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Fluid Responsiveness and the Six Guiding Principles of Fluid Resuscitation. Crit Care Med 2018; 44:1920-2. [PMID: 26571187 DOI: 10.1097/ccm.0000000000001483] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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102
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Uz Z, Ince C, Guerci P, Ince Y, P Araujo R, Ergin B, Hilty MP, van Gulik TM, de Mol BA. Recruitment of sublingual microcirculation using handheld incident dark field imaging as a routine measurement tool during the postoperative de-escalation phase-a pilot study in post ICU cardiac surgery patients. Perioper Med (Lond) 2018; 7:18. [PMID: 30116524 PMCID: PMC6083575 DOI: 10.1186/s13741-018-0091-x] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2017] [Accepted: 04/30/2018] [Indexed: 02/07/2023] Open
Abstract
Background Management of tissue perfusion following cardiac surgery is a challenging task where common clinical parameters do not reflect microcirculatory dysfunction. Heterogeneity in blood flow perfusion and abnormalities in capillary density characterize microcirculatory dysfunction. The restoration of a normal microcirculation may become a novel target for therapy in the future in addition to macrocirculatory parameters. The aim of this study is to determine how the sublingual microcirculatory parameters vary at the bedside in post-cardiac surgery patients which underwent diuretic therapy to correct fluid overload. Methods In this prospective observational pilot study, video clips of sublingual microcirculation in post-cardiac surgery patients receiving furosemide and/or spironolactone to achieve normal fluid balance were recorded using Cytocam-IDF imaging. Data was obtained on the first (T0), second (T1), and third (T2) day after the patients left the intensive care unit (ICU). Measurements were analyzed off-line to obtain the following microcirculatory parameters: total vessel density (TVD), microcirculatory flow index (MFI), proportion of perfused vessel (PPV), and perfused vessel density (PVD). Macrocirculatory parameters and body weight were also collected at these time points. Results Ninety measurements were performed in ten post ICU cardiac surgery patients. Thirteen measurements were excluded due to quality reasons; these excluded measurements were spread across the patients and time points, and there was no loss of patients or time points. An increase in TVD was observed from T0 to T1 (20 ± 2.7 to 24 ± 3.2 mm/mm2; p = 0.0410) and from T0 to T2 (20 ± 2.7 to 26 ± 3.3 mm/mm2; p = 0.0005). An increase in PVD was present from T0 to T1 (19 ± 2.3 to 24 ± 3.5 mm/mm2; p = 0.0072) and from T0 to T2 (19 ± 2.3 to 26 ± 3.4 mm/mm2, p = 0.0008). Fluid overload was assessed through a positive cumulative fluid balance on the day of ICU discharge. Conclusions Cytocam-IDF imaging to monitor microcirculation as a daily parameter is feasible and could become a valuable tool to non-invasively assess the tissue oxygenation at the bedside. An increase in TVD and PVD (functional capillary density) indicated the recruitment of the sublingual microcirculation in patients with diuretic therapy. Future research is needed to prove the correlation between the recruitment of the sublingual microcirculation and the de-escalation phase of the fluid management.
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Affiliation(s)
- Zühre Uz
- 1Department of Experimental Surgery and Translational Physiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Can Ince
- 2Department of Translational Physiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Philippe Guerci
- 2Department of Translational Physiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Yasin Ince
- 2Department of Translational Physiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Renata P Araujo
- 2Department of Translational Physiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Bulent Ergin
- 2Department of Translational Physiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Matthias P Hilty
- 2Department of Translational Physiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Thomas M van Gulik
- 1Department of Experimental Surgery and Translational Physiology, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
| | - Bas A de Mol
- 3Department of Cardio-Thoracic Surgery, Academic Medical Center, University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands
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Abstract
Fundamental features of septic shock are vasodilation, increased permeability, hypovolemia, and ventricular dysfunction. Vasodilation owing to increased nitric oxide and prostaglandins is treated with vasopressors (norepinephrine first). Increased permeability relates to several pathways (Slit/Robo4, vascular endothelial growth factor, angiopoietin 1 and 2/Tie2 pathway, sphingosine-1-phosphate, and heparin-binding protein), some of which are targets for therapies. Hypovolemia is common and crystalloid is recommended for fluid resuscitation. Cardiomyocyte-inflammatory interactions decrease contractility and dobutamine is recommended to increase cardiac output. There is benefit in decreasing heart rate in selected patients with esmolol. Ivabradine is a novel agent for heart rate reduction without decreasing contractility.
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Affiliation(s)
- James A Russell
- Department of Medicine, Centre for Heart Lung Innovation, St. Paul's Hospital, 1081 Burrard Street, Vancouver, British Columbia V6Z 1Y6, Canada.
| | - Barret Rush
- Division of Critical Care Medicine, St. Paul's Hospital, 1081 Burrard Street, Vancouver, British Columbia V6Z 1Y6, Canada
| | - John Boyd
- Department of Medicine, Centre for Heart Lung Innovation, St. Paul's Hospital, 1081 Burrard Street, Vancouver, British Columbia V6Z 1Y6, Canada
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Berthelsen RE, Perner A, Jensen AK, Jensen JU, Bestle MH. Fluid accumulation during acute kidney injury in the intensive care unit. Acta Anaesthesiol Scand 2018; 62:780-790. [PMID: 29512107 DOI: 10.1111/aas.13105] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 01/31/2018] [Accepted: 02/07/2018] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Fluid therapy is a ubiquitous intervention in patients admitted to the intensive care unit, but positive fluid balance may be associated with poor outcomes and particular in patients with acute kidney injury. Studies describing this have defined fluid overload either at specific time points or considered patients with a positive mean daily fluid balance as fluid overloaded. We wished to detail this further and performed joint model analyses of the association between daily fluid balance and outcome represented by mortality and renal recovery in patients admitted with acute kidney injury. METHOD We did a retrospective cohort study of patients admitted to the intensive care unit with acute kidney injury during a 2-year observation period. We used serum creatinine measurements to identify patients with acute kidney injury and collected sequential daily fluid balance during the first 5 days of admission to the intensive care unit. We used joint modelling techniques to correlate the development of fluid overload with survival and renal recovery adjusted for age, gender and disease severity. RESULTS The cohort contained 863 patients with acute kidney injury of whom 460 (53%) and 254 (29%) developed 5% and 10% fluid overload, respectively. We found that both 5% and 10% fluid overload was correlated with reduced survival and renal recovery. CONCLUSION Joint model analyses of fluid accumulation in patients admitted to the intensive care unit with acute kidney injury confirm that even a modest degree of fluid overload (5%) may be negatively associated with both survival and renal recovery.
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Affiliation(s)
- R. E. Berthelsen
- Department of Anaesthesiology and Intensive Care; Nordsjaellands Hospital; Hilleroed Denmark
| | - A. Perner
- Department of Intensive Care 4131; Rigshospitalet; Copenhagen Denmark
| | - A. K. Jensen
- Department of Research; Nordsjaellands Hospital; Hilleroed Denmark
- Department of Public Health, Section of Biostatistics; Copenhagen University; Copenhagen Denmark
| | - J.-U. Jensen
- CHIP & PERSIMUNE; Rigshospitalet; Copenhagen Denmark
| | - M. H. Bestle
- Department of Anaesthesiology and Intensive Care; Nordsjaellands Hospital; Hilleroed Denmark
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105
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Kim Y, Cho YS, Kym D, Yoon J, Yim H, Hur J, Chun W. Diagnostic performance of plasma and urine neutrophil gelatinase-associated lipocalin, cystatin C, and creatinine for acute kidney injury in burn patients: A prospective cohort study. PLoS One 2018; 13:e0199600. [PMID: 29944687 PMCID: PMC6019252 DOI: 10.1371/journal.pone.0199600] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Accepted: 06/11/2018] [Indexed: 11/27/2022] Open
Abstract
Background Diagnosing acute kidney injury quickly is imperative since it is known as an independent risk factor for mortality in burn patients. We evaluated the diagnostic power of creatinine, cystatin, serum and urine neutrophil gelatinase-associated lipocalin at different time periods and observed the changes from baseline for each biomarker. Methods This was a prospective observation study from January 2015 to February 2016. A total of 84 patients were enrolled consecutively. Serum creatinine, serum cystatin C, and serum and urine neutrophil gelatinase-associated lipocalin were measured at admission, 7th, 14th, 21st, and 28th days after admission. All samples were collected until acute kidney injury developed. Results Acute kidney injury developed in 35 patients. The mean age was 49.6 years with a male predominance. The median urine neutrophil gelatinase-associated lipocalin was the lowest (11.6 ng/dL) at admission, and the highest at 85.5 ng/dL on day 7. Mean creatinine level was the highest (0.88 mg/dL) at admission and the median creatinine level was the lowest (0.56 mg/dL) on the 14th day. The area under the curve of creatinine levels was the highest with 0.857 during the 1st week. The area under the curve of urine neutrophil gelatinase-associated lipocalin was the highest with 0.803 during the 5th week. Conclusions Within 1 week of acute kidney injury, creatinine level was the optimal biomarker for diagnosis while urine neutrophil gelatinase-associated lipocalin showed better diagnostic performance following the 4- week period.
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Affiliation(s)
- Youngmin Kim
- Department of Surgery and Critical Care, Burn Center, Hangang Sacred Heart Hospital, College of Medicine, Hallym University Medical Center, Seoul, Korea
| | - Yong Suk Cho
- Department of Surgery and Critical Care, Burn Center, Hangang Sacred Heart Hospital, College of Medicine, Hallym University Medical Center, Seoul, Korea
- * E-mail: (YSC); (DK)
| | - Dohern Kym
- Department of Surgery and Critical Care, Burn Center, Hangang Sacred Heart Hospital, College of Medicine, Hallym University Medical Center, Seoul, Korea
- * E-mail: (YSC); (DK)
| | - Jaechul Yoon
- Department of Surgery and Critical Care, Burn Center, Hangang Sacred Heart Hospital, College of Medicine, Hallym University Medical Center, Seoul, Korea
| | - Haejun Yim
- Department of Surgery and Critical Care, Burn Center, Hangang Sacred Heart Hospital, College of Medicine, Hallym University Medical Center, Seoul, Korea
| | - Jun Hur
- Department of Surgery and Critical Care, Burn Center, Hangang Sacred Heart Hospital, College of Medicine, Hallym University Medical Center, Seoul, Korea
| | - Wook Chun
- Department of Surgery and Critical Care, Burn Center, Hangang Sacred Heart Hospital, College of Medicine, Hallym University Medical Center, Seoul, Korea
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Zampieri FG. Elective ICU admission after major surgery: can too much support be futile? J Thorac Dis 2018; 10:S1992-S1994. [PMID: 30023100 DOI: 10.21037/jtd.2018.05.154] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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108
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Genga KR, Shimada T, Boyd JH, Walley KR, Russell JA. The Understanding and Management of Organism Toxicity in Septic Shock. J Innate Immun 2018; 10:502-514. [PMID: 29763894 DOI: 10.1159/000487818] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Accepted: 02/17/2018] [Indexed: 12/13/2022] Open
Abstract
The toxicity caused by different organisms in septic shock is substantially complex and characterized by an intricate pathogenicity that involves several systems and pathways. Immune cells' pattern recognition receptors initiate the host response to pathogens after the recognition of pathogen-associated molecular patterns. In essence, the subsequent activation of downstream pathways may progress to infection resolution or to a dysregulated host response that represents the hallmark of organ injury in septic shock. Likewise, the management of organism toxicity in septic shock is complicated and comprises a multiplicity of suitable targets. In this review, the classic immune responses to pathogens are discussed as well as other factors that are relevant in the pathogenicity of septic shock, including sepsis-induced immune suppression, inflammasome activation, intestinal permeability, and the role of lipids and proprotein convertase subtilisin/kexin type 9. Current therapies aiming to eliminate the organisms causing septic shock, recent and ongoing trials in septic shock treatment, and potential new therapeutic strategies are also explored.
