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Molin C, Wichmann S, Schønemann-Lund M, Møller MH, Bestle MH. Fluid administration and fluid accumulation in intensive care units-Protocol for an international inception cohort study (FLUID-ICU). Acta Anaesthesiol Scand 2024. [PMID: 38837207 DOI: 10.1111/aas.14464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2024] [Accepted: 05/18/2024] [Indexed: 06/07/2024]
Abstract
INTRODUCTION Fluid accumulation is associated with adverse outcomes in critically ill patients admitted to the intensive care unit (ICU). Fluid administration in the ICU may be a clinically relevant source of fluid accumulation in ICU patients. However, the extent is unknown, and no standard definition exists. We aim to provide epidemiological data on fluid accumulation, risk factors, use of fluid removal strategies, patient outcomes and describe current fluid administration practices in the ICU. METHODS We will conduct an international 14-day inception cohort study including a minimum of 1000 acutely admitted adult ICU patients. Data will be collected from medical records and laboratory reports at baseline and daily from ICU admission to discharge with a maximum of 28 days. Follow-up will be performed on day 90 after inclusion. The primary outcome is the number of patients with fluid accumulation. Secondary outcomes include the number of days with fluid accumulation, use of active fluid removal, days alive without life support at day 28, days alive and out of hospital day 90, and all-cause mortality at day 90. Furthermore, we will assess risk factors for fluid accumulation and its association with 90-day mortality and report on the types of fluid administration. CONCLUSION This international inception cohort study will provide contemporary epidemiological data on fluid administration and fluid accumulation in adult ICU patients.
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Affiliation(s)
- Clara Molin
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital, Hillerod, Denmark
| | - Sine Wichmann
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital, Hillerod, Denmark
| | - Martin Schønemann-Lund
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital, Hillerod, Denmark
| | - Morten H Møller
- Department of Intensive Care 4131, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Morten H Bestle
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital, Hillerod, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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2
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Hofer DM, Ruzzante L, Waskowski J, Messmer AS, Pfortmueller CA. Influence of fluid accumulation on major adverse kidney events in critically ill patients - an observational cohort study. Ann Intensive Care 2024; 14:52. [PMID: 38587575 PMCID: PMC11001812 DOI: 10.1186/s13613-024-01281-7] [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: 11/03/2023] [Accepted: 03/26/2024] [Indexed: 04/09/2024] Open
Abstract
BACKGROUND Fluid accumulation (FA) is known to be associated with acute kidney injury (AKI) during intensive care unit (ICU) stay but data on mid-term renal outcome is scarce. The aim of this study was to investigate the association between FA at ICU day 3 and major adverse kidney events in the first 30 days after ICU admission (MAKE30). METHODS Retrospective, single-center cohort study including adult ICU patients with sufficient data to compute FA and MAKE30. We defined FA as a positive cumulative fluid balance greater than 5% of bodyweight. The association between FA and MAKE30, including its sub-components, as well as the serum creatinine trajectories during ICU stay were examined. In addition, we performed a sensitivity analysis for the stage of AKI and the presence of chronic kidney disease (CKD). RESULTS Out of 13,326 included patients, 1,100 (8.3%) met the FA definition. FA at ICU day 3 was significantly associated with MAKE30 (adjusted odds ratio [aOR] 1.96; 95% confidence interval [CI] 1.67-2.30; p < 0.001) and all sub-components: need for renal replacement therapy (aOR 3.83; 95%CI 3.02-4.84), persistent renal dysfunction (aOR 1.72; 95%CI 1.40-2.12), and 30-day mortality (aOR 1.70; 95%CI 1.38-2.09), p all < 0.001. The sensitivity analysis showed an association of FA with MAKE30 independent from a pre-existing CKD, but exclusively in patients with AKI stage 3. Furthermore, FA was independently associated with the creatinine trajectory over the whole observation period. CONCLUSIONS Fluid accumulation is significantly associated with MAKE30 in critically ill patients. This association is independent from pre-existing CKD and strongest in patients with AKI stage 3.
