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White KC, Laupland KB, Ostermann M, Neto AS, Gatton ML, Hurford R, Clement P, Sanderson B, Bellomo R. Current Fluid Management Practice in Critically Ill Adults on Continuous Renal Replacement Therapy: A Binational, Observational Study. Blood Purif 2024; 53:624-633. [PMID: 38626729 PMCID: PMC11309063 DOI: 10.1159/000538421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 03/11/2024] [Indexed: 04/18/2024]
Abstract
INTRODUCTION In critically ill patients undergoing continuous renal replacement therapy (CRRT), a positive fluid balance (FB) is associated with adverse outcomes. However, current FB management practices in CRRT patients are poorly understood. We aimed to study FB and its components in British and Australian CRRT patients to inform future trials. METHODS We obtained detailed electronic health record data on all fluid-related variables during CRRT and hourly FB for the first 7 days of treatment. RESULTS We studied 1,616 patients from three tertiary intensive care units (ICUs) in two countries. After the start of CRRT, the mean cumulative FB became negative at 31 h and remained negative over 7 days to a mean nadir of -4.1 L (95% confidence interval (CI) of -4.6 to -3.5). The net ultrafiltration (NUF) rate was the dominant fluid variable (-67.7 mL/h; standard deviation (SD): 75.7); however, residual urine output (-34.7 mL/h; SD: 54.5), crystalloid administration (48.1 mL/h; SD: 44.6), and nutritional input (36.4 mL/h; SD: 29.7) significantly contributed to FB. Patients with a positive FB after 72 h of CRRT were more severely ill, required high-dose vasopressors, and had high lactate concentrations (5.0 mmol/L; interquartile range: 2.3-10.5). A positive FB was independently associated with increased hospital mortality (odds ratio: 1.70; 95% CI; p = 0.004). CONCLUSION In the study ICUs, most CRRT patients achieved a predominantly NUF-dependent negative FB. Patients with a positive FB at 72 h had greater illness severity and haemodynamic instability. Achieving equipoise for conducting trials that target a negative early FB in such patients may be difficult.
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Affiliation(s)
- Kyle C. White
- Intensive Care Unit, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
- Queensland University of Technology (QUT), Brisbane, QLD, Australia
| | - Kevin B. Laupland
- Queensland University of Technology (QUT), Brisbane, QLD, Australia
- Department of Intensive Care Services, Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia
| | - Marlies Ostermann
- King’s College London, Guy’s and St Thomas’ Hospital, Department of Critical Care, London, UK
| | - Ary Serpa Neto
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Critical Care, Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | - Rod Hurford
- Intensive Care Unit, Princess Alexandra Hospital, Woolloongabba, QLD, Australia
| | - Pierre Clement
- Department of Intensive Care Services, Royal Brisbane and Women’s Hospital, Brisbane, QLD, Australia
| | - Barnaby Sanderson
- King’s College London, Guy’s and St Thomas’ Hospital, Department of Critical Care, London, UK
| | - Rinaldo Bellomo
- Department of Critical Care, University of Melbourne, Melbourne, VIC, Australia
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
- Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia
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Ramasco F, Nieves-Alonso J, García-Villabona E, Vallejo C, Kattan E, Méndez R. Challenges in Septic Shock: From New Hemodynamics to Blood Purification Therapies. J Pers Med 2024; 14:176. [PMID: 38392609 PMCID: PMC10890552 DOI: 10.3390/jpm14020176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 01/15/2024] [Accepted: 01/30/2024] [Indexed: 02/24/2024] Open
Abstract
Sepsis and septic shock are associated with high mortality, with diagnosis and treatment remaining a challenge for clinicians. Their management classically encompasses hemodynamic resuscitation, antibiotic treatment, life support, and focus control; however, there are aspects that have changed. This narrative review highlights current and avant-garde methods of handling patients experiencing septic shock based on the experience of its authors and the best available evidence in a context of uncertainty. Following the first recommendation of the Surviving Sepsis Campaign guidelines, it is recommended that specific sepsis care performance improvement programs are implemented in hospitals, i.e., "Sepsis Code" programs, designed ad hoc, to achieve this goal. Regarding hemodynamics, the importance of perfusion and hemodynamic coherence stand out, which allow for the recognition of different phenotypes, determination of the ideal time for commencing vasopressor treatment, and the appropriate fluid therapy dosage. At present, this is not only important for the initial timing, but also for de-resuscitation, which involves the early weaning of support therapies, directed elimination of fluids, and fluid tolerance concept. Finally, regarding blood purification therapies, those aimed at eliminating endotoxins and cytokines are attractive in the early management of patients in septic shock.