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Affiliation(s)
| | - Tadanaga Shimada
- Centre for Heart Lung Innovation, Vancouver, British Columbia, Canada
| | - John H Boyd
- Centre for Heart Lung Innovation, Vancouver, British Columbia, Canada.,Division of Critical Care Medicine, St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - Keith R Walley
- Centre for Heart Lung Innovation, Vancouver, British Columbia, Canada.,Division of Critical Care Medicine, St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - James A Russell
- Centre for Heart Lung Innovation, Vancouver, British Columbia, .,Division of Critical Care Medicine, St. Paul's Hospital, Vancouver, British Columbia,
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Abstract
PURPOSE OF REVIEW Sepsis is a common and frequently fatal condition in which mortality has been consistently linked to increasing organ dysfunction. For example, acute kidney injury (AKI) occurs in 40-50% of septic patients and increases mortality six to eight-fold. However, the mechanisms by which sepsis causes organ dysfunction are not well understood and hence current therapy remains reactive and nonspecific. RECENT FINDINGS Recent studies have challenged the previous notion that organ dysfunction is solely secondary to hypoperfusion, by showing, for example, that AKI occurs in the setting of normal or increased renal blood flow; and that it is characterized not by acute tubular necrosis or apoptosis, but rather by heterogeneous areas of colocalized sluggish peritubular blood flow and tubular epithelial cell oxidative stress. Evidence has also shown that microvascular dysfunction, inflammation, and the metabolic response to inflammatory injury are fundamental pathophysiologic mechanisms that may explain the development of sepsis-induced AKI. SUMMARY The implications of these findings are significant because in the context of decades of negative clinical trials in the field, the recognition that other mechanisms are at play opens the possibility to better understand the processes of injury and repair, and provides an invaluable opportunity to design mechanism-targeted therapeutic interventions.
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110
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Abstract
PURPOSE OF REVIEW The past decade has seen more advances in our understanding of fluid therapy than the preceding decades combined. What was once thought to be a relatively benign panacea is increasingly being recognized as a potent pharmacological and physiological intervention that may pose as much harm as benefit. RECENT FINDINGS Recent studies have clearly indicated that the amount, type, and timing of fluid administration have profound effects on patient morbidity and outcomes. The practice of aggressive volume resuscitation for 'renal protection' and 'hemodynamic support' may in fact be contributing to end organ dysfunction. The practice of early goal-directed therapy for patients suffering from critical illness or undergoing surgery appears to offer no benefit over conventional therapy and may in fact be harmful. A new conceptual model for fluid resuscitation of critically ill patients has recently been developed and is explored here. SUMMARY The practice of giving more fluid early and often is being replaced with new conceptual models of fluid resuscitation that suggest fluid therapy be 'personalized' to individual patient pathophysiology.
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111
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Intermittent furosemide administration in patients with or at risk for acute kidney injury: Meta-analysis of randomized trials. PLoS One 2018; 13:e0196088. [PMID: 29689116 PMCID: PMC5915682 DOI: 10.1371/journal.pone.0196088] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 04/05/2018] [Indexed: 12/13/2022] Open
Abstract
Background Furosemide is the most common loop diuretic used worldwide. The off-label administration of furosemide bolus(es) for the prevention or to reverse acute kidney injury (AKI) is widespread but not supported by available evidence. We conducted a meta-analysis of randomized trials (RCTs) to investigate whether bolus furosemide to prevent or treat AKI is detrimental on patients’ survival. Methods Electronic databases were searched through October 2017 for RCTs comparing bolus furosemide administration versus any comparator in patients with or at risk for AKI. The primary endpoint was all-cause longest follow-up mortality. Secondary endpoints included new or worsening AKI, receipt of renal replacement therapy, length of hospital stay, and peak serum creatinine after randomization. Results A total of 28 studies randomizing 3,228 patients were included in the analysis. We found no difference in mortality between the two groups (143/892 [16%] in the furosemide group versus 141/881 [16%] in the control group; odds ratio [OR], 0.84; 95% confidence interval [CI], 0.63 to 1.13; p = 0.25). No significant differences in secondary outcomes were found. A significant improvement in survival was found in the subgroup of patients receiving furosemide bolus(es) as a preventive measure (43/613 [7.0%] versus 67/619 [10.8%], OR 0.62; 95% CI, 0.41 to 0.94; p = 0.03) Conclusions Intermittent furosemide administration is not associated with an increased mortality in patients with or at risk for AKI, although it may reduce mortality when used as a preventive measure. Future high-quality RCTs are needed to define the role of loop diuretics in AKI prevention and management. Trial registration The study protocol was registered on PROSPERO database for systematic reviews (Registration no. CRD42017078607 – http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42017078607).
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Calvo-Vecino J, Ripollés-Melchor J, Mythen M, Casans-Francés R, Balik A, Artacho J, Martínez-Hurtado E, Serrano Romero A, Fernández Pérez C, Asuero de Lis S, Errazquin AT, Gil Lapetra C, Motos AA, Reche EG, Medraño Viñas C, Villaba R, Cobeta P, Ureta E, Montiel M, Mané N, Martínez Castro N, Horno GA, Salas RA, Bona García C, Ferrer Ferrer ML, Franco Abad M, García Lecina AC, Antón JG, Gascón GH, Peligro Deza J, Pascual LP, Ruiz Garcés T, Roberto Alcácer AT, Badura M, Terrer Galera E, Fernández Casares A, Martínez Fernández MC, Espinosa Á, Abad-Gurumeta A, Feldheiser A, López Timoneda F, Zuleta-Alarcón A, Bergese S. Effect of goal-directed haemodynamic therapy on postoperative complications in low–moderate risk surgical patients: a multicentre randomised controlled trial (FEDORA trial). Br J Anaesth 2018; 120:734-744. [DOI: 10.1016/j.bja.2017.12.018] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Revised: 11/20/2017] [Accepted: 12/11/2017] [Indexed: 02/06/2023] Open
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113
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Intraoperative hypotension is associated with acute kidney injury in noncardiac surgery. Eur J Anaesthesiol 2018; 35:273-279. [DOI: 10.1097/eja.0000000000000735] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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114
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Joannidis M, Klein SJ, John S, Schmitz M, Czock D, Druml W, Jörres A, Kindgen-Milles D, Kielstein JT, Oppert M, Schwenger V, Willam C, Zarbock A. [Prevention of acute kidney injury in critically ill patients : Recommendations from the renal section of the DGIIN, ÖGIAIN and DIVI]. Med Klin Intensivmed Notfmed 2018; 113:358-369. [PMID: 29594317 DOI: 10.1007/s00063-018-0413-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 02/26/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) has both high mortality and morbidity. OBJECTIVES To prevent the occurrence of AKI, current recommendations from the renal section of the DGIIN (Deutschen Gesellschaft für Internistische Intensivmedizin und Notfallmedizin), ÖGIAIN (Österreichischen Gesellschaft für Internistische und Allgemeine Intensivmedizin und Notfallmedizin) and DIVI (Deutschen Interdisziplinären Vereinigung für Intensiv- und Notfallmedizin) are stated. MATERIALS AND METHODS The recommendations stated in this paper are based on the current Kidney Disease Improving Global Outcomes (KDIGO) guidelines, the published statements of the "Working Group on Prevention, AKI section of the European Society of Intensive Care Medicine" and the expert knowledge and clinical experience of the authors. RESULTS Currently there are no approved clinically effective drugs for the prevention of AKI. Therefore the mainstay of prevention is the optimization of renal perfusion by improving the mean arterial pressure (>65 mm Hg, higher target may be considered in hypertensive patients). This can be done by vasopressors, preferably norepinephrine and achieving or maintaining euvolemia. Hyperhydration that can lead to AKI itself should be avoided. In patients with maintained diuresis this can be done by diuretics that are per se no preventive drug for AKI. Radiocontrast enhanced imaging should not be withheld from patients at risk for AKI; if indicated, however, the contrast media should be limited to the smallest possible volume.
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Affiliation(s)
- M Joannidis
- Gemeinsame Einrichtung Internistische Intensiv- und Notfallmedizin, Department für Innere Medizin, Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich.
| | - S J Klein
- Gemeinsame Einrichtung Internistische Intensiv- und Notfallmedizin, Department für Innere Medizin, Medizinische Universität Innsbruck, Anichstraße 35, 6020, Innsbruck, Österreich
| | - S John
- Abteilung Internistische Intensivmedizin, Medizinische Klinik 8, Paracelsus Medizinische Privatuniversität Nürnberg, Klinikum Nürnberg-Süd, Universität Erlangen-Nürnberg, Nürnberg, Deutschland
| | - M Schmitz
- Klinik für Nephrologie, Städtisches Klinikum Solingen, Solingen, Deutschland
| | - D Czock
- Medizinische Klinik, Abteilung Klinische Pharmakologie und Pharmakoepidemiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - W Druml
- Department für Innere Medizin III, Allgemeines Krankenhaus Wien, Wien, Österreich
| | - A Jörres
- Medizinische Klinik I für Nephrologie, Transplantationsmedizin und internistische Intensivmedizin, Klinikum der Universität Witten/Herdecke, Köln-Merheim, Deutschland
| | - D Kindgen-Milles
- Klinik für Anästhesiologie, Heinrich-Heine-Universität, Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
| | - J T Kielstein
- Medizinische Klinik V, Nephrologie
- Rheumatologie
- Blutreinigungsverfahren, Städtisches Klinikum Braunschweig, Braunschweig, Deutschland
| | - M Oppert
- Klinik für Notfall- und internistische Intensivmedizin, Klinikum Ernst von Bergmann, Potsdam, Deutschland
| | - V Schwenger
- Klinik für Nieren‑, Hochdruck- und Autoimmunerkrankungen, Klinikum Stuttgart, Stuttgart, Deutschland
| | - C Willam
- Nephrologie und Hypertensiologie, Medizinische Klinik 4, Erlangen, Deutschland
| | - A Zarbock
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Albert-Schweitzer-Campus 1, Gebäude A1, 48149, Münster, Deutschland
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115
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Mottola C, Girerd N, Coiro S, Lamiral Z, Rossignol P, Frimat L, Girerd S. Evaluation of Subclinical Fluid Overload Using Lung Ultrasound and Estimated Plasma Volume in the Postoperative Period Following Kidney Transplantation. Transplant Proc 2018; 50:1336-1341. [PMID: 29880355 DOI: 10.1016/j.transproceed.2018.03.007] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Accepted: 03/01/2018] [Indexed: 12/11/2022]
Abstract
AIM B-lines count measured with lung ultrasound (LUS) quantifies extravascular lung water and is validated in the setting of acute cardiac failure or chronic dialysis. Patients are often kept in moderately overhydrated states during the early postoperative period following kidney transplantation (KT). We described congestion changes during the early postoperative period following KT and the feasibility of LUS in this setting. METHODS LUS (28 scanning-points method) and inferior vena cava (IVC) measurements were routinely performed in 36 patients after KT. Estimated plasma volume (ePV) was calculated from hemoglobin and hematocrit levels. RESULTS No patient had >15 B-lines during the hospital stay. B-lines slightly increased until Day 4 after KT (Day 1, 1.7 ± 1.7; Day 4, 2.5 ± 2.5) and decreased up to Day 10 (1.4 ± 2.2; P vs Day 4 <.05). More B-lines were observed in patients aged older than 60 (P = .01 at Day 4) whereas IVC diameter and ePV were similar. In patients older than 60, B-lines had weak correlation with body weight variation (r = 0.64; P < .05), IVC diameters (r = 0.59 at Day 4 and r = 0.58 at Day 10; P < .05) but a strong correlation with ePV (r = 0.93 at Day 14; P < .05). B-line changes from Day 1 to Day 10 correlated with IVC diameter changes (r = 0.62; P < .05). CONCLUSION LUS identifies subtle congestion changes during the early postoperative period following KT. The hyperhydration strategy usually followed during this period does not result in overt pulmonary congestion as assessed by LUS, even in older recipients.