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Affiliation(s)
- Debora M Hofer
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, Freiburgstrasse 18, Bern, CH-3010, Switzerland.
| | - Livio Ruzzante
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, Freiburgstrasse 18, Bern, CH-3010, Switzerland
| | - Jan Waskowski
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, Freiburgstrasse 18, Bern, CH-3010, Switzerland
| | - Anna S Messmer
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, Freiburgstrasse 18, Bern, CH-3010, Switzerland
| | - Carmen A Pfortmueller
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, Freiburgstrasse 18, Bern, CH-3010, Switzerland
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3
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Fan T, Wang J, Li L, Kang J, Wang W, Zhang C. Predicting the risk factors of diabetic ketoacidosis-associated acute kidney injury: A machine learning approach using XGBoost. Front Public Health 2023; 11:1087297. [PMID: 37089510 PMCID: PMC10117643 DOI: 10.3389/fpubh.2023.1087297] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 03/17/2023] [Indexed: 04/25/2023] Open
Abstract
Objective The purpose of this study was to develop and validate a predictive model based on a machine learning (ML) approach to identify patients with DKA at increased risk of AKI within 1 week of hospitalization in the intensive care unit (ICU). Methods Patients diagnosed with DKA from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database according to the International Classification of Diseases (ICD)-9/10 code were included. The patient's medical history is extracted, along with data on their demographics, vital signs, clinical characteristics, laboratory results, and therapeutic measures. The best-performing model is chosen by contrasting the 8 Ml models. The area under the receiver operating characteristic curve (AUC), sensitivity, accuracy, and specificity were calculated to select the best-performing ML model. Results The final study enrolled 1,322 patients with DKA in total, randomly split into training (1,124, 85%) and validation sets (198, 15%). 497 (37.5%) of them experienced AKI within a week of being admitted to the ICU. The eXtreme Gradient Boosting (XGBoost) model performed best of the 8 Ml models, and the AUC of the training and validation sets were 0.835 and 0.800, respectively. According to the result of feature importance, the top 5 main features contributing to the XGBoost model were blood urea nitrogen (BUN), urine output, weight, age, and platelet count (PLT). Conclusion An ML-based individual prediction model for DKA-associated AKI (DKA-AKI) was developed and validated. The model performs robustly, identifies high-risk patients early, can assist in clinical decision-making, and can improve the prognosis of DKA patients to some extent.
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Affiliation(s)
- Tingting Fan
- Department of Endocrinology, Second Affiliated Hospital of Jilin University, Changchun, China
| | - Jiaxin Wang
- Department of Endocrinology, Second Affiliated Hospital of Jilin University, Changchun, China
| | - Luyao Li
- Department of Endocrinology, Second Affiliated Hospital of Jilin University, Changchun, China
| | - Jing Kang
- Department of Endocrinology, Second Affiliated Hospital of Jilin University, Changchun, China
| | - Wenrui Wang
- Digestive Diseases Center, Department of Hepatopancreatobiliary Medicine, Second Affiliated Hospital of Jilin University, Changchun, China
| | - Chuan Zhang
- Department of Endocrinology, Second Affiliated Hospital of Jilin University, Changchun, China
- *Correspondence: Chuan Zhang,
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Inkinen N, Pettilä V, Valkonen M, Serlo M, Bäcklund M, Hästbacka J, Pulkkinen A, Selander T, Vaara ST. Non-interventional follow-up versus fluid bolus in RESPONSE to oliguria in hemodynamically stable critically ill patients: a randomized controlled pilot trial. Crit Care 2022; 26:401. [PMID: 36550559 PMCID: PMC9773608 DOI: 10.1186/s13054-022-04283-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Fluid bolus therapy is a common intervention to improve urine output. Data concerning the effect of a fluid bolus on oliguria originate mainly from observational studies and remain controversial regarding the actual benefit of such therapy. We compared the effect of a follow-up approach without fluid bolus to a 500 mL fluid bolus on urine output in hemodynamically stable