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Focused Real-Time Ultrasonography for Nephrologists. Int J Nephrol 2017; 2017:3756857. [PMID: 28261499 PMCID: PMC5312502 DOI: 10.1155/2017/3756857] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2016] [Revised: 10/09/2016] [Accepted: 11/01/2016] [Indexed: 02/06/2023] Open
Abstract
We propose that renal consults are enhanced by incorporating a nephrology-focused ultrasound protocol including ultrasound evaluation of cardiac contractility, the presence or absence of pericardial effusion, inferior vena cava size and collapsibility to guide volume management, bladder volume to assess for obstruction or retention, and kidney size and structure to potentially gauge chronicity of renal disease or identify other structural abnormalities. The benefits of immediate and ongoing assessment of cardiac function and intravascular volume status (prerenal), possible urinary obstruction or retention (postrenal), and potential etiologies of acute kidney injury or chronic kidney disease far outweigh the limitations of bedside ultrasonography performed by nephrologists. The alternative is reliance on formal ultrasonography, which creates a disconnect between those who order, perform, and interpret studies, creates delays between when clinical questions are asked and answered, and may increase expense. Ultrasound-enhanced physical examination provides immediate information about our patients, which frequently alters our assessments and management plans.
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Mueller C, Christ M, Cowie M, Cullen L, Maisel AS, Masip J, Miro O, McMurray J, Peacock FW, Price S, DiSomma S, Bueno H, Zeymer U, Mebazaa A. European Society of Cardiology-Acute Cardiovascular Care Association Position paper on acute heart failure: A call for interdisciplinary care. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2016; 6:81-86. [PMID: 26124458 DOI: 10.1177/2048872615593279] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Acute heart failure (AHF) continues to have unacceptably high rates of mortality and morbidity. This position paper highlights the need for more intense interdisciplinary cooperation as one key element to overcome the challenges associated with fragmentation in the care of AHF patients. Additional aspects discussed include the importance of early diagnosis and treatment, options for initial treatment, referral bias as a potential cause for treatment preferences among experts, considerable uncertainty regarding patient disposition, the diagnosis of accompanying acute myocardial infarction, the need for antibiotic therapy, as well as assessment of intravascular volume status.
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Affiliation(s)
| | - Michael Christ
- 2 Department of Emergency and Critical Care Medicine, Klinikum Nürnberg, Germany
| | - Martin Cowie
- 3 Department of Cardiology, Imperial College London, UK
| | - Louise Cullen
- 4 Department of Emergency Medicine, Royal Brisbane and Women's Hospital, Australia.,6 School of Medicine, The University of Queensland, Australia
| | - Alan S Maisel
- 7 Coronary Care Unit and Heart Failure Program, Veteran Affairs (VA) San Diego, USA
| | | | - Oscar Miro
- 9 Emergency Department, Hospital Clínic, Barcelona, Spain.,10 Research Group: 'Emergencies: Processes and Pathologies', Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Spain
| | - John McMurray
- 11 British Heart Foundation (BHF) Cardiovascular Research Centre, University of Glasgow, UK
| | | | - Susanna Price
- 13 Royal Brompton and Harefield National Health Service Foundation Trust, UK
| | - Salvatore DiSomma
- 14 Emergency Department, Sant'Andrea Hospital, Italy.,15 Faculty of Medicine and Psychology, 'LaSapienza ' Rome University, Italy
| | - Hector Bueno
- 16 Hospital General Universitario Gregorio Marañón, Spain
| | - Uwe Zeymer
- 17 Klinikum Ludwigshafen, Institut für Herzinfarktforschung Ludwigshafen, Germany
| | - Alexandre Mebazaa
- 18 Université Paris Diderot, France.,19 Hospital Lariboisière, France
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Johnson P. Practical Assessment of Volume Status in Daily Practice. Top Companion Anim Med 2016; 31:86-93. [PMID: 27968814 DOI: 10.1053/j.tcam.2016.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 08/04/2016] [Indexed: 02/06/2023]
Abstract
Fluid therapy is considered the cornerstone of treatment for patients suffering from various medical ailments particularly in emergency and critical care situations where hypovolemia commonly occurs. The ability to accurately assess a patient's volume status is critical to the decision making process when synthesizing and implementing a fluid therapy plan. Both extremes, over supplementation or not supplementing enough fluid can be detrimental to the patient. Precisely assessing a patient's blood volume without access to advanced often complicated equipment and monitoring devices is challenging. The aim of this paper is to review the practical means and tools available to aide in estimating a patient's volume status.