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Affiliation(s)
- C Mottola
- Transplant Unit, Nephrology Department, Nancy University Hospital, Lorraine University, Nancy, France
| | - N Girerd
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, INSERMU1116, Université de Lorraine, CHRU de Nancy, F-CRIN INI-CRCT, Vandoeuvre-lès-Nancy, France; INI-Cardiovascular and Renal Clinical Trialists F-CRIN network, Nancy, France
| | - S Coiro
- INI-Cardiovascular and Renal Clinical Trialists F-CRIN network, Nancy, France; Division of Cardiology, University of Perugia, School of Medicine, Perugia, Italy
| | - Z Lamiral
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, INSERMU1116, Université de Lorraine, CHRU de Nancy, F-CRIN INI-CRCT, Vandoeuvre-lès-Nancy, France
| | - P Rossignol
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, INSERMU1116, Université de Lorraine, CHRU de Nancy, F-CRIN INI-CRCT, Vandoeuvre-lès-Nancy, France; INI-Cardiovascular and Renal Clinical Trialists F-CRIN network, Nancy, France
| | - L Frimat
- Transplant Unit, Nephrology Department, Nancy University Hospital, Lorraine University, Nancy, France; INI-Cardiovascular and Renal Clinical Trialists F-CRIN network, Nancy, France
| | - S Girerd
- Transplant Unit, Nephrology Department, Nancy University Hospital, Lorraine University, Nancy, France; INSERM, Centre d'Investigations Cliniques Plurithématique 1433, INSERMU1116, Université de Lorraine, CHRU de Nancy, F-CRIN INI-CRCT, Vandoeuvre-lès-Nancy, France; INI-Cardiovascular and Renal Clinical Trialists F-CRIN network, Nancy, France.
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116
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Pfortmueller CA, Kabon B, Schefold JC, Fleischmann E. Crystalloid fluid choice in the critically ill : Current knowledge and critical appraisal. Wien Klin Wochenschr 2018; 130:273-282. [PMID: 29500723 DOI: 10.1007/s00508-018-1327-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2017] [Accepted: 02/11/2018] [Indexed: 12/24/2022]
Abstract
Intravenous infusion of crystalloid solutions is one of the most frequently administered medications worldwide. Available crystalloid infusion solutions have a variety of compositions and have a major impact on body systems; however, administration of crystalloid fluids currently follows a "one fluid for all" approach than a patient-centered fluid prescription. Normal saline is associated with hyperchloremic metabolic acidosis, increased rates of acute kidney injury, increased hemodynamic instability and potentially mortality. Regarding balanced infusates, evidence remains less clear since most studies compared normal saline to buffered infusion solutes.; however, buffered solutes are not homogeneous. The term "buffered solutes" only refers to the concept of acid-buffering in infusion fluids but this does not necessarily imply that the solutes have similar physiological impacts. The currently available data indicate that balanced infusates might have some advantages; however, evidence still is inconclusive. Taking the available evidence together, there is no single fluid that is superior for all patients and settings, because all currently available infusates have distinct differences, advantages and disadvantages; therefore, it seems inevitable to abandon the "one fluid for all" strategy towards a more differentiated and patient-centered approach to fluid therapy in the critically ill.
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Affiliation(s)
- Carmen A Pfortmueller
- Clinic for General Anesthesiology, Intensive Care and Pain Management, Medical University of Vienna, Vienna, Austria. .,Department of Intensive Care, Inselspital, Bern University Hospital, Bern, Switzerland.
| | - Barbara Kabon
- Clinic for General Anesthesiology, Intensive Care and Pain Management, Medical University of Vienna, Vienna, Austria
| | - Joerg C Schefold
- Department of Intensive Care, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Edith Fleischmann
- Clinic for General Anesthesiology, Intensive Care and Pain Management, Medical University of Vienna, Vienna, Austria
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Reply to: the central venous pressure, and 'a plea for some common-sense'. Eur J Anaesthesiol 2018; 35:322-323. [PMID: 29485459 DOI: 10.1097/eja.0000000000000772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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118
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Wang XT, Wang C, Zhang HM, Liu DW. Clarifications on Continuous Renal Replacement Therapy and Hemodynamics. Chin Med J (Engl) 2018; 130:1244-1248. [PMID: 28485326 PMCID: PMC5443032 DOI: 10.4103/0366-6999.205863] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective: Continuous renal replacement therapy (CRRT) is a continuous process of bedside blood purification which is widely used in the treatment of acute kidney injury (AKI) and for fluid management. However, since AKI and fluid overload are often found to be associated with hemodynamic abnormalities, determining the relationship between CRRT and hemodynamics remains a challenge in the treatment of critically ill patients. The aim of this review was to summarize key points in the relationship between CRRT and hemodynamics and to understand and monitor renal hemodynamics in critically ill patients, especially those with AKI. Data Sources: This review was based on data in articles published in the PubMed databases up to January 30, 2017, with the following keywords: “continuous renal replacement therapy,” “Hemodynamics,” and “Acute kidney injury.” Study Selection: Original articles and critical reviews on CRRT were selected for this review. Results: CRRT might treat AKI by hemodynamic therapy, and it was an important form of hemodynamic therapy. The targets of hemodynamic therapy should be established when using CRRT. Therefore, hemodynamic management and stability were very important during CRRT. Most studies suggested that renal hemodynamics should be clearly identified. Conclusions: CRRT is not only a replacement for organ function, but an important form of hemodynamic therapy. Improved hemodynamic management of critically ill patients can be achieved by establishing specific therapeutic hemodynamic targets and maintaining circulatory stability during CRRT. Over the long term, observation of renal hemodynamics will provide greater opportunities for the progression of CRRT hemodynamic therapy.
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Affiliation(s)
- Xiao-Ting Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Cui Wang
- Department of Critical Care Medicine, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou 550001, China
| | - Hong-Min Zhang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Da-Wei Liu
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
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119
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Duburcq T, Durand A, Tournoys A, Gnemmi V, Gmyr V, Pattou F, Jourdain M, Tamion F, Besnier E, Préau S, Parmentier-Decrucq E, Mathieu D, Poissy J, Favory R. Sodium lactate improves renal microvascular thrombosis compared to sodium bicarbonate and 0.9% NaCl in a porcine model of endotoxic shock: an experimental randomized open label controlled study. Ann Intensive Care 2018; 8:24. [PMID: 29445877 PMCID: PMC5812960 DOI: 10.1186/s13613-018-0367-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Accepted: 02/01/2018] [Indexed: 12/29/2022] Open
Abstract
Background Sodium lactate seemed to improve fluid balance and avoid fluid overload. The objective of this study was to determine if these beneficial effects can be at least partly explained by an improvement in disseminated intravascular coagulation (DIC)-associated renal microvascular thrombosis. Methods Ancillary work of an interventional randomized open label controlled experimental study. Fifteen female “Large White” pigs (2 months old) were challenged with intravenous infusion of E. coli endotoxin. Three groups of five animals were randomly assigned to receive different fluids: a treatment group received sodium lactate 11.2% (SL group); an isotonic control group received 0.9% NaCl (NC group); a hypertonic control group, with the same amount of osmoles and sodium than SL group, received sodium bicarbonate 8.4% (SB group). Glomerular filtration rate (GFR) markers, coagulation and inflammation parameters were measured over a 5-h period. Immediately after euthanasia, kidneys were withdrawn for histological study. Statistical analysis was performed with nonparametric tests and the Dunn correction for multiple comparisons. A p < 0.05 was considered significant. Results The direct immunofluorescence study revealed that the percentage of capillary sections thrombosed in glomerulus were significantly lesser in SL group [5 (0–28) %] compared to NC [64 (43–79) %, p = 0.01] and SB [64 (43–79), p = 0.03] groups. Alterations in platelet count and fibrinogen level occurred earlier and were significantly more pronounced in both control groups compared to SL group (p < 0.05 at 210 and 300 min). The increase in thrombin–antithrombin complexes was significantly higher in NC [754 (367–945) μg/mL; p = 0.03] and SB [463 (249–592) μg/mL; p = 0.03] groups than in SL group [176 (37–265) μg/mL]. At the end of the experiment, creatinine clearance was significantly higher in SL group [55.46 (30.07–67.85) mL/min] compared to NC group [1.52 (0.17–27.67) mL/min, p = 0.03]. Conclusions In this study, we report that sodium lactate improves DIC-associated renal microvascular thrombosis and preserves GFR. These findings could at least partly explain the better fluid balance observed with sodium lactate infusion.