critically ill patients with oliguria at least for 2 h (urine output < 0.5 mL/kg/h) in randomized setting. METHODS We randomized 130 patients in 1:1 fashion to receive either (1) non-interventional follow-up (FU) for 2 h or (2) 500 mL crystalloid fluid bolus (FB) administered over 30 min. The primary outcome was the proportion of patients who doubled their urine output, defined as 2-h urine output post-randomization divided by urine output 2 h pre-randomization. The outcomes were adjusted for the stratification variables (presence of sepsis or AKI) using two-tailed regression. Obtained odds ratios were converted to risk ratios (RR) with 95% confidence intervals (CI). The between-group difference in the continuous variables was compared using mean or median regression and expressed with 95% CIs. RESULTS Altogether 10 (15.9%) of 63 patients in the FU group and 22 (32.8%) of 67 patients in FB group doubled their urine output during the 2-h period, RR (95% CI) 0.49 (0.23-0.71), P = 0.026. Median [IQR] change in individual urine output 2 h post-randomization compared to 2 h pre-randomization was - 7 [- 19 to 17] mL in the FU group and 19[0-53] mL in the FB group, median difference (95% CI) - 23 (- 36 to - 10) mL, P = 0.001. Median [IQR] duration of oliguria in the FU group was 4 [2-8] h and in the FB group 2 [0-6] h, median difference (95%CI) 2 (0-4) h, P = 0.038. Median [IQR] cumulative fluid balance on study day was lower in the FU group compared to FB group, 678 [518-1029] mL versus 1071 [822-1505] mL, respectively, median difference (95%CI) - 387 (- 635 to - 213) mL, P < 0.001. CONCLUSIONS Follow-up approach to oliguria compared to administering a fluid bolus of 500 mL crystalloid in oliguric patients improved urine output less frequently but lead to lower cumulative fluid balance. Trial registration clinical. TRIALS gov, NCT02860572. Registered 9 August 2016.
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Affiliation(s)
- Nina Inkinen
- grid.460356.20000 0004 0449 0385Department of Anesthesia and Intensive Care, Central Finland Hospital Nova, Central Finland Health Care District, Hoitajantie 3, 40620 Jyväskylä, Finland ,grid.7737.40000 0004 0410 2071Division of Intensive Care Medicine, Department of Perioperative, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Ville Pettilä
- grid.7737.40000 0004 0410 2071Division of Intensive Care Medicine, Department of Perioperative, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Miia Valkonen
- grid.7737.40000 0004 0410 2071Division of Intensive Care Medicine, Department of Perioperative, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Maija Serlo
- grid.7737.40000 0004 0410 2071Division of Intensive Care Medicine, Department of Perioperative, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Minna Bäcklund
- grid.7737.40000 0004 0410 2071Division of Intensive Care Medicine, Department of Perioperative, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Johanna Hästbacka
- grid.7737.40000 0004 0410 2071Division of Intensive Care Medicine, Department of Perioperative, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Anni Pulkkinen
- grid.460356.20000 0004 0449 0385Department of Anesthesia and Intensive Care, Central Finland Hospital Nova, Central Finland Health Care District, Hoitajantie 3, 40620 Jyväskylä, Finland
| | - Tuomas Selander
- grid.410705.70000 0004 0628 207XScience Service Center, Kuopio University Hospital, Kuopio, Finland
| | - Suvi T. Vaara
- grid.7737.40000 0004 0410 2071Division of Intensive Care Medicine, Department of Perioperative, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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Ruste M, Sghaier R, Chesnel D, Didier L, Fellahi JL, Jacquet-Lagrèze M. Perfusion-based deresuscitation during continuous renal replacement therapy: A before-after pilot study (The early dry Cohort). J Crit Care 2022; 72:154169. [PMID: 36201978 DOI: 10.1016/j.jcrc.2022.154169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 09/15/2022] [Accepted: 09/25/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Active fluid removal has been suggested to improve prognosis following the resolution of acute circulatory failure. We have implemented a routine care protocol to guide fluid removal during continuous renal replacement therapy (CRRT). We designed a before-after pilot study to evaluate the impact of this deresuscitation strategy on the fluid balance. METHODS Consecutive ICU patients suffering from fluid overload and