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Affiliation(s)
- Paula Johnson
- Purdue University College of Veterinary Medicine, Veterinary Clinical Sciences, West Lafayette, IN, USA.
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Inferior Vena Cava Ultrasonography before General Anesthesia Can Predict Hypotension after Induction. Anesthesiology 2016; 124:580-9. [PMID: 26771910 DOI: 10.1097/aln.0000000000001002] [Citation(s) in RCA: 95] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Abstract
Background
Hypotension is a common side effect of general anesthesia induction, and when severe, it is related to adverse outcomes. Ultrasonography of inferior vena cava (IVC) is a reliable indicator of intravascular volume status. This study investigated whether preoperative ultrasound IVC measurements could predict hypotension after induction of anesthesia.
Methods
One hundred four adult patients, conforming to American Society of Anesthesiologists physical status I to III, scheduled for elective surgery after general anesthesia were recruited. Maximum IVC diameter (dIVCmax) and collapsibility index (CI) were measured preoperatively. Before induction, mean blood pressure (MBP) was recorded. After induction, MBP was recorded for 10 min after intubation. Hypotension was defined as greater than 30% decrease in MBP from baseline or MBP less than 60 mmHg. Receiver operating characteristic curve analysis with gray zone approach and regression analyses were used.
Results
IVC scanning was unsuccessful in 13.5% of patients. Data from 90 patients were analyzed. After induction, 42 patients developed hypotension. Areas (95% confidence interval) under the curves were 0.90 (0.82 to 0.95) for CI and 0.76 (0.66 to 0.84) for dIVCmax. The optimal cutoff values were 43% for CI and 1.8 cm for dIVCmax. The gray zone for CI was 38 to 43% and included 12% of patients and that for dIVCmax was 1.5 to 2.1 cm and included 59% of patients. After adjusting for other factors, it was found that CI was an independent predictor of hypotension with the odds ratio of 1.17 (1.09 to 1.26). CI was also positively associated with a percentage decrease in MBP (regression coefficient = 0.27).
Conclusions
Preoperative ultrasound IVC CI measurement was a reliable predictor of hypotension after induction of general anesthesia, wherein CI greater than 43% was the threshold.
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Salahuddin N, Hussain I, Alsaidi H, Shaikh Q, Joseph M, Hawa H, Maghrabi K. Measurement of the vascular pedicle width predicts fluid repletion: a cross-sectional comparison with inferior vena cava ultrasound and lung comets. J Intensive Care 2015; 3:55. [PMID: 26702359 PMCID: PMC4688935 DOI: 10.1186/s40560-015-0121-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Accepted: 12/16/2015] [Indexed: 01/21/2023] Open
Abstract
Background Determination of a patient’s volume status remains challenging. Ultrasound assessments of the inferior vena cava and lung parenchyma have been shown to reflect fluid status when compared to the more traditional static and dynamic methods. Yet, resource-limited intensive care units (ICUs) may still not have access to bedside ultrasound. The vascular pedicle width (VPW) measured on chest radiographs remains underutilized for fluid assessment. In this study, we aimed to determine the correlation between ultrasound assessment and vascular pedicle width and to identify a discriminant value that predicted a fluid replete state. Methods Eighty-four data points of simultaneous VPW and inferior vena cava measurements were collected on mechanically ventilated patients. VPW measurements were compared with lung comet scores, fluid balance, and a composite variable of inferior vena cava diameter greater than or equal to 2 cm and variability less than 15 %. Results A VPW of 64 mm accurately predicted fluid repletion with a positive predictive value equal to 88.5 % and an area under the curve (AUC) of 0.843, 95 % CI 0.75–0.93, p < 0.001. VPW closely correlated with inferior vena cava diameter (Pearson’s r = 0.64, p = <0.001). Poor correlations were observed between VPW and lung comet score, Pearson’s r = 0.12, p = 0.26, fluid balance, Pearson’s r = 0.3, p = 0.058, and beta natriuretic peptide, Pearson’s r = 0.12, p = 0.26. Conclusions This study shows a high predictive ability of the VPW for fluid repletion, as compared to an accepted method of volume assessment. Given the relationship of fluid overload and mortality, these results may assist fluid resuscitation in resource-limited intensive care units.
