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Affiliation(s)
- Raphaël Cinotti
- CHU Nantes, Pôle Anesthésie-Réanimation, Service d'Anesthésie Réanimation Chirurgicale, Hôpital Guillaume et René Laennec, Université de Nantes, 44800, Saint-Herblain, France
| | - Jean-Baptiste Lascarrou
- Médecine Intensive et Réanimation, Hôtel Dieu, University Hospital of Nantes, 1 place Alexis Ricordeau, 44093, Nantes, France
| | - Marie-Ange Azais
- Médecine Intensive et Réanimation, Centre Hospitalier Départemental de la Vendée, La Roche-sur-Yon, France
| | - Gwenhaël Colin
- Médecine Intensive et Réanimation, Centre Hospitalier Départemental de la Vendée, La Roche-sur-Yon, France
| | - Jean-Pierre Quenot
- Service de Médecine Intensive-Réanimation, CHU Dijon-Bourgogne, Dijon, France.,Equipe Lipness, Centre de Recherche INSERM UMR1231 et LabEx LipSTIC, Université de Bourgogne-Franche Comté, Dijon, France.,INSERM, CIC 1432, Module Épidémiologie Clinique, Université de Bourgogne-Franche Comté, Dijon, France
| | - Pierre-Joachim Mahé
- CHU Nantes, Pôle Anesthésie-Réanimation, Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu, Université de Nantes, 44093, Nantes, France
| | - Antoine Roquilly
- CHU Nantes, Pôle Anesthésie-Réanimation, Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu, Université de Nantes, 44093, Nantes, France.,Laboratoire UPRES EA 3826 «Thérapeutiques cliniques et expérimentales des infections», University Hospital of Nantes, 1 rue Gaston Veil, 44035, Nantes Cedex 1, France
| | - Aurélie Gaultier
- Direction de la recherche, Plateforme de Méthodologie et Biostatistique, CHU de Nantes, Nantes, France
| | - Karim Asehnoune
- CHU Nantes, Pôle Anesthésie-Réanimation, Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu, Université de Nantes, 44093, Nantes, France. .,Laboratoire UPRES EA 3826 «Thérapeutiques cliniques et expérimentales des infections», University Hospital of Nantes, 1 rue Gaston Veil, 44035, Nantes Cedex 1, France.
| | - Jean Reignier
- Médecine Intensive et Réanimation, Hôtel Dieu, University Hospital of Nantes, 1 place Alexis Ricordeau, 44093, Nantes, France.
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A randomized trial of albumin infusion to prevent intradialytic hypotension in hospitalized hypoalbuminemic patients. Crit Care 2021; 25:18. [PMID: 33407747 PMCID: PMC7789619 DOI: 10.1186/s13054-020-03441-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 12/16/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Intradialytic hypotension (IDH) is a frequent complication of intermittent hemodialysis (IHD), occurring from 15 to 50% of ambulatory sessions, and is more frequent among hospitalized patients with hypoalbuminemia. IDH limits adequate fluid removal and increases the risk for vascular access thrombosis, early hemodialysis (HD) termination, and mortality. Albumin infusion before and during therapy has been used for treating IDH with the varying results. We evaluated the efficacy of albumin infusion in preventing IDH during IHD in hypoalbuminemic inpatients. METHODS A randomized, crossover trial was performed in 65 AKI or ESKD patients with hypoalbuminemia (albumin < 3 g/dl) who required HD during hospitalization. Patients were randomized to receive 100 ml of either 0.9%sodium chloride or 25% albumin intravenously at the initiation of each dialysis. These two solutions were alternated for up to six sessions. Patients' vital signs and ultrafiltration removal rate were recorded every 15 to 30 min during dialysis. IDH was assessed by different definitions reported in the literature. All symptoms associated with a noted hypotensive event as well as interventions during the dialysis were recorded. RESULTS Sixty-five patients were submitted to 249 sessions; the mean age was 58 ([Formula: see text] 12), and 46 (70%) were male with a mean weight of 76 ([Formula: see text] 18) kg. The presence of IDH was lower during albumin sessions based on all definitions. The hypotension risk was significantly decreased based on the Kidney Disease Outcomes Quality Initiative definition; (15% with NS vs. 7% with albumin, p = 0.002). The lowest intradialytic SBP was significantly worse in patients who received 0.9% sodium chloride than albumin (NS 83 vs. albumin 90 mmHg, p = 0.035). Overall ultrafiltration rate was significantly higher in the albumin therapies [NS - 8.25 ml/kg/h (- 11.18 5.80) vs. 8.27 ml/kg/h (- 12.22 to 5.53) with albumin, p = 0.011]. CONCLUSION In hypoalbuminemic patients who need HD, albumin administration before the dialysis results in fewer episodes of hypotension and improves fluid removal. Albumin infusion may be of benefit to improve the safety of HD and achievement of fluid balance in these high-risk patients. ClinicalTrials.gov Identifier: NCT04522635.