undergoing CRRT for acute kidney injury underwent a perfusion-based deresuscitation protocol combining a restrictive intake, net ultrafiltration (UFnet) of 2 mL/kg/h, and monitoring of perfusion (early dry group, N = 42) and were compared to a historical group managed according to usual practices (control group, N = 45). The primary outcome was the cumulative fluid balance at day 5 or at discharge. RESULTS Adjusted cumulative fluid balance was significantly lower in the early dry group (median [IQR]: -7784 [-11,833 to -2933] mL) compared to the control group (-3492 [-9935 to -1736] mL; p = 0.04). The difference was mainly driven by a greater daily UFnet (31 [22-46] mL/kg/day vs. 24 [15-32] mL/kg/day; p = 0.01). There was no significant difference between both groups regarding hemodynamic tolerance. CONCLUSION Our perfusion-based deresuscitation protocol achieved a greater negative cumulative fluid balance compared to standard practices and was hemodynamically well tolerated.
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Affiliation(s)
- Martin Ruste
- Service d'anesthésie-réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, 59, Boulevard Pinel, 69677 Bron Cedex, France; Faculté de médecine Lyon Est, Université Claude Bernard Lyon 1, 8, Avenue Rockefeller, 69373 Lyon, Cedex 08, France.
| | - Raouf Sghaier
- Service d'anesthésie-réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, 59, Boulevard Pinel, 69677 Bron Cedex, France
| | - Delphine Chesnel
- Service d'anesthésie-réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, 59, Boulevard Pinel, 69677 Bron Cedex, France; Faculté de médecine Lyon Sud, Université Claude Bernard Lyon 1, 165, chemin du Petit Revoyet, 69921 Oullins, France
| | - Léa Didier
- Service d'anesthésie-réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, 59, Boulevard Pinel, 69677 Bron Cedex, France; Faculté de médecine Lyon Est, Université Claude Bernard Lyon 1, 8, Avenue Rockefeller, 69373 Lyon, Cedex 08, France
| | - Jean-Luc Fellahi
- Service d'anesthésie-réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, 59, Boulevard Pinel, 69677 Bron Cedex, France; Faculté de médecine Lyon Est, Université Claude Bernard Lyon 1, 8, Avenue Rockefeller, 69373 Lyon, Cedex 08, France; Laboratoire CarMeN, Inserm UMR 1060, Université Claude Bernard Lyon 1, Lyon, France
| | - Matthias Jacquet-Lagrèze
- Service d'anesthésie-réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, 59, Boulevard Pinel, 69677 Bron Cedex, France; Faculté de médecine Lyon Est, Université Claude Bernard Lyon 1, 8, Avenue Rockefeller, 69373 Lyon, Cedex 08, France; Laboratoire CarMeN, Inserm UMR 1060, Université Claude Bernard Lyon 1, Lyon, France
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Zeuthen E, Wichmann S, Schønemann-Lund M, Järvisalo MJ, Rubenson-Wahlin R, Sigurðsson MI, Holen E, Bestle MH. Nordic survey on assessment and treatment of fluid overload in intensive care. Front Med (Lausanne) 2022; 9:1067162. [PMID: 36507497 PMCID: PMC9732460 DOI: 10.3389/fmed.2022.1067162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 11/09/2022] [Indexed: 11/27/2022] Open
Abstract
Introduction Fluid overload in patients in the intensive care unit (ICU) is associated with higher mortality. There are few randomized controlled trials to guide physicians in treating patients with fluid overload in the ICU, and no guidelines exist. We aimed to elucidate how ICU physicians from Nordic countries define, assess, and treat fluid overload in the ICU. Materials and methods We developed an online questionnaire with 18 questions. The questions were pre-tested and revised by specialists in intensive care medicine. Through a network of national coordinators. The survey was distributed to a wide range of Nordic ICU physicians. The distribution started on January 5th, 2022 and ended on May 6th, 2022. Results We received a total of 1,066 responses from Denmark, Norway, Finland, Sweden, and Iceland. When assessing fluid status, respondents applied clinical parameters such as clinical examination findings, cumulative fluid balance, body weight, and urine output more frequently than cardiac/lung ultrasound, radiological appearances, and cardiac output monitoring. A large proportion of the respondents agreed that a 5% increase or more in body weight from baseline supported the diagnosis of fluid overload. The preferred de-resuscitation strategy was diuretics (91%), followed by minimization of maintenance (76%) and resuscitation fluids (71%). The