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Affiliation(s)
- Thibault Duburcq
- Centre de Réanimation - Rue Emile Laine, CHU de Lille - Hôpital R Salengro, 59037, Lille Cedex, France.
| | - Arthur Durand
- Centre de Réanimation - Rue Emile Laine, CHU de Lille - Hôpital R Salengro, 59037, Lille Cedex, France.,LIRIC Inserm U995 Glycation: From Inflammation to Aging, 59000, Lille, France
| | | | - Viviane Gnemmi
- Centre de Biologie Pathologie, CHU Lille, 59000, Lille, France
| | - Valery Gmyr
- INSERM U1190 Translational Research for Diabetes, Univ Lille, 59000, Lille, France.,European Genomic Institute for Diabetes, 59000, Lille, France
| | - François Pattou
- INSERM U1190 Translational Research for Diabetes, Univ Lille, 59000, Lille, France.,European Genomic Institute for Diabetes, 59000, Lille, France
| | - Mercedes Jourdain
- Centre de Réanimation - Rue Emile Laine, CHU de Lille - Hôpital R Salengro, 59037, Lille Cedex, France.,INSERM U1190 Translational Research for Diabetes, Univ Lille, 59000, Lille, France.,European Genomic Institute for Diabetes, 59000, Lille, France
| | - Fabienne Tamion
- Medical Intensive Care Unit, Rouen University Hospital, Rouen, France
| | - Emmanuel Besnier
- Medical Intensive Care Unit, Rouen University Hospital, Rouen, France
| | - Sebastien Préau
- Centre de Réanimation - Rue Emile Laine, CHU de Lille - Hôpital R Salengro, 59037, Lille Cedex, France
| | - Erika Parmentier-Decrucq
- Centre de Réanimation - Rue Emile Laine, CHU de Lille - Hôpital R Salengro, 59037, Lille Cedex, France
| | - Daniel Mathieu
- Centre de Réanimation - Rue Emile Laine, CHU de Lille - Hôpital R Salengro, 59037, Lille Cedex, France
| | - Julien Poissy
- Centre de Réanimation - Rue Emile Laine, CHU de Lille - Hôpital R Salengro, 59037, Lille Cedex, France
| | - Raphaël Favory
- Centre de Réanimation - Rue Emile Laine, CHU de Lille - Hôpital R Salengro, 59037, Lille Cedex, France.,LIRIC Inserm U995 Glycation: From Inflammation to Aging, 59000, Lille, France
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Ziesmann MT, Marshall JC. Multiple Organ Dysfunction: The Defining Syndrome of Sepsis. Surg Infect (Larchmt) 2018; 19:184-190. [PMID: 29360419 DOI: 10.1089/sur.2017.298] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Sepsis as a process has been recognized since the time of the Ancient Greeks. The concept has evolved recently to reflect a disease process of a severe, systemic response to infection. Acute, life-threatening but potentially reversible organ dysfunction is its hallmark, and unresolving organ dysfunction is the dominant cause of death in critical illness. Its evolution, persistence, and resolution reflect a complex interplay of factors originating in the initial inciting insult, the innate immune and metabolic response of the host, and the beneficial and harmful consequences of intensive care unit (ICU) supportive care. DISCUSSION We describe the common clinical manifestations of the six prototypic organ system dysfunction syndromes of severe sepsis and review the associated epidemiology and suspected pathophysiology.
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Affiliation(s)
- Markus T Ziesmann
- Departments of Surgery and Critical Care Medicine, St. Michael's Hospital, University of Toronto , Toronto, Ontario, Canada
| | - John C Marshall
- Departments of Surgery and Critical Care Medicine, St. Michael's Hospital, University of Toronto , Toronto, Ontario, Canada
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121
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Ricci Z, Romagnoli S, Ronco C. The 10 false beliefs in adult critical care nephrology. Intensive Care Med 2017; 44:1302-1305. [PMID: 29196792 DOI: 10.1007/s00134-017-5011-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Accepted: 11/28/2017] [Indexed: 12/25/2022]
Affiliation(s)
- Zaccaria Ricci
- Department of Cardiology and Cardiac Surgery, Pediatric Cardiac Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Piazza Sant'Onofrio, 4, 00165, Rome, Italy.
| | - Stefano Romagnoli
- Department of Anesthesiology and Intensive Care, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla, 3, 50139, Florence, Italy
| | - Claudio Ronco
- Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Via Rodolfi, 37, 36100, Vicenza, Italy.,International Renal Research Institute of Vicenza (IRRIV), Via Rodolfi, 37, 36100, Vicenza, Italy
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122
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Saleh MH, Elghonemi MO. Association of acute kidney injury defined with the AKIN criteria and poor outcome in acute respiratory distress syndrome patients. THE EGYPTIAN JOURNAL OF BRONCHOLOGY 2017. [DOI: 10.4103/1687-8426.203796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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123
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Abstract
Post-operative acute kidney injury (AKI) is a common complication of surgery with significant short- and long-term adverse consequences. The adoption of diagnostic criteria for AKI (RIFLE, AKIN and KDIGO) has facilitated comparison of data reported by different centres, confirming that even mild AKI is associated with excess mortality. It remains unclear whether this is caused by the kidney injury itself or whether AKI is simply a marker of underlying disease severity. There is no trial evidence to support the use of any specific therapeutic intervention in post-operative AKI. Best current treatment is, therefore, preventative by optimizing hydration and avoidance of nephrotoxins, emphasizing the importance of earlier detection and identification of individuals at high risk for AKI. In this review, we examine the latest literature on the management of post-operative AKI in adult patients, specifically the diagnosis and definition of AKI, epidemiology and pathogenesis and risk stratification in cardiac and non-cardiac surgery. We also review the latest evidence on pharmacological and non-pharmacological interventions.
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Affiliation(s)
- S Bell
- Renal Unit, Ninewells Hospital, Dundee DD1 9SY, Scotland
| | - V C Ross
- Renal Unit, Ninewells Hospital, Dundee DD1 9SY, Scotland
| | - K A Zealley
- Department of Anaesthetics, Ninewells Hospital, Dundee DD1 SY, Scotland
| | - F Millar
- Department of Anaesthetics, Ninewells Hospital, Dundee DD1 SY, Scotland
| | - C Isles
- Renal Unit, Dumfries and Galloway Royal Infirmary, Dumfries, Scotland
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124
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Younan D, Griffin R, Reiff D, Richey J, Schinnerer E, Pittet JF, Zaky A. Echocardiographic correlates are associated with in-hospital mortality in trauma and burn patients. Am J Surg 2017; 214:798-803. [DOI: 10.1016/j.amjsurg.2017.02.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Revised: 01/27/2017] [Accepted: 02/05/2017] [Indexed: 11/17/2022]
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125
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Kashani KB, Mao SA, Safadi S, Amiot BP, Glorioso JM, Lieske JC, Nyberg SL, Zhang X. Association between kidney intracapsular pressure and ultrasound elastography. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:251. [PMID: 29047410 PMCID: PMC5648471 DOI: 10.1186/s13054-017-1847-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 09/28/2017] [Indexed: 01/01/2023]
Abstract
Background Kidney congestion is a common pathophysiologic pathway of acute kidney injury (AKI) in sepsis and heart failure. There is no noninvasive tool to measure kidney intracapsular pressure (KIP) directly. Methods We evaluated the correlation of KIP with kidney elasticity measured by ultrasound surface wave elastography (USWE). We directly measured transcatheter KIP in three pigs at baseline and after bolus infusion of normal saline, norepinephrine, vasopressin, dopamine, and fenoldopam; infiltration of 2-L peritoneal dialysis solution in the intra-abdominal space; and venous, arterial, and ureteral clamping. KIP was compared with USWE wave speed. Results Only intra-abdominal installation of peritoneal dialysis fluid was associated with significant change in KIP (mean (95% CI) increase, 3.7 (3.2–4.2)] mmHg; P < .001). Although intraperitoneal pressure and KIP did not differ under any experimental condition, bladder pressure was consistently and significantly greater than KIP under all circumstances (mean (95% CI) bladder pressure vs. KIP, 3.8 (2.9–4.) mmHg; P < .001). USWE wave speed significantly correlated with KIP (adjusted coefficient of determination, 0.71; P < .001). Estimate (95% CI) USWE speed for KIP prediction stayed significant after adjustment for KIP hypertension (−0.8 (− 1.4 to − 0.2) m/s; P = .008) whereas systolic and diastolic blood pressures were not significant predictors of KIP. Conclusions In a pilot study of the swine model, we found ultrasound surface wave elastography speed is significantly correlated with transcatheter measurement of kidney intracapsular and intra-abdominal pressures, while bladder pressure overestimated kidney intracapsular pressure.
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Affiliation(s)
- Kianoush B Kashani
- Division of Nephrology and Hypertension, Mayo Clinic, 200 First St SW, Rochester, Minnesota, 55905, USA. .,Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota, USA.
| | - Shennen A Mao
- Division of Transplantation Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Sami Safadi
- Division of Nephrology and Hypertension, Mayo Clinic, 200 First St SW, Rochester, Minnesota, 55905, USA
| | - Bruce P Amiot
- Division of Surgery Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Jaime M Glorioso
- Division of Transplantation Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - John C Lieske
- Division of Nephrology and Hypertension, Mayo Clinic, 200 First St SW, Rochester, Minnesota, 55905, USA.,Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota, USA
| | - Scott L Nyberg
- Division of Transplantation Surgery, Mayo Clinic, Rochester, Minnesota, USA.,Division of Surgery Research, Mayo Clinic, Rochester, Minnesota, USA
| | - Xiaoming Zhang
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA.,Department of Physiology and Biomedical Engineering, Mayo Clinic, Rochester, Minnesota, USA
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126
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Myles PS, Andrews S, Nicholson J, Lobo DN, Mythen M. Contemporary Approaches to Perioperative IV Fluid Therapy. World J Surg 2017; 41:2457-2463. [PMID: 28484814 DOI: 10.1007/s00268-017-4055-y] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Intravenous fluid therapy is required for most surgical patients, but inappropriate regimens are commonly prescribed. The aim of this narrative review was to provide evidence-based guidance on appropriate perioperative fluid management. METHOD We did a systematic literature search of the literature to identify relevant studies and meta-analyses to develop recommendations. RESULTS Of 275 retrieved articles, we identified 25 articles to inform this review. "Normal" saline (0.9% sodium chloride) is not physiological and can result in sodium overload and hyperchloremic acidosis. Starch colloid solutions are not recommended in surgical patients at-risk of sepsis or renal failure. Most surgical patients can have clear fluids and/or administration of carbohydrate-rich drinks up to 2 h before surgery. An intraoperative goal-directed fluid strategy may reduce postoperative complications and reduce hospital length of stay. Regular postoperative assessment of the patient's fluid status and requirements should include looking for physical signs of dehydration or hypovolemia, or fluid overload. Both hypovolemia and salt and water overload lead to adverse events, complications and prolonged hospital stay. Urine output can be an unreliable indicator of hydration status in the postoperative surgical patient. Excess fluid administration has been linked to acute kidney injury, gastrointestinal dysfunction, and cardiac and pulmonary complications. CONCLUSION There is good evidence supporting the avoidance of unnecessary fasting and the value of an individualized perioperative IV fluid regimen, with transition to oral fluids as soon as possible, to help patients recover from major surgery.