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10
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Wiedermann CJ. Phases of fluid management and the roles of human albumin solution in perioperative and critically ill patients. Curr Med Res Opin 2020; 36:1961-1973. [PMID: 33090028 DOI: 10.1080/03007995.2020.1840970] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Positive fluid balance is common among critically ill patients and leads to worse outcomes, particularly in sepsis, acute respiratory distress syndrome, and acute kidney injury. Restrictive fluid infusion and active removal of accumulated fluid are being studied as approaches to prevent and treat fluid overload. Use of human albumin solutions has been investigated in different phases of restrictive fluid resuscitation, and this narrative literature review was undertaken to evaluate hypoalbuminemia and the roles of human serum albumin with respect to hypovolemia and its management. METHODS PubMed/EMBASE search terms were: "resuscitation," "fluids," "fluid therapy," "fluid balance," "plasma volume," "colloids," "crystalloids," "albumin," "hypoalbuminemia," "starch," "saline," "balanced salt solution," "gelatin," "goal-directed therapy" (English-language, pre-January 2020). Additional papers were identified by manual searching of reference lists. RESULTS Restrictive fluid administration, plus early vasopressor use, may reduce fluid balance, but in some cases fluid overload cannot be entirely avoided. Deresuscitation, with fluid actively removed through diuretics or ultrafiltration, reduces duration of mechanical ventilation and intensive care unit stay. Combining hyperoncotic human albumin solution with diuretics increases hemodynamic stability and diuresis. Hyperoncotic albumin corrects hypoalbuminemia and raises colloid osmotic pressure, limiting edema formation and potentially improving endothelial function. Serum levels of albumin relative to C-reactive protein and lactate may predict which patients will benefit most from albumin therapy. CONCLUSIONS Hyperoncotic human albumin solution facilitates restrictive fluid therapy and the effectiveness of deresuscitative measures. Current evidence is mostly from observational studies, and more randomized trials are needed to better establish a personalized approach to fluid management.
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Affiliation(s)
- Christian J Wiedermann
- Institute of Public Health, Medical Decision Making and HTA, University of Health Sciences, Medical Informatics and Technology, Hall (Tyrol), Austria
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11
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Honore PM, Barreto Gutierrez L, Kugener L, Redant S, Attou R, Gallerani A, De Bels D. A retrospective study in adult patients with septic shock and multiple organ failure demonstrated improved 28-day survival with adjunct TPE compared to standard care alone: true effect or mediated by a negative fluid balance achieved by RRT? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:602. [PMID: 33032656 PMCID: PMC7545928 DOI: 10.1186/s13054-020-03315-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Accepted: 09/30/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Patrick M Honore
- ICU Department, Centre Hospitalier Universitaire Brugmann-Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium.