majority declared that despite mild hypotension, mild hypernatremia, and ongoing vasopressor, they would not withhold treatment of fluid overload and would continue diuretics. The respondents were divided when it came to treating fluid overload with loop diuretics in patients receiving noradrenaline. Around 1% would not administer noradrenaline and diuretics simultaneously and 35% did not have a fixed upper limit for the dosage. The remaining respondents 63% reported different upper limits of noradrenaline infusion (0.05-0.50 mcg/kg/min) when administering loop diuretics. Conclusion Self-reported practices among Nordic ICU physicians when assessing, diagnosing, and treating fluid overload reveals variability in the practice. A 5% increase in body weight was considered a minimum to support the diagnosis of fluid overload. Clinical examination findings were preferred for assessing, diagnosing and treating fluid overload, and diuretics were the preferred treatment modality.
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Affiliation(s)
- Emilie Zeuthen
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital, North Zealand, Denmark,*Correspondence: Emilie Zeuthen,
| | - Sine Wichmann
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital, North Zealand, Denmark
| | - Martin Schønemann-Lund
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital, North Zealand, Denmark
| | - Mikko J. Järvisalo
- Perioperative Services, Intensive Care and Pain Medicine, Turku University Hospital, Turku, Finland,Kidney Center, Turku University Hospital, University of Turku, Turku, Finland
| | - Rebecka Rubenson-Wahlin
- Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden,Department of Anesthesia and Intensive Care, Södersjukhuset, Stockholm, Sweden
| | - Martin I. Sigurðsson
- Department of Anesthesia and Critical Care, Landspitali – The National University Hospital of Iceland, Reykjavík, Iceland,Faculty of Medicine, University of Iceland, Reykjavík, Iceland
| | - Erling Holen
- Department of Anesthesia and Intensive Care, Helse Stavanger University Hospital, Stavanger, Norway
| | - Morten H. Bestle
- Department of Anesthesia and Intensive Care, Copenhagen University Hospital, North Zealand, Denmark,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Wichmann S, Itenov TS, Berthelsen RE, Lange T, Perner A, Gluud C, Lawson-Smith P, Nebrich L, Wiis J, Brøchner AC, Hildebrandt T, Behzadi MT, Strand K, Andersen FH, Strøm T, Järvisalo M, Damgaard KAJ, Vang ML, Wahlin RR, Sigurdsson MI, Thormar KM, Ostermann M, Keus F, Bestle MH. Goal directed fluid removal with furosemide versus placebo in intensive care patients with fluid overload: a trial protocol for a randomised, blinded trial (GODIF Trial). Acta Anaesthesiol Scand 2022; 66:1138-1145. [PMID: 35898170 PMCID: PMC9541596 DOI: 10.1111/aas.14121] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 07/03/2022] [Indexed: 11/28/2022]
Abstract
Background Fluid overload is a risk factor for mortality in intensive care unit (ICU) patients. Administration of loop diuretics is the predominant treatment of fluid overload, but evidence for its benefit is very uncertain when assessed in a systematic review of randomised clinical trials. The GODIF trial will assess the benefits and harms of goal directed fluid removal with furosemide versus placebo in ICU patients with fluid overload. Methods An investigator‐initiated, international, randomised, stratified, blinded, parallel‐group trial allocating 1000 adult ICU patients with fluid overload to infusion of furosemide versus placebo. The goal is to achieve a neutral fluid balance. The primary outcome is days alive and out of hospital 90 days after randomisation. Secondary outcomes are all‐cause mortality at day 90 and 1‐year after randomisation; days alive at day 90 without life support; number of participants with one or more serious adverse events or reactions; health‐related quality of life and cognitive function at 1‐year follow‐up. A sample size of 1000 participants is required to detect an improvement of 8% in days alive and out of hospital 90 days after randomisation with a power of 90% and a risk of type 1 error of 5%. The conclusion of the trial will be based on the point estimate and 95% confidence interval; dichotomisation will not be used. ClinicalTrials.gov identifier: NCT04180397. Perspective The GODIF trial will provide important evidence of possible benefits and harms of fluid removal with furosemide in adult ICU patients with fluid overload.