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Affiliation(s)
- Paul S Myles
- Department of Anaesthesia and Perioperative Medicine, Alfred Hospital and Monash University, Commercial Road, Melbourne, VIC, 3004, Australia.
| | - Sam Andrews
- Department of Anaesthesia and Perioperative Medicine, Alfred Hospital, Melbourne, VIC, Australia
| | - Jonathan Nicholson
- Department of Anaesthesia and Perioperative Medicine, Alfred Hospital, Melbourne, VIC, Australia
| | - Dileep N Lobo
- Nottingham Digestive Diseases Centre, National Institute of Health Research (NIHR) Biomedical Research Centre, Nottingham University Hospitals and University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Monty Mythen
- Smiths Medical Professor of Anaesthesia and Critical Care, National Institute of Health Research Biomedical Research Centre, University College London Hospitals, London, UK
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Ellis RJ, Del Vecchio SJ, Ng KL, Dimeski G, Pascoe EM, Hawley CM, Johnson DW, Vesey DA, Coombes JS, Morais C, Francis RS, Wood ST, Gobe GC. Factors associated with acutely elevated serum creatinine following radical tumour nephrectomy: the Correlates of Kidney Dysfunction-Tumour Nephrectomy Database study. Transl Androl Urol 2017; 6:899-909. [PMID: 29184790 PMCID: PMC5673817 DOI: 10.21037/tau.2017.08.15] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 08/21/2017] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND To identify factors associated with acutely elevated serum creatinine (SCr) within 7 days of radical tumour nephrectomy. METHODS The study population consisted of 130 consecutive patients managed for renal tumours. The primary outcome was acute kidney injury (AKI) (defined as SCr increase ≥50% above baseline), assessed using multivariable logistic regression analysis. The secondary outcome was SCr percentage increase, assessed using multivariable linear regression analysis. RESULTS Following nephrectomy, the mean percentage increase in SCr in the first week was 55%±29%, and 77 (59%) patients experienced AKI. Independent predictors of AKI post-nephrectomy were male gender [adjusted odds ratio (OR): 2.67; 95% confidence interval (95% CI): 1.01, 6.93], urine albumin-creatinine ratio (OR: 0.66; 95% CI: 0.47, 0.91), preoperative estimated glomerular filtration rate (eGFR) (OR: 1.03; 95% CI: 1.00, 1.05), laparoscopic nephrectomy (OR: 3.02; 95% CI: 1.00, 9.12), and non-clear cell renal cell carcinoma (RCC) (OR: 2.93; 95% CI: 1.04, 8.29). Independent predictors of a SCr increase were male gender (β: 12.0; 95% CI: 2.69, 21.3), urine albumin-creatinine ratio (β: -3.36; 95% CI: -6.55, -0.16), preoperative eGFR (β: 0.38; 95% CI: 0.10, 0.66), laparoscopic nephrectomy (β: 12.7; 95% CI: 1.05, 24.3) and obesity (β: 9.94, 95% CI: 0.61, 19.3). CONCLUSIONS Male gender, albuminuria, eGFR and laparoscopic nephrectomy independently associated with acutely elevated serum creatinine following radical tumour nephrectomy.
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Affiliation(s)
- Robert J. Ellis
- Kidney Disease Research Group, Diamantina Institute, Faculty of Medicine, University of Queensland, Brisbane, Australia
- Department of Urology, Princess Alexandra Hospital, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
| | - Sharon J. Del Vecchio
- Kidney Disease Research Group, Diamantina Institute, Faculty of Medicine, University of Queensland, Brisbane, Australia
- Department of Urology, Princess Alexandra Hospital, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
| | - Keng Lim Ng
- Kidney Disease Research Group, Diamantina Institute, Faculty of Medicine, University of Queensland, Brisbane, Australia
- Department of Urology, Princess Alexandra Hospital, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
| | - Goce Dimeski
- Kidney Disease Research Group, Diamantina Institute, Faculty of Medicine, University of Queensland, Brisbane, Australia
- Department of Chemical Pathology, Princess Alexandra Hospital, Brisbane, Australia
| | - Elaine M. Pascoe
- Translational Research Institute, Brisbane, Australia
- Australasian Kidney Trials Network, Faculty of Medicine, University of Queensland, Brisbane, Australia
| | - Carmel M. Hawley
- Kidney Disease Research Group, Diamantina Institute, Faculty of Medicine, University of Queensland, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
- Australasian Kidney Trials Network, Faculty of Medicine, University of Queensland, Brisbane, Australia
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
| | - David W. Johnson
- Kidney Disease Research Group, Diamantina Institute, Faculty of Medicine, University of Queensland, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
- Australasian Kidney Trials Network, Faculty of Medicine, University of Queensland, Brisbane, Australia
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
| | - David A. Vesey
- Kidney Disease Research Group, Diamantina Institute, Faculty of Medicine, University of Queensland, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
| | - Jeff S. Coombes
- UQ NHMRC Chronic Kidney Disease Centre for Research Excellence (CKD.QLD), Royal Brisbane and Women’s Hospital, Brisbane, Australia
- School of Human Movement and Nutrition Science, University of Queensland, Brisbane, Australia
| | - Christudas Morais
- Kidney Disease Research Group, Diamantina Institute, Faculty of Medicine, University of Queensland, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
| | - Ross S. Francis
- Kidney Disease Research Group, Diamantina Institute, Faculty of Medicine, University of Queensland, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
- Australasian Kidney Trials Network, Faculty of Medicine, University of Queensland, Brisbane, Australia
- Department of Nephrology, Princess Alexandra Hospital, Brisbane, Australia
| | - Simon T. Wood
- Kidney Disease Research Group, Diamantina Institute, Faculty of Medicine, University of Queensland, Brisbane, Australia
- Department of Urology, Princess Alexandra Hospital, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
| | - Glenda C. Gobe
- Kidney Disease Research Group, Diamantina Institute, Faculty of Medicine, University of Queensland, Brisbane, Australia
- Translational Research Institute, Brisbane, Australia
- UQ NHMRC Chronic Kidney Disease Centre for Research Excellence (CKD.QLD), Royal Brisbane and Women’s Hospital, Brisbane, Australia
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Abstract
Acute kidney injury (AKI) is a clinical syndrome occurring in the context of multiple and diverse disease entities. Although the term AKI implies renal damage as well as functional impairment or a combination of both, diagnosis is solely based on the functional parameters serum creatinine and urine output. Independent of the underlying disease and even assuming full recovery of renal function, AKI is associated with increased morbidity and mortality not only during the acute situation, but also long term. Awareness of the individual risk profile of each patient and the variety of causes and clinical manifestations of AKI is pivotal for prophylaxis, diagnosis, and therapy. The complexity of the clinical syndrome in the context of sepsis, solid organ transplantation, malignancy, and autoimmune diseases requires differentiated diagnostic and therapeutic approaches and interdisciplinary care.
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Affiliation(s)
- A Bienholz
- Klinik für Nephrologie, Universitätsklinikum Essen, Universität Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Deutschland.
| | - A Kribben
- Klinik für Nephrologie, Universitätsklinikum Essen, Universität Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Deutschland
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Roberts DA, Shaw AD. Impact of volume status and volume therapy on the kidney. Best Pract Res Clin Anaesthesiol 2017; 31:345-352. [PMID: 29248141 DOI: 10.1016/j.bpa.2017.08.008] [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: 08/08/2017] [Accepted: 08/17/2017] [Indexed: 10/19/2022]
Abstract
Volume resuscitation to correct hypotension in surgical and critically ill patients is a common practice. Available evidence suggests that iatrogenic volume overload is associated with worse outcomes in established acute kidney injury. Intraoperative arterial hypotension is associated with postoperative renal dysfunction, and prompt correction with fluid management protocols that combine inotrope infusions with volume therapy targeted to indices of volume responsiveness should be considered. From the perspective of renal function, the minimum amount of intravenous fluid required to maintain perfusion and oxygen delivery is desirable. Available evidence and expert opinion suggest that balanced crystalloid solutions are preferable to isotonic saline for volume resuscitation. Moreover, albumin has a similar safety profile as crystalloids. Hetastarch-containing colloids have a clear association with acute kidney injury.
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Affiliation(s)
- David A Roberts
- Vanderbilt University Medical Center, 1211 Medical Center Drive, 2301 VUH C/o Robin Snyder, USA; Department of Anesthesiology, Vanderbilt University Medical Center, USA.
| | - Andrew D Shaw
- Vanderbilt University Medical Center, 1211 Medical Center Drive, 2301 VUH C/o Robin Snyder, USA; Department of Anesthesiology, Vanderbilt University Medical Center, USA.
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131
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Clark A, Neyra JA, Madni T, Imran J, Phelan H, Arnoldo B, Wolf SE. Acute kidney injury after burn. Burns 2017; 43:898-908. [DOI: 10.1016/j.burns.2017.01.023] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Revised: 12/13/2016] [Accepted: 01/16/2017] [Indexed: 01/04/2023]
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132
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Connor MJ, Karakala N. Continuous Renal Replacement Therapy: Reviewing Current Best Practice to Provide High-Quality Extracorporeal Therapy to Critically Ill Patients. Adv Chronic Kidney Dis 2017; 24:213-218. [PMID: 28778360 DOI: 10.1053/j.ackd.2017.05.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Continuous renal replacement therapy (CRRT) use continues to expand globally. Despite improving technology, CRRT remains a complex intervention. Delivery of high-quality CRRT requires close collaboration of a multidisciplinary team including members of the critical care medicine, nephrology, nursing, pharmacy, and nutrition support teams. While significant gaps in medical evidence regarding CRRT persist, the growing evidence base supports evolving best practice and consensus to define high-quality CRRT. Unfortunately, there is wide variability in CRRT operating characteristics and limited uptake of these best practices. This article will briefly review the current best practice on important aspects of CRRT delivery including CRRT dose, anticoagulation, dialysis vascular access, fluid management, and drug dosing in CRRT.
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133
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O'Connor ME, Jones SL, Glassford NJ, Bellomo R, Prowle JR. Defining fluid removal in the intensive care unit: A national and international survey of critical care practice. J Intensive Care Soc 2017; 18:282-288. [PMID: 29123557 DOI: 10.1177/1751143717699423] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Design and objectives To identify and compare how intensive care unit specialists in the United Kingdom and Australia and New Zealand self-reportedly define, assess and manage fluid overload in critically ill patients using a structured online questionnaire. Results We assessed 219 responses. Australia and New Zealand and United Kingdom intensive care unit specialists reported using clinical examination findings, bedside tools and radiological features to assess fluid status, diagnose fluid overload and initiate fluid removal in the critically ill. An elevated central venous pressure is not regarded as helpful in diagnosing fluid overload and targeting a clinician-set fluid balance is the most popular management strategy. Renal replacement therapy is used ahead of more diuretic therapy in patients who are oligo/anuric, or when diuretic therapy has not generated an adequate response. Conclusions This self-reported account of practice by United Kingdom and Australia and New Zealand intensivists demonstrates that fluid overload remains poorly defined with variability in both management and practice.
