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Mansouri A, Buzzi M, Gibot S, Charpentier C, Schneider F, Louis G, Outin H, Monnier A, Quenot JP, Badie J, Argaud L, Bruel C, Soudant M, Agrinier N. Fluid balance control in critically ill patients: results from as-treated analyses of POINCARE-2 randomized trial. Crit Care 2023; 27:426. [PMID: 37932787 PMCID: PMC10626740 DOI: 10.1186/s13054-023-04701-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 10/22/2023] [Indexed: 11/08/2023] Open
Abstract
BACKGROUND Intention-to-treat analyses of POINCARE-2 trial led to inconclusive results regarding the effect of a conservative fluid balance strategy on mortality in critically ill patients. The present as-treated analysis aimed to assess the effectiveness of actual exposure to POINCARE-2 strategy on 60-day mortality in critically ill patients. METHODS POINCARE‑2 was a stepped wedge randomized controlled trial. Eligible patients were ≥ 18 years old, under mechanical ventilation and had an expected length of stay in ICU > 24 h. POINCARE-2 strategy consisted of daily weighing over 14 days, and subsequent restriction of fluid intake, administration of diuretics, and/or ultrafiltration. We computed a score of exposure to the strategy based on deviations from the strategy algorithm. We considered patients with a score ≥ 75 as exposed to the strategy. We used logistic regression adjusted for confounders (ALR) or for an instrumental variable (IVLR). We handled missing data using multiple imputations. RESULTS A total of 1361 patients were included. Overall, 24.8% of patients in the control group and 69.4% of patients in the strategy group had a score of exposure ≥ 75. Exposure to the POINCARE-2 strategy was not associated with 60-day all-cause mortality (ALR: OR 1.2, 95% CI 0.85-1.55; IVLR: OR 1.0, 95% CI 0.76-1.33). CONCLUSION Actual exposure to POINCARE-2 conservative strategy was not associated with reduced mortality in critically ill patients. Trial registration POINCARE-2 trial is registered at ClinicalTrials.gov (NCT02765009). Registered 29 April 2016.
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Affiliation(s)
- Adil Mansouri
- CHRU Nancy Hôpitaux de Brabois, INSERM, CIC, Epidémiologie Clinique, Université de Lorraine, 9 Allée du Morvan, 54000, Vandœuvre-lès-Nancy, Nancy, France
| | - Marie Buzzi
- CHRU Nancy Hôpitaux de Brabois, INSERM, CIC, Epidémiologie Clinique, Université de Lorraine, 9 Allée du Morvan, 54000, Vandœuvre-lès-Nancy, Nancy, France.
- APEMAC, Université de Lorraine, 54500, Nancy, France.
| | - Sébastien Gibot
- Service de Réanimation Médicale, CHRU Nancy, Université de Lorraine, 54000, Nancy, France
| | - Claire Charpentier
- Service d'Anesthésie Réanimation Chirurgicale, CHRU Nancy, Université de Lorraine, 54000, Nancy, France
| | - Francis Schneider
- Service de Médecine Intensive-Réanimation, CHU Strasbourg, INSERM U 1121, Hôpital de Hautepierre, 67000, Strasbourg, France
| | - Guillaume Louis
- Service de Réanimation Polyvalente, CHR Metz-Thionville, 57000, Metz, France
| | - Hervé Outin
- Service de Réanimation, CHI Poissy Saint-Germain, 78303, Poissy, France
| | - Alexandra Monnier
- Service de Médecine Intensive-Réanimation Médicale, Nouvel Hôpital Civil, CHU Strasbourg, Université de Strasbourg, 67000, Strasbourg, France
| | - Jean-Pierre Quenot
- Service de Médecine Intensive-Réanimation, CHU Dijon-Bourgogne, 21000, Dijon, France
| | - Julio Badie
- Service de Réanimation Médicale, Hôpital Nord Franche-Comté, 90015, Belfort, France
| | - Laurent Argaud
- Service de Réanimation Médicale, Hospices Civils de Lyon, Hôpital Edouard Herriot, 69000, Lyon, France
| | - Cédric Bruel
- Service de Réanimation Polyvalente, Groupe Hospitalier Paris Saint-Joseph, 75000, Paris, France
| | - Marc Soudant
- CHRU Nancy Hôpitaux de Brabois, INSERM, CIC, Epidémiologie Clinique, Université de Lorraine, 9 Allée du Morvan, 54000, Vandœuvre-lès-Nancy, Nancy, France
| | - Nelly Agrinier