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Affiliation(s)
- Sine Wichmann
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Hilleroed, Denmark
| | - Theis S Itenov
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Hilleroed, Denmark
| | - Rasmus E Berthelsen
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Hilleroed, Denmark
| | - Theis Lange
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.,Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Pia Lawson-Smith
- Department of Intensive Care, Odense University Hospital, Odense, Denmark
| | - Lars Nebrich
- Department of Anaesthesia and Intensive Care, Zealand University Hospital, Koege, Denmark
| | - Jørgen Wiis
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Anne C Brøchner
- Department of Anaesthesia and Intensive Care, University Hospital of Southern Denmark, Kolding, Denmark
| | - Thomas Hildebrandt
- Department of Anaesthesia and Intensive Care, Zealand University Hospital, Roskilde, Denmark
| | - Meike T Behzadi
- Department of Intensive Care, Aalborg University Hospital, Aalborg, Denmark
| | - Kristian Strand
- Department of Intensive Care, Stavanger University Hospital, Stavanger, Norway
| | - Finn H Andersen
- Department of Intensive Care, Ålesund Hospital, Møre and Romsdal Health Trust, Ålesund, Norway.,Department of Circulation and Medical Imaging, Faculty of medicine and health science, Norwegian University of Science and Technology, Trondheim, Norway
| | - Thomas Strøm
- Department of Anaesthesia and Intensive Care, Sygehus Sønderjylland, Aabenraa, Denmark
| | - Mikko Järvisalo
- Perioperative Services, Intensive Care and Pain Medicine, Turku University Hospital, Turku, Finland
| | - Kjeld A J Damgaard
- Department of Anaesthesia and Intensive Care, Regionshospital Nordjylland, Hjørring, Denmark
| | - Marianne L Vang
- Department of Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Rebecka R Wahlin
- Department of Anaesthesia and Intensive Care, Södersjukhuset AB, Stockholm, Sweden
| | - Martin I Sigurdsson
- Department of Anaesthesia and Intensive Care, Landspitali, Reykjavik, Iceland.,Faculty of Medicine, University of Iceland, Reykjavik, Icelandi
| | - Katrin M Thormar
- Department of Anaesthesia and Intensive Care, Landspitali, Reykjavik, Iceland
| | - Marlies Ostermann
- Department of Intensive Care, King's College London, Guy's & St. Thomas' Foundation Trust, London, UK
| | - Frederik Keus
- Department of Critical Care, University Medical Centre Groningen, Groningen, The Netherlands
| | - Morten H Bestle
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Hilleroed, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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8
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Wichmann S, Barbateskovic M, Liang N, Itenov TS, Berthelsen RE, Lindschou J, Perner A, Gluud C, Bestle MH. Loop diuretics in adult intensive care patients with fluid overload: a systematic review of randomised clinical trials with meta-analysis and trial sequential analysis. Ann Intensive Care 2022; 12:52. [PMID: 35696008 PMCID: PMC9192894 DOI: 10.1186/s13613-022-01024-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 05/12/2022] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Fluid overload is a risk factor for organ dysfunction and death in intensive care unit (ICU) patients, but no guidelines exist for its management. We systematically reviewed benefits and harms of a single loop diuretic, the predominant treatment used for fluid overload in these patients. METHODS We conducted a systematic review with meta-analysis and Trial Sequential Analysis (TSA) of a single loop diuretic vs. other interventions reported in randomised clinical trials, adhering to our published protocol, the Cochrane Handbook, and PRISMA statement. We assessed the risks of bias with the ROB2-tool and certainty of evidence with GRADE. This study was registered in the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42020184799). RESULTS