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Affiliation(s)
- Michael E O'Connor
- Adult Critical Care Unit, Royal London Hospital, Barts Health NHS Trust, London, UK.,Critical Care and Perioperative Medicine Research Group, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Sarah L Jones
- Intensive Care Unit, Royal Darwin Hospital, Tiwi, Australia
| | - Neil J Glassford
- Department of Intensive Care, Austin Hospital, Melbourne, Australia.,Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, Australia.,Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.,School of Medicine, The University of Melbourne, Melbourne, Australia
| | - John R Prowle
- Adult Critical Care Unit, Royal London Hospital, Barts Health NHS Trust, London, UK.,Critical Care and Perioperative Medicine Research Group, William Harvey Research Institute, Queen Mary University of London, London, UK
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134
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Besen BAMP, Romano TG, Mendes PV, Gallo CA, Zampieri FG, Nassar AP, Park M. Early Versus Late Initiation of Renal Replacement Therapy in Critically Ill Patients: Systematic Review and Meta-Analysis. J Intensive Care Med 2017; 34:714-722. [PMID: 28569129 DOI: 10.1177/0885066617710914] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Early initiation of renal replacement therapy (RRT) effect on survival and renal recovery of critically ill patients is still uncertain. We aimed to systematically review current evidence comparing outcomes of early versus late initiation of RRT in critically ill patients. METHODS We searched the Medline (via Pubmed), LILACS, Science Direct, and CENTRAL databases from inception until November 2016 for randomized clinical trials (RCTs) or observational studies comparing early versus late initiation of RRT in critically ill patients. The primary outcome was mortality. Duration of mechanical ventilation, intensive care unit (ICU) length of stay (LOS), hospital LOS, and renal function recovery were secondary outcomes. Meta-analysis and trial sequential analysis (TSA) were used for the primary outcome. RESULTS Sixty-two studies were retrieved and analyzed, including 11 RCTs. There was no difference in mortality between early and late initiation of RRT among RCTs (odds ratio [OR] = 0.78; 95% confidence interval [CI]: 0.52-1.19; I2 = 63.1%). Trial sequential analysis of mortality across all RCTs achieved futility boundaries at both 1% and 5% type I error rates, although a subgroup analysis of studies including only acute kidney injury patients was not conclusive. There was also no difference in time on mechanical ventilation, ICU and hospital LOS, or renal recovery among studies. Early initiation of RRT was associated with reduced mortality among prospective (OR = 0.69; 95% CI: 0.49-0.96; I2 = 85.9%) and retrospective (OR = 0.61; 95% CI: 0.41-0.92; I2 = 90.9%) observational studies, both with substantial heterogeneity. However, subgroup analysis excluding low-quality observational studies did not achieve statistical significance. CONCLUSION Pooled analysis of randomized trials indicates early initiation of RRT is not associated with lower mortality rates. The potential benefit of reduced mortality associated with early initiation of RRT was limited to low-quality observational studies.
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Affiliation(s)
- Bruno Adler Maccagnan Pinheiro Besen
- 1 Intensive Care Unit, Emergency department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil.,2 Intensive Care Unit, Hospital da Luz, Amil, São Paulo, Brazil
| | - Thiago Gomes Romano
- 3 Nephrology Department, ABC Medical School, Santo Andre, Brazil.,4 Research Institute, Hospital Sírio-Libanês, São Paulo, Brazil
| | - Pedro Vitale Mendes
- 1 Intensive Care Unit, Emergency department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil.,4 Research Institute, Hospital Sírio-Libanês, São Paulo, Brazil
| | - Cesar Albuquerque Gallo
- 1 Intensive Care Unit, Emergency department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil
| | - Fernando Godinho Zampieri
- 5 Research Institute, HCor-Hospital do Coração, São Paulo, Brazil.,6 Intensive Care Unit, Hospital Alemão Oswaldo Cruz, São Paulo, Brazil
| | - Antonio Paulo Nassar
- 1 Intensive Care Unit, Emergency department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil.,7 Intensive Care Unit, A.C. Camargo Cancer Center, São Paulo, Brazil
| | - Marcelo Park
- 1 Intensive Care Unit, Emergency department, Hospital das Clínicas, University of São Paulo Medical School, São Paulo, Brazil.,4 Research Institute, Hospital Sírio-Libanês, São Paulo, Brazil
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135
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Joannidis M, Druml W, Forni LG, Groeneveld ABJ, Honore PM, Hoste E, Ostermann M, Oudemans-van Straaten HM, Schetz M. Prevention of acute kidney injury and protection of renal function in the intensive care unit: update 2017 : Expert opinion of the Working Group on Prevention, AKI section, European Society of Intensive Care Medicine. Intensive Care Med 2017; 43:730-749. [PMID: 28577069 PMCID: PMC5487598 DOI: 10.1007/s00134-017-4832-y] [Citation(s) in RCA: 193] [Impact Index Per Article: 27.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 05/02/2017] [Indexed: 12/19/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) in the intensive care unit is associated with significant mortality and morbidity. OBJECTIVES To determine and update previous recommendations for the prevention of AKI, specifically the role of fluids, diuretics, inotropes, vasopressors/vasodilators, hormonal and nutritional interventions, sedatives, statins, remote ischaemic preconditioning and care bundles. METHOD A systematic search of the literature was performed for studies published between 1966 and March 2017 using these potential protective strategies in adult patients at risk of AKI. The following clinical conditions were considered: major surgery, critical illness, sepsis, shock, exposure to potentially nephrotoxic drugs and radiocontrast. Clinical endpoints included incidence or grade of AKI, the need for renal replacement therapy and mortality. Studies were graded according to the international GRADE system. RESULTS We formulated 12 recommendations, 13 suggestions and seven best practice statements. The few strong recommendations with high-level evidence are mostly against the intervention in question (starches, low-dose dopamine, statins in cardiac surgery). Strong recommendations with lower-level evidence include controlled fluid resuscitation with crystalloids, avoiding fluid overload, titration of norepinephrine to a target MAP of 65-70 mmHg (unless chronic hypertension) and not using diuretics or levosimendan for kidney protection solely. CONCLUSION The results of recent randomised controlled trials have allowed the formulation of new recommendations and/or increase the strength of previous recommendations. On the other hand, in many domains the available evidence remains insufficient, resulting from the limited quality of the clinical trials and the poor reporting of kidney outcomes.
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Affiliation(s)
- M Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Anichstasse 35, 6020, Innsbruck, Austria.
| | - W Druml
- Department of Internal Medicine III, University Hospital Vienna, Vienna, Austria
| | - L G Forni
- Department of Clinical and Experimental Medicine, Faculty of Health and Medical Sciences, University of Surrey and Surrey Perioperative Anaesthesia and Critical Care Collaborative Research Group (SPACeR), Intensive Care Unit, Royal Surrey County Hospital NHS Foundation Trust, Egerton Road, Guildford, GU2 7XX, United Kingdom
| | | | - P M Honore
- Department of Intensive Care, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - E Hoste
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent University, De Pintelaan 185, 9000, Ghent, Belgium
| | - M Ostermann
- Department of Critical Care and Nephrology, Guy's and St Thomas' Hospital, London, United Kingdom
| | - H M Oudemans-van Straaten
- Department of Adult Intensive Care, VU University Medical Centre, De Boelelaan 1118, 1081 HZ, Amsterdam, The Netherlands
| | - M Schetz
- Clinical Department and Laboratory of Intensive Care Medicine, Division of Cellular and Molecular Medicine, KU Leuven University, Leuven, Belgium
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136
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Hertzberg D, Rydén L, Pickering JW, Sartipy U, Holzmann MJ. Acute kidney injury-an overview of diagnostic methods and clinical management. Clin Kidney J 2017; 10:323-331. [PMID: 28616210 PMCID: PMC5466115 DOI: 10.1093/ckj/sfx003] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 01/13/2017] [Indexed: 12/12/2022] Open
Abstract
Acute kidney injury (AKI) is a common condition in multiple clinical settings. Patients with AKI are at an increased risk of death, over both the short and long term, and of accelerated renal impairment. As the condition has become more recognized and definitions more unified, there has been a rapid increase in studies examining AKI across many different clinical settings. This review focuses on the classification, diagnostic methods and clinical management that are available, or promising, for patients with AKI. Furthermore, preventive measures with fluids, acetylcysteine, statins and remote ischemic preconditioning, as well as when dialysis should be initiated in AKI patients are discussed. The classification of AKI includes both changes in serum creatinine concentrations and urine output. Currently, no kidney injury biomarkers are included in the classification of AKI, but proposals have been made to include them as independent diagnostic markers. Treatment of AKI is aimed at addressing the underlying causes of AKI, and at limiting damage and preventing progression. The key principles are: to treat the underlying disease, to optimize fluid balance and optimize hemodynamics, to treat electrolyte disturbances, to discontinue or dose-adjust nephrotoxic drugs and to dose-adjust drugs with renal elimination.
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Affiliation(s)
- Daniel Hertzberg
- Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
| | - Linda Rydén
- Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Anesthesiology, Surgical Services and Intensive Care Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - John W. Pickering
- Deparment of Medicine, University of Otago Christchurch and Emergency Department, Christchurch Hospital, Christchurch, New Zealand
| | - Ulrik Sartipy
- Section of Cardiothoracic Surgery, Karolinska University Hospital, Stockholm, Sweden
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Martin J. Holzmann
- Department of Medicine, Solna, Karolinska Institutet, Stockholm, Sweden
- Department of Emergency Medicine, Huddinge, Karolinska University Hospital, Stockholm, Sweden
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137
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Ripollés-Melchor J, Chappell D, Aya HD, Espinosa Á, Mhyten MG, Abad-Gurumeta A, Bergese SD, Casans-Francés R, Calvo-Vecino JM. Fluid therapy recommendations for major abdominal surgery. Via RICA recommendations revisited. Part II: Goal directed hemodynamic therapy. Rationale for optimising intravascular volume. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2017; 64:339-347. [PMID: 28343684 DOI: 10.1016/j.redar.2017.02.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 02/11/2017] [Accepted: 02/13/2017] [Indexed: 06/06/2023]
Affiliation(s)
- J Ripollés-Melchor
- Departamento de Anestesia, Hospital Universitario Infanta Leonor, Universidad Complutense de Madrid, Madrid, España.
| | - D Chappell
- Departamento de Anestesia, Hospital Universitario LMU de Múnich, Múnich, Alemania
| | - H D Aya
- Departamento de Cuidados Intensivos, St George's University Hospitals, NHS Foundation Trust, Londres, Reino Unido
| | - Á Espinosa
- Departamento de Anestesia Cardiovascular y Torácica, y Cuidados Intensivos, Bahrain Defence Force Hospital, Riffa, Reino de Baréin
| | - M G Mhyten
- University College London Hospital, National Institute for Health Research, Biomedical Research Centre, Londres, Reino Unido
| | - A Abad-Gurumeta
- Departamento de Anestesia, Hospital Universitario Infanta Leonor, Universidad Complutense de Madrid, Madrid, España
| | - S D Bergese
- Departamento de Anestesia y Neurocirugía, Wexner Medical Center, The Ohio State University, Columbus, OH, Estados Unidos
| | - R Casans-Francés
- Departamento de Anestesia, Hospital Clínico Universitario Lozano Blesa, Zaragoza, España
| | - J M Calvo-Vecino
- Departamento de Anestesia, Complejo Asistencial Universitario de Salamanca, Universidad de Salamanca (CAUSA), Salamanca, España
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138
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Vanmassenhove J, Kielstein J, Jörres A, Biesen WV. Management of patients at risk of acute kidney injury. Lancet 2017; 389:2139-2151. [PMID: 28561005 DOI: 10.1016/s0140-6736(17)31329-6] [Citation(s) in RCA: 151] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2016] [Revised: 04/01/2017] [Accepted: 04/04/2017] [Indexed: 02/02/2023]
Abstract
Acute kidney injury (AKI) is a multifaceted syndrome that occurs in different settings. The course of AKI can be variable, from single hit and complete recovery, to multiple hits resulting in end-stage renal disease. No interventions to improve outcomes of established AKI have yet been developed, so prevention and early diagnosis are key. Awareness campaigns and education for health-care professionals on diagnosis and management of AKI-with attention to avoidance of volume depletion, hypotension, and nephrotoxic interventions-coupled with electronic early warning systems where available can improve outcomes. Biomarker-based strategies have not shown improvements in outcome. Fluid management should aim for early, rapid restoration of circulatory volume, but should be more limited after the first 24-48 h to avoid volume overload. Use of balanced crystalloid solutions versus normal saline remains controversial. Renal replacement therapy should only be started on the basis of hard criteria, but should not be delayed when criteria are met. On the basis of recent evidence, the risk of contrast-induced AKI might be overestimated for many conditions.