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Affiliation(s)
- Fernando Ramasco
- Department of Anaesthesiology and Surgical Intensive Care, Hospital Universitario de La Princesa, Diego de León 62, 28006 Madrid, Spain
| | - Jesús Nieves-Alonso
- Department of Anaesthesiology and Surgical Intensive Care, Hospital Universitario de La Princesa, Diego de León 62, 28006 Madrid, Spain
| | - Esther García-Villabona
- Department of Anaesthesiology and Surgical Intensive Care, Hospital Universitario de La Princesa, Diego de León 62, 28006 Madrid, Spain
| | - Carmen Vallejo
- Department of Anaesthesiology and Surgical Intensive Care, Hospital Universitario de La Princesa, Diego de León 62, 28006 Madrid, Spain
| | - Eduardo Kattan
- Departamento de Medicina Intensiva del Adulto, Facultad de Medicina, Pontificia Universidad Católica de Chile, Marcoleta 367, Santiago 8320000, Chile
| | - Rosa Méndez
- Department of Anaesthesiology and Surgical Intensive Care, Hospital Universitario de La Princesa, Diego de León 62, 28006 Madrid, Spain
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Jacquet-Lagrèze M, Pernollet A, Kattan E, Ait-Oufella H, Chesnel D, Ruste M, Schweizer R, Allaouchiche B, Hernandez G, Fellahi JL. Prognostic value of capillary refill time in adult patients: a systematic review with meta-analysis. Crit Care 2023; 27:473. [PMID: 38042855 PMCID: PMC10693708 DOI: 10.1186/s13054-023-04751-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 11/19/2023] [Indexed: 12/04/2023] Open
Abstract
PURPOSE Acute circulatory failure leads to tissue hypoperfusion. Capillary refill time (CRT) has been widely studied, but its predictive value remains debated. We conducted a meta-analysis to assess the ability of CRT to predict death or adverse events in a context at risk or confirmed acute circulatory failure in adults. METHOD MEDLINE, EMBASE, and Google scholar databases were screened for relevant studies. The pooled area under the ROC curve (AUC ROC), sensitivity, specificity, threshold, and diagnostic odds ratio using a random-effects model were determined. The primary analysis was the ability of abnormal CRT to predict death in patients with acute circulatory failure. Secondary analysis included the ability of CRT to predict death or adverse events in patients at risk or with confirmed acute circulatory failure, the comparison with lactate, and the identification of explanatory factors associated with better accuracy. RESULTS A total of 60,656 patients in 23 studies were included. Concerning the primary analysis, the pooled AUC ROC of 13 studies was 0.66 (95%CI [0.59; 0.76]), and pooled sensitivity was 54% (95%CI [43; 64]). The pooled specificity was 72% (95%CI [55; 84]). The pooled diagnostic odds ratio was 3.4 (95%CI [1.4; 8.3]). Concerning the secondary analysis, the pooled AUC ROC of 23 studies was 0.69 (95%CI [0.65; 0.74]). The prognostic value of CRT compared to lactate was not significantly different. High-quality CRT was associated with a greater accuracy. CONCLUSION CRT poorly predicted death and adverse events in patients at risk or established acute circulatory failure. Its accuracy is greater when high-quality CRT measurement is performed.
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Affiliation(s)
- Matthias Jacquet-Lagrèze
- Service d'anesthésie-Réanimation, Hôpital Cardiologique Louis Pradel, 59 Bd Pinel, 69500, Hospices Civils de LyonBron, France.
- Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, 8, Avenue Rockefeller, 69373, Lyon Cedex 08, France.
- CarMeN Laboratoire, Inserm UMR 1060, Université Claude Bernard, Lyon 1, Lyon, France.
| | - Aymeric Pernollet
- Service d'anesthésie-Réanimation, Hôpital Cardiologique Louis Pradel, 59 Bd Pinel, 69500, Hospices Civils de LyonBron, France
- Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, 8, Avenue Rockefeller, 69373, Lyon Cedex 08, France
| | - Eduardo Kattan
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
- The Latin American Intensive Care Network (LIVEN), Santiago, Chile
| | - Hafid Ait-Oufella
- Hôpital Saint-Antoine, Service de Médecine Intensive-Réanimation, Sorbonne Université, Paris, France
| | - Delphine Chesnel
- Service d'anesthésie-Réanimation, Hôpital Cardiologique Louis Pradel, 59 Bd Pinel, 69500, Hospices Civils de LyonBron, France
- Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, 8, Avenue Rockefeller, 69373, Lyon Cedex 08, France
| | - Martin Ruste
- Service d'anesthésie-Réanimation, Hôpital Cardiologique Louis Pradel, 59 Bd Pinel, 69500, Hospices Civils de LyonBron, France
- Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, 8, Avenue Rockefeller, 69373, Lyon Cedex 08, France
- CarMeN Laboratoire, Inserm UMR 1060, Université Claude Bernard, Lyon 1, Lyon, France
| | - Rémi Schweizer
- Service d'anesthésie-Réanimation, Hôpital Cardiologique Louis Pradel, 59 Bd Pinel, 69500, Hospices Civils de LyonBron, France
- Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, 8, Avenue Rockefeller, 69373, Lyon Cedex 08, France
| | - Bernard Allaouchiche
- Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, 8, Avenue Rockefeller, 69373, Lyon Cedex 08, France
- Service d'anesthésie-Réanimation, Hôpital Lyon Sud, Hospices Civils de Lyon, 165 Chem. du Grand Revoyet, 69495, Pierre-Bénite, France
| | - Glenn Hernandez
- Departamento de Medicina Intensiva, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
- The Latin American Intensive Care Network (LIVEN), Santiago, Chile
| | - Jean-Luc Fellahi
- Service d'anesthésie-Réanimation, Hôpital Cardiologique Louis Pradel, 59 Bd Pinel, 69500, Hospices Civils de LyonBron, France
- Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, 8, Avenue Rockefeller, 69373, Lyon Cedex 08, France
- CarMeN Laboratoire, Inserm UMR 1060, Université Claude Bernard, Lyon 1, Lyon, France
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White KC, Nasser A, Gatton ML, Laupland KB. Current management of fluid balance in critically ill patients with acute kidney injury: A scoping review. CRIT CARE RESUSC 2023; 25:126-135. [PMID: 37876369 PMCID: PMC10581269 DOI: 10.1016/j.ccrj.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Abstract
Objective The overall objective of this scoping review is to assess the extent of the literature related to the fluid management of critically ill patients with acute kidney injury (AKI). Introduction AKI is common in critically ill patients where fluid therapy is a mainstay of treatment. An association between fluid balance (FB) and adverse patient-centred outcomes in critically ill patients with AKI regardless of severity has been demonstrated. The evidence for the prospective intervention of FB and its impact on outcomes is unknown. Inclusion criteria All studies investigating FB in patients with AKI admitted to an intensive care unit were included. Literature not related to FB in the critically ill patient with AKI population was excluded. Methods We searched MEDLINE, EMBASE, and CINAHL from January 1st, 2012, onwards. We included primary research studies, experimental and observational, recruiting adult participants admitted to an intensive care unit who had an AKI. We extracted data on study and patient characteristics, as well as FB, renal-based outcomes, and patient-centred outcomes. Two reviewers independently screened citations for eligible studies and performed data extraction. Results Of the 13,767 studies reviewed, 22 met the inclusion criteria. Two studies examined manipulation of fluid input, 18 studies assessed enhancing fluid removal, and two studies applied a restrictive fluid protocol. Sixteen studies examined patients receiving renal replacement therapy, five studies included non-renal replacement therapy patients, and one study included both. Current evidence is broad with varied approaches to managing fluid input and fluid removal. The studies did not demonstrate a consensus approach for any aspect of the fluid management of critically ill patients. There was a limited application of a restrictive fluid protocol with no conclusions possible. Conclusions The current body of evidence for the management of FB in critically ill patients with AKI is limited in nature. The current quality of evidence is unable to guide current clinical practice. The key outcome of this review is to highlight areas for future research.