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Affiliation(s)
- Nawal Salahuddin
- Adult Critical Care Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Iqbal Hussain
- Adult Critical Care Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Hakam Alsaidi
- Adult Critical Care Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Quratulain Shaikh
- Adult Critical Care Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Mini Joseph
- Department of Nursing, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Hassan Hawa
- Adult Critical Care Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Khalid Maghrabi
- Adult Critical Care Medicine, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
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56
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Pitman JT, Thapa GB, Stuart Harris N. Field Ultrasound Evaluation of Central Volume Status and Acute Mountain Sickness. Wilderness Environ Med 2015; 26:319-26. [DOI: 10.1016/j.wem.2015.02.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2014] [Revised: 02/09/2015] [Accepted: 02/16/2015] [Indexed: 11/26/2022]
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Gupta RG, Hartigan SM, Kashiouris MG, Sessler CN, Bearman GML. Early goal-directed resuscitation of patients with septic shock: current evidence and future directions. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19:286. [PMID: 26316210 PMCID: PMC4552276 DOI: 10.1186/s13054-015-1011-9] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Severe sepsis and septic shock are among the leading causes of mortality in the intensive care unit. Over a decade ago, early goal-directed therapy (EGDT) emerged as a novel approach for reducing sepsis mortality and was incorporated into guidelines published by the international Surviving Sepsis Campaign. In addition to requiring early detection of sepsis and prompt initiation of antibiotics, the EGDT protocol requires invasive patient monitoring to guide resuscitation with intravenous fluids, vasopressors, red cell transfusions, and inotropes. The effect of these measures on patient outcomes, however, remains controversial. Recently, three large randomized trials were undertaken to re-examine the effect of EGDT on morbidity and mortality: the ProCESS trial in the United States, the ARISE trial in Australia and New Zealand, and the ProMISe trial in England. These trials showed that EGDT did not significantly decrease mortality in patients with septic shock compared with usual care. In particular, whereas early administration of antibiotics appeared to increase survival, tailoring resuscitation to static measurements of central venous pressure and central venous oxygen saturation did not confer survival benefit to most patients. In the following review, we examine these findings as well as other evidence from recent randomized trials of goal-directed resuscitation. We also discuss future areas of research and emerging paradigms in sepsis trials.
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Affiliation(s)
- Ravi G Gupta
- Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, P.O. Box 980050, Richmond, VA, 23298, USA.
| | - Sarah M Hartigan
- Division of General Internal Medicine, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, P.O. Box 980070, Richmond, VA, 23298, USA
| | - Markos G Kashiouris
- Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, P.O. Box 980050, Richmond, VA, 23298, USA
| | - Curtis N Sessler
- Division of Pulmonary Disease and Critical Care Medicine, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, P.O. Box 980050, Richmond, VA, 23298, USA
| | - Gonzalo M L Bearman
- Division of Infectious Diseases, Department of Internal Medicine, Virginia Commonwealth University School of Medicine, P.O. Box 980019, Richmond, VA, 23298, USA
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58
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Rhee H, Jang KS, Shin MJ, Lee JW, Kim IY, Song SH, Lee DW, Lee SB, Kwak IS, Seong EY. Use of Multifrequency Bioimpedance Analysis in Male Patients with Acute Kidney Injury Who Are Undergoing Continuous Veno-Venous Hemodiafiltration. PLoS One 2015; 10:e0133199. [PMID: 26186370 PMCID: PMC4505923 DOI: 10.1371/journal.pone.0133199] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 06/24/2015] [Indexed: 02/06/2023] Open
Abstract
Introduction Fluid overload is a well-known predictor of mortality in patients with acute kidney injury (AKI). Multifrequency bioimpedance analysis (MF-BIA) is a promising tool for quantifying volume status. However, few studies have analyzed the effect of MF-BIA-defined volume status on the mortality of critically ill patients with AKI. This retrospective medical research study aimed to investigate this issue. Methods We retrospectively reviewed the medical records of patients with AKI who underwent continuous veno-venous hemodiafiltration (CVVHDF) from Jan. 2013 to Feb. 2014. Female patients were excluded to control for sex-based differences. Volume status was measured using MF-BIA (Inbody S20, Seoul, Korea) at the time of CVVHDF initiation, and volume parameters were adjusted with height squared (H2). Binary logistic regression analyses were performed to test independent factors for prediction of in-hospital mortality. Results A total of 208 male patients were included in this study. The mean age was 65.19±12.90 years. During the mean ICU stay of 18.29±27.48 days, 40.4% of the patients died. The in-hospital mortality rate increased with increasing total body water (TBW)/H2 quartile. In the multivariable analyses, increased TBW/H2 (OR 1.312(1.009-1.705), p=0.043) and having lower serum albumin (OR 0.564(0.346-0.919, p=0.022) were independently associated with higher in-hospital mortality. When the intracellular water (ICW)/H2 or extracellular water (ECW)/H2 was adjusted instead of the TBW/H2, only excess ICW/H2 was independently associated with increased mortality (OR 1.561(1.012-2.408, p=0.044). Conclusions MF-BIA-defined excess TBW/H2 and ICW/H2 are independently associated with higher in-hospital mortality in male patients with AKI undergoing CVVHDF.