We included 10 trials (804 participants), all at overall high risk of bias. For loop diuretics vs. placebo/no intervention, we found no difference in all-cause mortality (relative risk (RR) 0.72, 95% confidence interval (CI) 0.49-1.06; 4 trials; 359 participants; I2 = 0%; TSA-adjusted CI 0.15-3.48; very low certainty of evidence). Fewer serious adverse events were registered in the group treated with loop diuretics (RR 0.81, 95% CI 0.66-0.99; 6 trials; 476 participants; I2 = 0%; very low certainty of evidence), though contested by TSA (TSA-adjusted CI 0.55-1.20). CONCLUSIONS The evidence is very uncertain about the effect of loop diuretics on mortality and serious adverse events in adult ICU patients with fluid overload. Loop diuretics may reduce the occurrence of these outcomes, but large randomised placebo-controlled trials at low risk of bias are needed.
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Affiliation(s)
- Sine Wichmann
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Dyrehavevej 29, 3400, Hillerød, Denmark.
| | - Marija Barbateskovic
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital-Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Ning Liang
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, 16 Nanxiaojie, Dongzhimen, Beijing, 100700, China
| | - Theis Skovsgaard Itenov
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Dyrehavevej 29, 3400, Hillerød, Denmark
| | - Rasmus Ehrenfried Berthelsen
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Dyrehavevej 29, 3400, Hillerød, Denmark
| | - Jane Lindschou
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital-Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital - Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital-Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
- Department of Regional Health Research, The Faculty of Health Sciences, University of Southern Denmark, Campusvej 55, 5230, Odense, Denmark
| | - Morten Heiberg Bestle
- Department of Anaesthesiology, Copenhagen University Hospital - North Zealand, Dyrehavevej 29, 3400, Hillerød, Denmark
- Department of Clinical Medicine, University of Copenhagen, Blegdamsvej 3B, 2200, Copenhagen, Denmark
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9
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Fluid management in patients with acute kidney injury - A post-hoc analysis of the FINNAKI study. J Crit Care 2021; 64:205-210. [PMID: 34020407 DOI: 10.1016/j.jcrc.2021.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Revised: 04/28/2021] [Accepted: 05/01/2021] [Indexed: 11/22/2022]
Abstract
PURPOSE Whether positive fluid balance among patients with acute kidney injury (AKI) stems from decreased urine output, overzealous fluid administration, or both is poorly characterized. MATERIALS AND METHODS This was a post hoc analysis of the prospective multicenter observational Finnish Acute Kidney Injury study including 824 AKI and 1162 non-AKI critically ill patients. RESULTS We matched 616 AKI (diagnosed during the three first intensive care unit (ICU) days) and non-AKI patients using propensity score. During the three first ICU days, AKI patients received median [IQR] of 11.4 L [8.0-15.2]L fluids and non-AKI patients 10.2 L [7.5-13.7]L, p < 0.001 while the fluid output among AKI patients was 4.7 L [3.0-7.2]L and among non-AKI patients 5.8 L [4.1-8.0]L, p < 0.001. In AKI patients, the median [IQR] cumulative fluid balance was 2.5 L [-0.2-6.0]L compared to 0.9 L [-1.4-3.6]L among non-AKI patients, p < 0.001. Among the 824 AKI patients, smaller volumes of fluid input with a multivariable OR of 0.90 (0.88-0.93) and better fluid output (multivariable OR 1.12 (1.07-1.18)) associated with enhanced change of resolution of AKI. CONCLUSIONS AKI patients received more fluids albeit having lower fluid output compared to matched critically ill non-AKI patients. Smaller volumes of fluid input and higher fluid output were associated with better AKI recovery.