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Affiliation(s)
| | - Jan Kielstein
- Medical Clinic V, Nephrology, Hypertension and Blood Purification, Academic Teaching Hospital Braunschweig, Braunschweig, Germany
| | - Achim Jörres
- Department of Medicine 1, Nephrology, Transplantation and Medical Intensive Care, University Witten/Herdecke, Medical Centre Cologne Merheim, Cologne, Germany
| | - Wim Van Biesen
- Renal Division, Ghent University Hospital, Ghent, Belgium.
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139
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Park JT. Postoperative acute kidney injury. Korean J Anesthesiol 2017; 70:258-266. [PMID: 28580076 PMCID: PMC5453887 DOI: 10.4097/kjae.2017.70.3.258] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Revised: 05/04/2017] [Accepted: 05/08/2017] [Indexed: 01/07/2023] Open
Abstract
Acute kidney injury (AKI) after cardiac surgery is a common and serious complication. Several definitions of AKI have been proposed recently, and include both increases in serum creatinine levels and decreases in urine output as diagnostic criteria. The pathophysiology of postoperative AKI is complex and involves both ischemic injury and systemic inflammation. Identifying risk factors, such as old age, underlying diabetes, heart failure, and obesity, may aid in the application of preventative methods for postoperative AKI. Additionally, recognizing different risks after different types of surgical procedures would be valuable. Novel biomarkers that could detect AKI more precisely at an earlier time point are being investigated. Several new biomarkers have been assessed in large multi-center studies and are believed to accommodate conventional clinical findings in diagnosing postoperative AKI. In high-risk patients, preventative measures, such as the maintenance of adequate hemodynamics and sufficient fluid resuscitation, could lower the incidence of postoperative AKI. Avoiding nephrotoxic agents and optimizing preoperative hemoglobin levels to avoid excessive transfusions would also be beneficial. In situations in which medical management fails to maintain sufficient urine output and acid-base and electrolyte homeostasis, early initiation of renal replacement therapy should be considered.
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Affiliation(s)
- Jung Tak Park
- Department of Internal Medicine, Institute of Kidney Disease Research, Yonsei University College of Medicine, Seoul, Korea
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140
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Determinants of Urinary Output Response to IV Furosemide in Acute Kidney Injury: A Pharmacokinetic/Pharmacodynamic Study. Crit Care Med 2017; 44:e923-9. [PMID: 27183025 DOI: 10.1097/ccm.0000000000001823] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVES This study assessed the determinants of urinary output response to furosemide in acute kidney injury; specifically, whether the response is related to altered pharmacokinetics or pharmacodynamics. DESIGN Prospective cohort. SETTING Tertiary ICU. PATIENTS Thirty critically ill patients with acute kidney injury without preexisting renal impairment or recent diuretic exposure. INTERVENTION A single dose of IV furosemide. MEASUREMENTS AND MAIN RESULTS Baseline markers of intravascular volume status were obtained prior to administering furosemide. Six-hour creatinine clearance, hourly plasma/urinary furosemide concentrations, and hourly urinary output were used to assess furosemide pharmacokinetics/pharmacodynamics parameters. Of 30 patients enrolled, 11 had stage-1 (37%), nine had stage-2 (30%), and 10 had stage-3 (33%) Acute Kidney Injury Network acute kidney injury. Seventy-three percent were septic, 47% required norepinephrine, and 53% were mechanically ventilated. Urinary output doubled in 20 patients (67%) following IV furosemide. Measured creatinine clearance was strongly associated with the amount of urinary furosemide excreted and was the only reliable predictor of the urinary output after furosemide (area under the receiver-operating-characteristic curve, 0.75; 95% CI, 0.57-0.93). In addition to an altered pharmacokinetics (p < 0.01), a reduced pharmacodynamics response to furosemide also became important when creatinine clearance was reduced to less than 40 mL/min/1.73 m (p = 0.01). Acute kidney injury staging and markers of intravascular volume, including central venous pressure, brain-natriuretic-peptide concentration, and fractional urinary sodium excretion were not predictive of urinary output response to furosemide. CONCLUSIONS The severity of acute kidney injury, as reflected by the measured creatinine clearance, alters both pharmacokinetics and pharmacodynamics of furosemide in acute kidney injury, and was the only reliable predictor of the urinary output response to furosemide in acute kidney injury.
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141
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Fluid management in acute kidney injury. Intensive Care Med 2017; 43:807-815. [DOI: 10.1007/s00134-017-4817-x] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 04/22/2017] [Indexed: 12/17/2022]
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142
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Outcomes from a cohort of patients with acute kidney injury subjected to continuous venovenous hemodiafiltration: The role of negative fluid balance. PLoS One 2017; 12:e0175897. [PMID: 28426835 PMCID: PMC5398654 DOI: 10.1371/journal.pone.0175897] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Accepted: 04/02/2017] [Indexed: 12/21/2022] Open
Abstract
Background Several factors influence the outcomes in acute kidney injury (AKI), especially in intensive care unit (ICU) patients. In this scenario, continuous renal replacement therapies (CRRT) are used to control metabolic derangements and blood volume. Knowing this fact, it may be possible to change the course of the disease and decrease the high mortality rate observed. Thus, we aimed to evaluate the main risk factors for death in AKI patients needing CRRT. Results This was a prospective, observational cohort study of ICU patients (N = 183) with AKI who underwent continuous venovenous hemodiafiltration (CVVHDF) as their initial dialysis modality choice. The patients were predominantly male (62.8%) and their median age was 65 (55–76) years. The most frequent comorbidities were cardiovascular disease (39.3%), hypertension (32.8%), diabetes (24%), and cirrhosis (20.7%). The main cause of AKI was sepsis (52.5%). At beginning of CVVHDF, 152 patients (83%) were using vasopressors. The median SAPS 3 and SOFA score at ICU admission was 61 (50–74) and 10 (7–12), respectively. The dialysis dose delivered was 33.2 (28.9–38.7) ml/kg/h. The median time between ICU admission and CVVHDF initiation was 2 (1–4) days. The median cumulative fluid balance during the CVVHDF period was -1838 (-5735 +2993) ml. The mortality rate up to90 days was 58%. The independent mortality risk factors in propensity score model were: chronic obstructive pulmonary disease (OR = 3.44[1.14–10.4; p = 0.028]), hematologic malignancy (OR = 5.14[1.66–15.95; p = 0.005]), oliguria (OR = 2.36[1.15–4.9; p = 0.02]), positive daily fluid balance during CVVHDF (OR = 4.55[2.75–13.1; p<0.001]), and total SOFA score on first dialysis day (OR = 1.27[1.12–1.45; p<0.001]). Conclusions Dialysis-related factors may influence the outcomes. In our cohort, positive daily fluid balance during CRRT was associated with lower survival. Multicenter, randomized studies are needed to assess fluid balance as a primary outcome to define the best strategy in this patient population.
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143
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Haines R, Crichton S, Wilson J, Treacher D, Ostermann M. Cardiac biomarkers are associated with maximum stage of acute kidney injury in critically ill patients: a prospective analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:88. [PMID: 28399905 PMCID: PMC5388994 DOI: 10.1186/s13054-017-1674-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/10/2016] [Accepted: 03/17/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND This study aimed to investigate whether cardiac troponin T (cTnT), cardiac troponin I (cTnI) and serum N-terminal pro-brain natriuretic peptide (NT-proBNP) are associated with acute kidney injury (AKI) and need for acute renal replacement therapy (RRT) in adult patients admitted to the intensive care unit (ICU). METHODS We analysed prospectively collected data for patients admitted to the ICU between June and December 2010 for non-cardiac reasons. The Kidney Disease Improving Global Outcomes creatinine criteria were applied to identify patients with AKI including those who received acute RRT. Severity of illness was determined by the Acute Physiology and Chronic Health Evaluation (APACHE) II score and the Serial Organ Failure Assessment (SOFA) score. Regression analyses were performed to assess the association between cTnT, cTnI and NT-proBNP concentrations on the first day of ICU stay, maximum AKI stages and need for acute RRT. Sensitivity analysis was performed in which patients who developed a myocardial infarction during their stay in the ICU were excluded. RESULTS Of 138 patients included, 73 (53%) had AKI and 40 (29%) required acute RRT. Patients with AKI were significantly older, more likely to have sepsis and had higher APACHE II and SOFA scores on admission to the ICU. In univariable analysis, cTnT, cTnI and NT-proBNP were significantly higher in those with AKI requiring acute RRT, but after adjustment for baseline differences in severity of illness, cumulative fluid balance and pre-existing comorbidities, only NT-proBNP remained significantly associated with worst stage of AKI and need for RRT. cTnT and cTnI were independently associated with the odds of any AKI but not with need for RRT. In a sensitivity analysis in which patients who had an acute myocardial infarction while in the ICU were excluded, NT-proBNP remained independently associated with AKI and acute RRT. CONCLUSIONS In critically ill patients admitted to the ICU for non-cardiac reasons, admission NT-proBNP had the strongest independent association with maximum stage of AKI and need for RRT.
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Affiliation(s)
- Ryan Haines
- Department of Critical Care, King's College London, Guy's and St Thomas' Foundation Hospital, London, SE1 7EH, UK
| | - Siobhan Crichton
- Division of Health and Social Care Research, King's College London, London, UK
| | - Jessica Wilson
- Department of Critical Care, King's College London, Guy's and St Thomas' Foundation Hospital, London, SE1 7EH, UK
| | - David Treacher
- Department of Critical Care, King's College London, Guy's and St Thomas' Foundation Hospital, London, SE1 7EH, UK
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's and St Thomas' Foundation Hospital, London, SE1 7EH, UK.
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144
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Langston C. Managing Fluid and Electrolyte Disorders in Kidney Disease. Vet Clin North Am Small Anim Pract 2017; 47:471-490. [DOI: 10.1016/j.cvsm.2016.09.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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145
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Abstract
Since its original description in 1832, fluid resuscitation has become the cornerstone of early and aggressive treatment of severe sepsis and septic shock. However, questions remain about optimal fluid composition, dose, and rate of administration for critically ill patients. This article reviews pertinent physiology of the circulatory system, pathogenesis of septic shock, and phases of sepsis resuscitation, and then focuses on the type, rate, and amount of fluid administration for severe sepsis and septic shock, so providers can choose the right fluid, for the right patient, at the right time.