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Affiliation(s)
- Harin Rhee
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Republic of Korea
- Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Keum Sook Jang
- Department of Nursing, Pusan National University Hospital, Busan, Republic of Korea
| | - Min Ji Shin
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Republic of Korea
- Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Jang Won Lee
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Republic of Korea
- Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Il Young Kim
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Republic of Korea
| | - Sang Heon Song
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Republic of Korea
- Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Dong Won Lee
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Republic of Korea
| | - Soo Bong Lee
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Republic of Korea
| | - Ihm Soo Kwak
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Republic of Korea
- Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Eun Young Seong
- Department of Internal Medicine, Pusan National University School of Medicine, Busan, Republic of Korea
- Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
- * E-mail:
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59
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Management of severe hyponatremia: infusion of hypertonic saline and desmopressin or infusion of vasopressin inhibitors? Am J Med Sci 2015; 348:432-9. [PMID: 25247759 PMCID: PMC4206391 DOI: 10.1097/maj.0000000000000331] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Rapid correction of severe hyponatremia carries the risk of osmotic demyelination. Two recently introduced methods of correction of hyponatremia have diametrically opposite effects on aquaresis. Inhibitors of vasopressin V2 receptor (vaptans) lead to the production of dilute urine, whereas infusion of desmopressin causes urinary concentration. Identification of the category of hyponatremia that will benefit from one or the other treatment is critical. In general, vaptans are effective in hyponatremias presenting with concentrated urine and, with the exception of hypovolemic hyponatremia, can be used as their primary treatment. Desmopressin is effective in hyponatremias presenting with dilute urine or developing urinary dilution after saline infusion. In this setting, desmopressin infusion helps prevent overcorrection of the hyponatremia. Monitoring of the changes in serum sodium concentration as a guide to treatment changes is imperative regardless of the initial treatment of severe hyponatremia.
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60
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Abstract
Approximately 18% of patients undergoing cardiac surgery experience AKI (on the basis of modern standardized definitions of AKI), and approximately 2%-6% will require hemodialysis. The development of AKI after cardiac surgery portends poor short- and long-term prognoses, with those developing RIFLE failure or AKI Network stage III having an almost 2-fold increase in the risk of death. AKI is caused by a variety of factors, including nephrotoxins, hypoxia, mechanical trauma, inflammation, cardiopulmonary bypass, and hemodynamic instability, and it may be affected by the clinician's choice of fluids and vasoactive agents as well as the transfusion strategy used. The risk of AKI may be ameliorated by avoidance of nephrotoxins, achievement of adequate glucose control preoperatively, and use of goal-directed therapy hemodynamic strategies. Remote ischemic preconditioning is an exciting future strategy, but more work is needed before widespread implementation. Unfortunately, there are no pharmacologic agents known to reduce the risk of AKI or treat established AKI.
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Affiliation(s)
| | | | - Mitchell H Rosner
- Medicine, University of Virginia Health System, Charlottesville, Virginia
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61
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Thiele RH, Gan TJ. Hemodynamic monitoring devices. Best Pract Res Clin Anaesthesiol 2014; 28:305-7. [PMID: 25480762 DOI: 10.1016/j.bpa.2014.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Accepted: 09/26/2014] [Indexed: 10/24/2022]
Affiliation(s)
- Robert H Thiele
- Departments of Anesthesiology and Biomedical Engineering Director, Technology in Anesthesia and Critical Care Group Co-Director, UVA Enhanced Recovery After Surgery Program University of Virginia, Charlottesville, VA, USA.
| | - Tong-Joo Gan
- Department of Anesthesiology, Stony Brook University, NY, USA.