| | - Leonel Barreto Gutierrez
- ICU Department, Centre Hospitalier Universitaire Brugmann-Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
| | - Luc Kugener
- ICU Department, Centre Hospitalier Universitaire Brugmann-Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
| | - Sebastien Redant
- ICU Department, Centre Hospitalier Universitaire Brugmann-Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
| | - Rachid Attou
- ICU Department, Centre Hospitalier Universitaire Brugmann-Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
| | - Andrea Gallerani
- ICU Department, Centre Hospitalier Universitaire Brugmann-Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
| | - David De Bels
- ICU Department, Centre Hospitalier Universitaire Brugmann-Brugmann University Hospital, Place Van Gehuchtenplein, 4, 1020, Brussels, Belgium
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12
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Bissell BD, Donaldson JC, Morris PE, Neyra JA. A narrative review of pharmacologic de-resuscitation in the critically ill. J Crit Care 2020; 59:156-162. [PMID: 32674002 DOI: 10.1016/j.jcrc.2020.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 06/28/2020] [Accepted: 07/03/2020] [Indexed: 02/06/2023]
Abstract
Despite evidence highlighting harms of fluid overload, minimal guidance exists on counteraction via utilization of diuretics in the de-resuscitation phase. While diuretics have been shown to decrease net volume and improve clinical outcomes in the critically ill, a lack of standardization surrounding selection of diuretic regimen or monitoring of de-resuscitation exists. Current monitoring parameters of de-resuscitation often rely on clinical signs of fluid overload, end organ recovery and other biochemical surrogate markers which are often deemed unreliable. The majority of evidence suggests that achieving a net-negative fluid balance within 72 h after shock resolution may be of benefit; however, approaches to such goal are uncertain. Loop diuretics are a widely available type of diuretic for removal of volume in patients with sufficient kidney function, with the potential for adjunct diuretics in special circumstances. At present, administration of diuretics within the broad critically ill population fails to find uniformity and often efficacy. Given the lack of randomized controlled trials in this susceptible population, we aim to provide a thorough therapeutic understanding of diuretic pharmacotherapy which is necessary in order to achieve desired goal of fluid balance and improve overall outcomes.
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Affiliation(s)
- Brittany D Bissell
- University of Kentucky College of Medicine, Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, 740 South Limestone, Lexington, Kentucky 40536, United States of America; University of Kentucky College of Pharmacy, Department of Pharmacy Practice and Science, 789 South Limestone, Lexington, Kentucky 40536, United States of America.
| | - J Chris Donaldson
- University of Kentucky College of Pharmacy, Department of Pharmacy Practice and Science, 789 South Limestone, Lexington, Kentucky 40536, United States of America.
| | - Peter E Morris
- University of Kentucky College of Medicine, Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, 740 South Limestone, Lexington, Kentucky 40536, United States of America.
| | - Javier A Neyra
- University of Kentucky College of Medicine, Department of Internal Medicine, Division of Nephrology, Bone and Mineral Metabolism, 740 South Limestone, Lexington, Kentucky 40536, United States of America.
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Abstract
PURPOSE OF REVIEW Continuous renal replacement therapy (CRRT) is now the mainstay of renal organ support in the critically ill. As our understanding of CRRT delivery and its impact on patient outcomes improves there is a focus on researching the potential benefits of tailored, patient-specific treatments to meet dynamic needs. RECENT FINDINGS The most up-to-date studies investigating aspects of CRRT prescription that can be individualized: CRRT dose, timing, fluid management, membrane selection, anticoagulation and vascular access are reviewed. The use of different doses of CRRT lack conventional high-quality evidence and importantly studies reveal variation in assessment of dose delivery. Research reveals conflicting evidence for clinicians in distinguishing which patients will benefit from 'watchful waiting' vs. early initiation of CRRT. Both dynamic CRRT dosing and precision fluid management using CRRT are difficult to investigate and currently only observational data supports individualization of prescriptions. Similarly, individualization of membrane choice is largely experimental. SUMMARY Clinicians have limited evidence to individualize the prescription of CRRT. To develop this, we need to understand the requirements for renal support for individual patients, such as electrolyte imbalance, fluid overload or clearance of systemic inflammatory mediators to allow us to target these abnormalities in appropriately designed randomized trials.