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10
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Wichmann S, Barbateskovic M, Lindschou J, Gluud C, Perner A, Bestle MH. Loop diuretics in adult intensive care patients with fluid overload: A protocol for a systematic review of randomised clinical trials with meta-analysis and Trial Sequential Analysis. Acta Anaesthesiol Scand 2020; 64:1327-1334. [PMID: 32531069 DOI: 10.1111/aas.13655] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Accepted: 05/25/2020] [Indexed: 01/05/2023]
Abstract
BACKGROUND In the intensive care unit, fluid overload is frequent and a risk factor for organ dysfunction and increased mortality. Primarily, lung and kidney functions may be impaired by fluid overload resulting in acute respiratory failure and acute kidney injury. No clinical guidelines exist for treatment of fluid overload in intensive care patients. Loop diuretics, most often furosemide, appear to be the most frequently used pharmacological intervention. The aim of this protocol is to describe the methods of a systematic review assessing the evidence of treatment with loop diuretics in adult intensive care patients with fluid overload. METHODS We will conduct a systematic review with meta-analysis and report it according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statements, use the recommendations of the Cochrane Handbook and assess the quality of the evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. We will include randomised clinical trials identified through searches of major international databases and trial registers. Two authors will independently screen and select trials for inclusion, extract data and assess the methodological quality using the Cochrane risk of bias tool. Extracted data will be analysed using Review Manager and Trial Sequential Analysis. The protocol is registered at PROSPERO. DISCUSSION We aim to provide reliable evidence on the use of loop diuretics in adult intensive care patients with fluid overload to guide clinicians, decision makers and trialists on clinical practice.
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Affiliation(s)
- Sine Wichmann
- Department of Anaesthesiology Nordsjællands HospitalUniversity of Copenhagen Hillerød Denmark
| | - Marija Barbateskovic
- 2Copenhagen Trial Unit Centre for Clinical Intervention Research, RigshospitaletUniversity of Copenhagen Copenhagen Denmark
| | - Jane Lindschou
- 2Copenhagen Trial Unit Centre for Clinical Intervention Research, RigshospitaletUniversity of Copenhagen Copenhagen Denmark
| | - Christian Gluud
- 2Copenhagen Trial Unit Centre for Clinical Intervention Research, RigshospitaletUniversity of Copenhagen Copenhagen Denmark
| | - Anders Perner
- Department of Intensive Care, Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Morten H. Bestle
- Department of Anaesthesiology Nordsjællands HospitalUniversity of Copenhagen Hillerød Denmark
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11
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Fluid Overload and Mortality in Adult Critical Care Patients—A Systematic Review and Meta-Analysis of Observational Studies*. Crit Care Med 2020; 48:1862-1870. [DOI: 10.1097/ccm.0000000000004617] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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12
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Renal Replacement Therapy in Critical Care: When to Start? CURRENT ANESTHESIOLOGY REPORTS 2019. [DOI: 10.1007/s40140-019-00325-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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13
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Vaara ST, Reinikainen M, Bouchard J. Fluid accumulation in acute kidney injury: More evidence toward harm and current challenges. Acta Anaesthesiol Scand 2018; 62:739-741. [PMID: 29864215 DOI: 10.1111/aas.13142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- S T Vaara
- Division of Intensive Care Medicine, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.,Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - M Reinikainen
- Department of Intensive Care, North Karelia Central Hospital, Joensuu, Finland
| | - J Bouchard
- Division of Nephrology, Department of Medicine, Sacré-Coeur Hospital, University of Montreal, Montreal, Quebec, Canada
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