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Affiliation(s)
- Kyle C. White
- Intensive Care Unit, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
- Faculty of Health, Queensland University of Technology (QUT), Brisbane, Queensland, Australia
- Intensive Care Unit, Queen Elizabeth II Jubilee Hospital, Coopers Plains, Queensland, Australia
| | - Ahmad Nasser
- Intensive Care Unit, Queen Elizabeth II Jubilee Hospital, Coopers Plains, Queensland, Australia
- Faculty of Medicine, University of Queensland, Herston, Queensland, Australia
| | - Michelle L. Gatton
- Faculty of Health, Queensland University of Technology (QUT), Brisbane, Queensland, Australia
| | - Kevin B. Laupland
- Faculty of Health, Queensland University of Technology (QUT), Brisbane, Queensland, Australia
- Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
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Ruste M, Schweizer R, Fellahi JL, Jacquet-Lagrèze M. Fluid removal tolerance during the de-escalation phase: is preload unresponsiveness the best guiding candidate? Crit Care 2023; 27:154. [PMID: 37081541 PMCID: PMC10116653 DOI: 10.1186/s13054-023-04444-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 04/14/2023] [Indexed: 04/22/2023] Open
Affiliation(s)
- Martin Ruste
- Service d'anesthésie-Réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, 59, Boulevard Pinel, 69677, Bron Cedex, France.
- Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, 8, Avenue Rockefeller, 69373, Lyon Cedex 08, France.
- Laboratoire CarMeN, Inserm UMR 1060, Université Claude Bernard Lyon 1, Lyon, France.
| | - Rémi Schweizer
- Service d'anesthésie-Réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, 59, Boulevard Pinel, 69677, Bron Cedex, France
| | - Jean-Luc Fellahi
- Service d'anesthésie-Réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, 59, Boulevard Pinel, 69677, Bron Cedex, France
- Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, 8, Avenue Rockefeller, 69373, Lyon Cedex 08, France
- Laboratoire CarMeN, Inserm UMR 1060, Université Claude Bernard Lyon 1, Lyon, France
| | - Matthias Jacquet-Lagrèze
- Service d'anesthésie-Réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, 59, Boulevard Pinel, 69677, Bron Cedex, France
- Faculté de Médecine Lyon Est, Université Claude Bernard Lyon 1, 8, Avenue Rockefeller, 69373, Lyon Cedex 08, France
- Laboratoire CarMeN, Inserm UMR 1060, Université Claude Bernard Lyon 1, Lyon, France
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Pfortmueller CA, Dabrowski W, Malbrain MLNG. Fluid de-resuscitation in critical illness - A journey into uncertain territory. J Crit Care 2023:154249. [PMID: 36870802 DOI: 10.1016/j.jcrc.2022.154249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 12/29/2022] [Indexed: 03/06/2023]
Affiliation(s)
- Carmen Andrea Pfortmueller
- Department of Intensive Care, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland.
| | - Wojciech Dabrowski
- First Department of Anaesthesiology and Intensive Therapy, Medical University of Lublin, Lublin, Poland
| | - Manu L N G Malbrain
- First Department of Anaesthesiology and Intensive Therapy, Medical University of Lublin, Lublin, Poland; International Fluid Academy, Lovenjoel, Belgium; Medical Data Management, Medaman, Geel, Belgium
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