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Affiliation(s)
- Rob Loflin
- University of Rochester Medical Center, Rochester, NY, USA
| | - Michael E Winters
- Critical Care Program, Internal Medicine, Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
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146
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Pickkers P, Ostermann M, Joannidis M, Zarbock A, Hoste E, Bellomo R, Prowle J, Darmon M, Bonventre JV, Forni L, Bagshaw SM, Schetz M. The intensive care medicine agenda on acute kidney injury. Intensive Care Med 2017; 43:1198-1209. [PMID: 28138736 DOI: 10.1007/s00134-017-4687-2] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 01/16/2017] [Indexed: 12/14/2022]
Abstract
Acute kidney injury (AKI) is a common complication in the critically ill. Current standard of care mainly relies on identification of patients at risk, haemodynamic optimization, avoidance of nephrotoxicity and the use of renal replacement therapy (RRT) in established AKI. The detection of early biomarkers of renal tissue damage is a recent development that allows amending the late and insensitive diagnosis with current AKI criteria. Increasing evidence suggests that the consequences of an episode of AKI extend long beyond the acute hospitalization. Citrate has been established as the anticoagulant of choice for continuous RRT. Conflicting results have been published on the optimal timing of RRT and on the renoprotective effect of remote ischaemic preconditioning. Recent research has contradicted that acute tubular necrosis is the common pathology in AKI, that septic AKI is due to global kidney hypoperfusion, that aggressive fluid therapy benefits the kidney, that vasopressor therapy harms the kidney and that high doses of RRT improve outcome. Remaining uncertainties include the impact of aetiology and clinical context on pathophysiology, therapy and prognosis, the clinical benefit of biomarker-driven interventions, the optimal mode of RRT to improve short- and long-term patient and kidney outcomes, the contribution of AKI to failure of other organs and the optimal approach for assessing and promoting renal recovery. Based on the established gaps in current knowledge the trials that must have priority in the coming 10 years are proposed together with the definition of appropriate clinical endpoints.
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Affiliation(s)
- Peter Pickkers
- Department of Intensive Care Medicine (710), Radboud University Medical Centre, Geert Grooteplein Zuid 10, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Marlies Ostermann
- Department of Critical Care, Guy's and St Thomas' Hospital, King's College London, London, SE1 9RT, UK
| | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Alexander Zarbock
- Department of Anesthesiology, Critical Care and Pain Medicine, University Hospital Münster, Albert-Schweitzer Campus 1, Building A1, 48149, Münster, Germany
| | - Eric Hoste
- Department of Intensive Care Medicine, Ghent University Hospital, De Pintelaan 185, 9000, Ghent, Belgium.,Research Foundation-Flanders, Brussels, Belgium
| | - Rinaldo Bellomo
- School of Medicine, The University of Melbourne, Melbourne, VIC, Australia.,Department of Intensive Care, Austin Hospital Heidelberg, Melbourne, VIC, 3084, Australia
| | - John Prowle
- William Harvey Research Institute, Queen Mary University of London, London, UK.,Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Michael Darmon
- Medical-Surgical ICU, Saint-Etienne University Hospital and Jacques Lisfranc Medical School, Saint-Etienne, 42000, France
| | - Joseph V Bonventre
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | - Lui Forni
- Surrey Perioperative Anaesthesia and Critical Care Collaborative Research Group, Royal Surrey County Hospital, NHS Foundation Trust and School of Health Sciences, Faculty of Health and Medical Sciences, University of Surrey, Guildford, GU2 7XH, UK.,Intensive Care Unit, Royal Surrey County Hospital, NHS Foundation Trust, Egerton Road, Guildford, GU2 7XX, UK
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 2-124 Clinical Sciences Building, 8440-112 ST NW, Edmonton, AB, T6G2B7, Canada
| | - Miet Schetz
- Clinical Department and Laboratory of Intensive Care Medicine, Division of Cellular and Molecular Medicine, KU Leuven University, Herestraat 49, B3000, Louvain, Belgium.
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147
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Abstract
Acute kidney injury (AKI) has been associated with an increased risk of death and morbidity in many clinical scenarios. The prevention and treatment of AKI therefore has been advocated as a high-priority research focus. However, nearly all strategies tested in this setting have failed to prevent or cure AKI and fluid loading remains a cornerstone of preventive and curative treatment of AKI. Concerns have been raised, however, regarding both the efficacy and safety of fluid loading to prevent or reverse AKI. In this review, we address the question of the best use of fluid loading based on current preclinical and clinical data in a mechanistically guided approach. Impacts of fluid resuscitation on renal hemodynamics, from macrocirculation to microcirculation, with physiological end points as well as renal consequences of different fluids available are discussed. Finally, the complex relationship between renal hemodynamics is discussed.
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Affiliation(s)
- Matthieu Legrand
- Department of Anesthesiology and Critical Care and Burn Unit, Assitance Publique Hôpitaux de Paris, Hôpital St-Louis, Paris, France; Unité mixte de recherche INSERM 942, Institut National de la Santé et de la Recherche Médicale, Lariboisière Hospital, Paris, France; University Paris Diderot, Paris, France
| | - Can Ince
- Department of Intensive Care, Erasmus Medical Center University Hospital, Rotterdam, The Netherlands; Department of Translational Physiology, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands.
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148
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Patel A, Prowle JR, Ackland GL. Postoperative goal-directed therapy and development of acute kidney injury following major elective noncardiac surgery: post-hoc analysis of POM-O randomized controlled trial. Clin Kidney J 2017; 10:348-356. [PMID: 28616213 PMCID: PMC5466093 DOI: 10.1093/ckj/sfw118] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 10/06/2016] [Indexed: 11/16/2022] Open
Abstract
Background: The role of goal-directed therapy (GDT) in preventing creatinine rise following noncardiac surgery is unclear. We performed a post-hoc analysis of a randomized controlled trial to assess the relationship between postoperative optimization of oxygen delivery and development of acute kidney injury (AKI)/creatinine rise following noncardiac surgery. Methods: Patients were randomly assigned immediately postoperatively to receive either fluid and/or dobutamine therapy to maintain/restore their preoperative oxygen delivery, or protocolized standard care (oxygen delivery only recorded). Primary end point was serial changes in postoperative creatinine within 48 h postoperatively. Secondary outcomes were development of AKI (KDIGO criteria) and minimal creatinine rise (MCR; no decline from preoperative creatinine), related to all-cause morbidity and length of stay. Results: Postoperative reductions in serum creatinine were similar (P = 0.76) in patients randomized to GDT [10 µmol/L (95% confidence interval, CI: 17 to −1); n = 95] or protocolized care [8 µmol/L (95% CI: 17 to −6); n = 92]. Postoperative haemodynamic management was not associated with the development of MCR [78/187 (41.7%)] or AKI [13/187; (7.0%)]. Intraoperative requirement for norepinephrine was more likely in patients who developed postoperative rises in creatinine [relative risk (RR): 1.66 (95% CI: 1.04–2.67); P = 0.04], despite similar volumes of intraoperative fluid being administered. Persistently higher lactate during the intervention period was associated with AKI (mean difference: 1.15 mmol/L (95% CI: 0.48–1.81); P = 0.01]. Prolonged hospital stay was associated with AKI but not MCR [RR: 2.71 (95% CI: 1.51–4.87); P = 0.0008]. Conclusion: These data provide further insights into how perioperative haemodynamic alterations relate to postoperative increases in creatinine once systemic inflammation is established.
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Affiliation(s)
- Amour Patel
- William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London, UK
| | - John R Prowle
- William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London, UK
| | - Gareth L Ackland
- William Harvey Research Institute, Queen Mary University of London, Charterhouse Square, London, UK
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149
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Abstract
Perioperative acute kidney injury (AKI) is associated with an increased morbidity and mortality. The incidence of AKI varies depending on preoperative risk factors and the surgical setting. Preoperative risk stratification is critical for informed consent and perioperative planning. Perioperative renal protection strategies are potentially invaluable in the prevention of AKI. Current advances in the development of biomarkers may offer the opportunity for early diagnosis and the implementation of therapeutic strategies. Increased awareness and concerted efforts by all perioperative physicians are needed to provide an improved outcome for surgical patients.
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Affiliation(s)
- Selma Ishag
- Division of General Anesthesiology, Barnes-Jewish Hospital, Washington University, South Campus, Campus Box 8054, 660 South Euclid Avenue, St Louis, MO 63110-1093, USA.
| | - Charuhas V Thakar
- Division of Nephrology, Kidney CARE Program, University of Cincinnati, 231 Albert Sabin Way, Cincinnati, OH 45267, USA; Renal Section, Cincinnati VA Medical Center, 231 Albert Sabin Way, Cincinnati, OH 45267, USA
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150
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Askenazi DJ, Heung M, Connor MJ, Basu RK, Cerdá J, Doi K, Koyner JL, Bihorac A, Golestaneh L, Vijayan A, Okusa M, Faubel S. Optimal Role of the Nephrologist in the Intensive Care Unit. Blood Purif 2016; 43:68-77. [PMID: 27923227 PMCID: PMC5340591 DOI: 10.1159/000452317] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
As advances in Critical Care Medicine continue, critically ill patients are surviving despite the severity of their illness. The incidence of acute kidney injury (AKI) has increased, and its impact on clinical outcomes as well as medical expenditures has been established. The role, indications and technological advancements of renal replacement therapy (RRT) have evolved, allowing more effective therapies with less complications. With these changes, Critical Care Nephrology has become an established specialty, and ongoing collaborations between critical care physicians and nephrologist have improved education of multi-disciplinary team members and patient care in the ICU. Multidisciplinary programs to support these changes have been stablished in some hospitals to maximize the delivery of care, while other programs have continue to struggle in their ability to acquire the necessary resources to maximize outcomes, educate their staff, and develop quality initiatives to evaluate and drive improvements. Clearly, the role of the nephrologist in the ICU has evolved, and varies widely among institutions. This special article will provide insights that will hopefully optimize the role of the nephrologist as the leader of the acute care nephrology program, as clinician for critically ill patients, and as teacher for all members of the health care team.
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Affiliation(s)
- David J. Askenazi
- Department of Pediatrics—Division of Pediatric Nephrology, University of Alabama at Birmingham, Birmingham, USA
| | - Michael Heung
- Department of Medicine—Division of Nephrology, University of Michigan, Ann Arbor, Michigan, USA
| | - Michael J. Connor
- Department of Medicine—Division of Renal Medicine, Emory University, Atlanta, Georgia, USA
| | - Rajit K. Basu
- Center for Acute Care Nephrology, Cincinnati Children’s Hospital Center, Cincinnati, Ohio, USA
| | - Jorge Cerdá
- Department of Medicine, Albany Medical College, Albany, New York, USA
| | - Kent Doi
- Department of Emergency and Critical Care Medicine, The University of Tokyo Hospital, Bunkyo, Tokyo, Japan
| | - Jay L. Koyner
- Department of Medicine—Section of Nephrology, University of Chicago, Chicago, Illinois, USA
| | - Azra Bihorac
- Department of Anesthesiology—University of Florida, Gainesville, Florida, USA
| | | | - Anitha Vijayan
- Division of Nephrology, Washington University, St Louis, Missouri, USA
| | - Mark Okusa
- Division of Nephrology, University of Virginia Health System, Charlottesville, Virginia, USA
| | - Sarah Faubel
- Department of Medicine—University of Colorado, and Denver VA Medical Center, Denver, Colorado, USA
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