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Perner A, Hjortrup PB, Arabi Y. Focus on fluid therapy in critically ill patients. Intensive Care Med 2019; 45:1469-1471. [PMID: 31346676 DOI: 10.1007/s00134-019-05703-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 07/17/2019] [Indexed: 12/29/2022]
Affiliation(s)
- Anders Perner
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
| | - Peter B Hjortrup
- Department of Anaesthesia and Intensive Care, Zealand University Hospital, Køge, Denmark
| | - Yaseen Arabi
- King Abdullah International Medical Research Center and Intensive Care Department, King Abdulaziz Medical City, College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Kingdom of Saudi Arabia
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15
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Krzych ŁJ, Czempik PF. Impact of furosemide on mortality and the requirement for renal replacement therapy in acute kidney injury: a systematic review and meta-analysis of randomised trials. Ann Intensive Care 2019; 9:85. [PMID: 31342205 PMCID: PMC6656832 DOI: 10.1186/s13613-019-0557-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 07/12/2019] [Indexed: 01/08/2023] Open
Abstract
Objective To examine the impact of furosemide on mortality and the need for renal replacement therapy (RRT) in adult patients with acute kidney injury (AKI) based on current evidence. Data sources PubMed (Medline) and Embase were searched from 1998 to October 2018. Study selection We retrieved data from randomised controlled trials comparing prevention/treatment with furosemide at any stage of AKI with alternative treatment/standard of care/placebo. The outcome was short-term mortality and the requirement for RRT, when applicable. Data extraction Two reviewers independently extracted appropriate data. PRISMA guidelines were followed for data preparation and reporting. Data synthesis We identified 20 relevant studies (2608 patients: 1330 in the treatment arm and 1278 in the control arm). Heterogeneity between studies was deemed acceptable, and the publication bias was low. Furosemide had neither an impact on mortality (OR = 1.015; 95% CI 0.825–1.339) nor the need for RRT (OR = 0.947; 95% CI 0.521–1.721). Furosemide had also no effect on the outcomes in strata defined by intervention strategy (prevention/treatment), AKI origin (cardio-renal syndrome, post-cardiopulmonary bypass, critical illness), control arm comparator (RRT, saline/placebo/standard of care) and its dose (< 160/≥ 160 mg) (p > 0.05 for all). Subjects who received furosemide with matched hydration in prevention of contrast-induced nephropathy (CIN) had a less frequent need for RRT (OR = 0.218; 95% CI 0.05–1.04; p = 0.055). Conclusions Furosemide administration has neither an impact on mortality nor the requirement for RRT. Patients at risk of CIN may benefit from furosemide administration. Further well-designed RCTs are needed to verify these findings. Electronic supplementary material The online version of this article (10.1186/s13613-019-0557-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Łukasz J Krzych
- Department of Anaesthesiology and Intensive Care, School of Medicine in Katowice, Medical University of Silesia, 14 Medyków, 40-752, Katowice, Poland
| | - Piotr F Czempik
- Department of Anaesthesiology and Intensive Care, School of Medicine in Katowice, Medical University of Silesia, 14 Medyków, 40-752, Katowice, Poland.
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16
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Renal Replacement Therapy in Critical Care: When to Start? CURRENT ANESTHESIOLOGY REPORTS 2019. [DOI: 10.1007/s40140-019-00325-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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17
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Colbert GB, Szerlip HM. Euvolemia-A critical target in the management of acute kidney injury. Semin Dial 2018; 32:30-34. [PMID: 30412310 DOI: 10.1111/sdi.12753] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
It has been clearly established that critically ill patients with sepsis require prompt fluid resuscitation. The optimal amount of fluid and when to taper this resuscitation is less clear. There is a growing evidence that fluid overload leads to acute kidney injury, and increased morbidity and mortality. A clinician's best intentions in resuscitating a patient can lead to too much of a good thing. Currently, there are several bedside tools to aid in determining a patient's response to a fluid challenge as well as in the assessment of the current volume status. Guidelines are not available on the exact rate of fluid overload removal and what medicinal or mechanical modality is most favorable. We discuss our experience and an examination of the literature on the problems with fluid overload, and how a patient may benefit from forced fluid removal.
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Affiliation(s)
- Gates B Colbert
- Department of Medicine, Division of Nephrology, Baylor University Medical Center at Dallas, Dallas, Texas
| | - Harold M Szerlip
- Department of Medicine, Division of Nephrology, Baylor University Medical Center at Dallas, Dallas, Texas
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18
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Vaara ST, Reinikainen M, Bouchard J. Fluid accumulation in acute kidney injury: More evidence toward harm and current challenges. Acta Anaesthesiol Scand 2018; 62:739-741. [PMID: 29864215 DOI: 10.1111/aas.13142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- S T Vaara
- Division of Intensive Care Medicine, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - M Reinikainen
- Department of Intensive Care, North Karelia Central Hospital, Joensuu, Finland
| | - J Bouchard
- Division of Nephrology, Department of Medicine, Sacré-Coeur Hospital, University of Montreal, Montreal, Quebec, Canada
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