- CHRU Nancy Hôpitaux de Brabois, INSERM, CIC, Epidémiologie Clinique, Université de Lorraine, 9 Allée du Morvan, 54000, Vandœuvre-lès-Nancy, Nancy, France
- APEMAC, Université de Lorraine, 54500, Nancy, France
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Silversides JA, Major E, Ferguson AJ, Mann EE, McAuley DF, Marshall JC, Blackwood B, Fan E. Conservative fluid management or deresuscitation for patients with sepsis or acute respiratory distress syndrome following the resuscitation phase of critical illness: a systematic review and meta-analysis. Intensive Care Med 2016; 43:155-170. [PMID: 27734109 DOI: 10.1007/s00134-016-4573-3] [Citation(s) in RCA: 246] [Impact Index Per Article: 30.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Accepted: 09/22/2016] [Indexed: 12/29/2022]
Abstract
BACKGROUND It is unknown whether a conservative approach to fluid administration or deresuscitation (active removal of fluid using diuretics or renal replacement therapy) is beneficial following haemodynamic stabilisation of critically ill patients. PURPOSE To evaluate the efficacy and safety of conservative or deresuscitative fluid strategies in adults and children with acute respiratory distress syndrome (ARDS), sepsis or systemic inflammatory response syndrome (SIRS) in the post-resuscitation phase of critical illness. METHODS We searched Medline, EMBASE and the Cochrane central register of controlled trials from 1980 to June 2016, and manually reviewed relevant conference proceedings from 2009 to the present. Two reviewers independently assessed search results for inclusion and undertook data extraction and quality appraisal. We included randomised trials comparing fluid regimens with differing fluid balances between groups, and observational studies investigating the relationship between fluid balance and clinical outcomes. RESULTS = 75 %) compared with a liberal strategy or standard care. CONCLUSIONS In adults and children with ARDS, sepsis or SIRS, a conservative or deresuscitative fluid strategy results in an increased number of ventilator-free days and a decreased length of ICU stay compared with a liberal strategy or standard care. The effect on mortality remains uncertain. Large randomised trials are needed to determine optimal fluid strategies in critical illness.
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Affiliation(s)
- Jonathan A Silversides
- Centre for Experimental Medicine, Wellcome-Wolfson Institute, Queen's University of Belfast, 97 Lisburn Road, Belfast, BT9 7BL, UK. .,Department of Critical Care Services, Belfast Health and Social Care Trust, Belfast City Hospital, Lisburn Road, Belfast, BT9 7AB, UK.
| | - Emmet Major
- Department of Critical Care Services, Belfast Health and Social Care Trust, Belfast City Hospital, Lisburn Road, Belfast, BT9 7AB, UK
| | - Andrew J Ferguson
- Department of Intensive Care, Southern Health and Social Care Trust, Craigavon Area Hospital, 68 Lurgan Road, Portadown, BT63 5QQ, UK
| | - Emma E Mann
- Department of Critical Care Services, Belfast Health and Social Care Trust, Belfast City Hospital, Lisburn Road, Belfast, BT9 7AB, UK
| | - Daniel F McAuley
- Centre for Experimental Medicine, Wellcome-Wolfson Institute, Queen's University of Belfast, 97 Lisburn Road, Belfast, BT9 7BL, UK.,Regional Intensive Care Unit, Department of Critical Care Services, Belfast Health and Social Care Trust, Royal Victoria Hospital, Grosvenor Road, Belfast, BT12 6BA, UK
| | - John C Marshall
- Interdepartmental Division of Critical Care, University of Toronto, 585 University Avenue, PMB 11-123, Toronto, ON, M5G 2N2, Canada.,Department of Critical Care Medicine, St Michael's Hospital, 30 Bond Street, Bond 4-014, Toronto, ON, M5B 1W8, Canada
| | - Bronagh Blackwood
- Centre for Experimental Medicine, Wellcome-Wolfson Institute, Queen's University of Belfast, 97 Lisburn Road, Belfast, BT9 7BL, UK
| | - Eddy Fan
- Interdepartmental Division of Critical Care, University of Toronto, 585 University Avenue, PMB 11-123, Toronto, ON, M5G 2N2, Canada
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