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62
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Compton F, Vogel M, Zidek W, van der Giet M, Westhoff T. Changes in volumetric hemodynamic parameters induced by fluid removal on hemodialysis in critically ill patients. Ther Apher Dial 2014; 19:23-9. [PMID: 25196396 DOI: 10.1111/1744-9987.12193] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Management of volume status is difficult in critically ill patients with renal failure. Volumetric hemodynamic indices are increasingly being used to guide fluid therapy in the intensive care unit (ICU), but are not established to monitor hemodialysis-induced fluid removal in critically ill patients. Using volumetric hemodynamic monitoring, changes in extravascular lung water index (EVLWI) and intrathoracic blood volume index (ITBVI) were measured immediately before and after hemodialysis sessions in 35 ICU patients. Additional hemodynamic and oxygenation related parameters were recorded at the same time, and online relative blood volume (RBV) monitoring was performed during hemodialysis. EVLWI decreased significantly with fluid removal (median 10.0 vs. 9.6 mL/kg, P = 0.001), whereas ITBVI remained stable (median 1012 vs. 1029 mL/m(2) , P = 0.402). Significant changes were also observed in stroke volume variation (median 12.0 vs. 13.0 %, P = 0.012), cardiac index (median 4.2 vs. 3.5 mL/min/m(2) , P = 0.003), mean arterial pressure (median 77 vs. 85.5 mmHg, P = 0.006), norepinephrine dose (median 0.092 vs. 0.114 μg/kg per min, P = 0.043), and hemoglobin values (median 9.5 vs. 10.4 gm/dL, P = 0.036). RBV decreased by 7.8% (median); there was no correlation with either the volumetric measurements or the other hemodynamic parameters recorded. EVLWI reduction with dialysis reflects the removal of excess body fluid, whereas preservation of cardiac preload is indicated by ITBVI stability. Volumetric hemodynamic measurements provide additional information concerning fluid status and are thus potentially useful to guide fluid removal on hemodialysis in critically ill patients.
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Affiliation(s)
- Friederike Compton
- Department of Nephrology, Charité University Medicine Berlin, Berlin, Germany
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63
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Rosner MH, Ostermann M, Murugan R, Prowle JR, Ronco C, Kellum JA, Mythen MG, Shaw AD. Indications and management of mechanical fluid removal in critical illness. Br J Anaesth 2014; 113:764-71. [PMID: 25182016 DOI: 10.1093/bja/aeu297] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND The Acute Dialysis Quality Initiative (ADQI) dedicated its Twelfth Consensus Conference (2013) to all aspects of fluid therapy, including the management of fluid overload (FO). The aim of the working subgroup 'Mechanical fluid removal' was to review the indications, prescription, and management of mechanical fluid removal within the broad context of fluid management of critically ill patients. METHODS The working group developed a list of preliminary questions and objectives and performed a modified Delphi analysis of the existing literature. Relevant studies were identified through a literature search using the MEDLINE database and bibliographies of relevant research and review articles. RESULTS After review of the existing literature, the group agreed the following consensus statements: (i) in critically ill patients with FO and with failure of or inadequate response to pharmacological therapy, mechanical fluid removal should be considered as a therapy to optimize fluid balance. (ii) When using mechanical fluid removal or management, targets for rate of fluid removal and net fluid removal should be based upon the overall fluid balance of the patient and also physiological variables, individualized, and reassessed frequently. (iii) More research on the role and practice of mechanical fluid removal in critically ill patients not meeting fluid balance goals (including in children) is necessary. CONCLUSION Mechanical fluid removal should be considered as a therapy for FO, but more research is necessary to determine its exact role and clinical application.
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Affiliation(s)
- M H Rosner
- Division of Nephrology, University of Virginia Health System, Charlottesville, VA, USA
| | - M Ostermann
- Department of Critical Care Medicine, King's College London, King's Health Partners, Guy's and St Thomas' Foundation Hospital, London SE1 7EH, UK
| | - R Murugan
- The Center for Critical Care Nephrology, CRISMA, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - J R Prowle
- Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - C Ronco
- Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute (IRRIV), San Bortolo Hospital, Vicenza, Italy
| | - J A Kellum
- The Center for Critical Care Nephrology, CRISMA, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - M G Mythen
- University College London Hospital and University College London NIHR Biomedical Research Centre, London, UK
| | - A D Shaw
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
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Abstract
PURPOSE OF REVIEW This review highlights the principal advances in critical care over the past year, and discusses the impact of these advances on the diagnosis and management of acute kidney injury (AKI). RECENT FINDINGS Recent literature has focused on assessment of volume status and fluid management, particularly in the setting of respiratory and cardiac failure. Other critical care topics are reviewed using a system-based approach. SUMMARY The incidence of AKI appears to be increasing, and despite advances in the provision of critical care and renal replacement therapies, there has been little improvement in its associated morbidity and mortality. Nonetheless, recent advances in critical care will impact the diagnosis and management of AKI, as well as shape the future research agenda. Continued work in the fields of critical care and nephrology will undoubtedly be centered on improved biomarkers for the detection of AKI, specific therapies to mitigate or reverse AKI, and techniques to prevent the development of AKI in the critically ill population.
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65
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Abstract
Up to 30% of patients undergoing cardiac surgery develop AKI, with 1% requiring RRT. AKI is an independent risk factor for morbidity and mortality. Postoperatively, even minimal changes in serum creatinine are associated with a substantial increase in mortality. No intervention has been definitely proven effective in reducing kidney injury. The successful prevention and management of AKI involves identifying patients at risk for AKI, recognizing subtle abnormalities in a timely manner, performing basic clinical assessments, and responding appropriately to data obtained. With that in mind, in this Attending Rounds, a woman with AKI in the setting of cardiac surgery is presented to highlight the use of history, physical exam, hemodynamic monitoring, laboratory data trends, and urine indices in establishing the correct diagnosis and appropriate management.
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Affiliation(s)
- Ashita J Tolwani
- Division of Nephrology, University of Alabama, Birmingham, Alabama
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66
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Pre-procedural bioimpedance vectorial analysis of fluid status and prediction of contrast-induced acute kidney injury. J Am Coll Cardiol 2014; 63:1387-94. [PMID: 24530668 DOI: 10.1016/j.jacc.2014.01.025] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 01/10/2014] [Accepted: 01/13/2014] [Indexed: 01/19/2023]
Abstract
OBJECTIVES The aim of this study was to evaluate the relationship between pre-procedural fluid status assessed by bioimpedance vector analysis (BIVA) and development of contrast-induced acute kidney injury (CI-AKI). BACKGROUND Accurate fluid management in patients undergoing angiographic procedures is of critical importance in limiting the risk of CI-AKI. Therefore, establishing peri-procedural fluid volume related to increased risk of CI-AKI development is essential. METHODS We evaluated the fluid status by BIVA of 900 consecutive patients with stable coronary artery disease (CAD) immediately before coronary angiography, measuring the resistance/height (R/H) ratio and impedance/height (Z/H) vector. CI-AKI was defined as an increase in serum creatinine ≥0.5 mg/dl above baseline within 3 days after contrast administration (iodixanol). RESULTS CI-AKI occurred in 54 patients (6.0%). Pre-procedural R/H ratios were significantly higher in patients with CI-AKI than without CI-AKI (395 ± 71 Ohm/m vs. 352 ± 58 Ohm/m, p = 0.001 for women; 303 ± 59 Ohm/m vs. 279 ± 45 Ohm/m, p = 0.009 for men), indicating lower fluid volume in the patients with CI-AKI. When patients were stratified according to R/H ratio, there was an almost 3-fold higher risk in patients with higher values (odds ratio [OR]: 2.9; 95% confidence interval [CI]: 1.5 to 5.5; p = 0.002). The optimal receiver-operating characteristic curve analysis threshold values of R/H ratio for predicting CI-AKI were 380 Ohm/m for women and 315 Ohm/m for men. R/H ratio above these thresholds was found to be a significant and independent predictor of CI-AKI (OR: 3.1; 95% CI: 1.8 to 5.5; p = 0.001). CONCLUSIONS Lower fluid status evaluated by BIVA immediately before contrast medium administration resulted in a significant and independent predictor of CI-AKI in patients with stable CAD. This simple noninvasive analysis should be tested in guiding tailored volume repletion.
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