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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; 68:1120-1125. [PMID: 38837207 DOI: 10.1111/aas.14464] [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: 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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Merrill D, Craven JM, Silvey S, Gouger D, Wang C, Patel R, Yajnik V. The Impact of Fluid Balance on Acute Kidney Injury in Nontraumatic Subarachnoid Hemorrhage. J Intensive Care Med 2024; 39:693-700. [PMID: 38374621 DOI: 10.1177/08850666241226900] [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] [Indexed: 02/21/2024]
Abstract
Background: Nontraumatic subarachnoid hemorrhage (SAH) can lead to poor neurologic outcomes, particularly when delayed cerebral ischemia (DCI) occurs. Maintenance of euvolemia following SAH is thought to reduce the risk of DCI. However, attempts at maintaining euvolemia often err on the side of hypervolemia. In this study, we assessed the relationship between fluid balance and acute kidney injury (AKI) in SAH patients, assessing hypervolemia versus euvolemia and their impact on AKI. Methods: In a quaternary care center, neuroscience intensive care unit we conducted a retrospective longitudinal analysis in adult patients who suffered a nontraumatic SAH. Results: Out of 139 patients, 15 (10.8%) patients developed an AKI while hospitalized, with 7 stage I, 3 stage II, and 5 stage III injuries. Acute kidney injury patients had higher peak sodium (150.1 mEq/L vs 142.7 mEq/L, 95% confidence interval [CI]: [2.7-12.1 mEq/L]), higher discharge chloride (109.1 mEq/L vs 104.9 mEq/L, 95% CI: [0.7-7.6 mEq/L]), and lower hemoglobin at discharge (9.3 g/dL vs 11.3 g/dL, 95% CI: [1.0-2.9 g/dL]). At 7 days, AKI patients had a fluid balance that was 1.82 L higher (P = .04), and 3.38 L higher at 14 days (P = .02), in comparison to day 3. Acute kidney injury was associated with significant mortality increases. This increase in mortality was found at 30 days from admission with a 9.52-fold increase, and at 60 days with a 6.25-fold increase. As a secondary outcome, vasospasm (19 patients, 13.7%) showed no association with AKI. Conclusions: Acute kidney injury following SAH is correlated with clinically significant hypervolemia, elevated sodium, elevated chloride, decreased urine output, and decreased hemoglobin at discharge-risk factors for all SAH patients. This study further elucidates the harm of hypervolemia and gives greater practical evidence to physicians attempting to balance the dangers of vasospasm and AKI.
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Affiliation(s)
- Dante Merrill
- Virginia Commonwealth Medical Center, Department of Internal Medicine, Richmond VA, USA
| | - Jack M Craven
- John Hopkins Health System, Department of Anesthesiology, Baltimore, MD, USA
| | - Scott Silvey
- Virginia Commonwealth University, Department of Biostatistics, Richmond, VA, USA
| | - Daniel Gouger
- John Hopkins Health System, Department of Anesthesiology, Baltimore, MD, USA
| | - Chen Wang
- Virginia Commonwealth University, Department of Biostatistics, Richmond, VA, USA
| | - Rishi Patel
- Medical University of South Carolina, Department of Anesthesiology, Charleston, SC, USA
| | - Vishal Yajnik
- Virginia Commonwealth Medical Center, Department of Anesthesiology, Richmond VA, USA
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Beni CE, Arbabi S, Robinson BRH, O'Keefe GE. Early Fluid Is Less Fluid: Comparing Early Versus Late ICU Resuscitation in Severely Injured Trauma Patients. Crit Care Explor 2024; 6:e1097. [PMID: 38958536 PMCID: PMC11224828 DOI: 10.1097/cce.0000000000001097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/04/2024] Open
Abstract
OBJECTIVES The temporal trends of crystalloid resuscitation in severely injured trauma patients after ICU admission are not well characterized. We hypothesized early crystalloid resuscitation was associated with less volume and better outcomes than delaying crystalloid. DESIGN Retrospective, observational. SETTING High-volume level 1 academic trauma center. PATIENTS Adult trauma patients admitted to the ICU with emergency department serum lactate greater than or equal to 4 mmol/dL, elevated lactate (≥ 2 mmol/L) at ICU admission, and normal lactate by 48 hours. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS For the 333 subjects, we analyzed patient and injury characteristics and the first 48 hours of ICU course. Receipt of greater than or equal to 500 mL/hr of crystalloid in the first 6 hours of ICU admission was used to distinguish early vs. late resuscitation. Outcomes included ICU length of stay (LOS), ventilator days, and acute kidney injury (AKI). Unadjusted and multivariable regression methods were used to compare early resuscitation vs. late resuscitation. Compared with the early resuscitation group, the late resuscitation group received more volume by 48 hours (5.5 vs. 4.1 L; p ≤ 0.001), had longer ICU LOS (9 vs. 5 d; p ≤ 0.001), more ventilator days (5 vs. 2 d; p ≤ 0.001), and higher occurrence rate of AKI (38% vs. 11%; p ≤ 0.001). On multivariable regression, late resuscitation remained associated with longer ICU LOS and ventilator days and higher odds of AKI. CONCLUSIONS Delaying resuscitation is associated with both higher volumes of crystalloid by 48 hours and worse outcomes compared with early resuscitation. Judicious crystalloid given early in ICU admission could improve outcomes in the severely injured.
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Affiliation(s)
| | - Saman Arbabi
- Department of Surgery, Harborview Medical Center, University of Washington, Seattle, WA
- Harborview Injury Prevention and Research Center, Harborview Medical Center, University of Washington, Seattle, WA
| | - Bryce R H Robinson
- Department of Surgery, Harborview Medical Center, University of Washington, Seattle, WA
- Harborview Injury Prevention and Research Center, Harborview Medical Center, University of Washington, Seattle, WA
| | - Grant E O'Keefe
- Department of Surgery, Harborview Medical Center, University of Washington, Seattle, WA
- Harborview Injury Prevention and Research Center, Harborview Medical Center, University of Washington, Seattle, WA
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Natraj R, Bhaskaran AK, Rola P, Haycock K, Siuba MTT, Ranjit S. Venous Congestion Assessed by Venous Excess Ultrasound (VExUS) and Acute Kidney Injury in Children with Right Ventricular Dysfunction. Indian J Crit Care Med 2024; 28:447-452. [PMID: 38738193 PMCID: PMC11080090 DOI: 10.5005/jp-journals-10071-24705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 04/03/2024] [Indexed: 05/14/2024] Open
Abstract
Background Right ventricular dysfunction (RVD) is a complication following congenital cardiac surgery in children and can lead to systemic venous congestion, low cardiac output, and organ dysfunction. Venous congestion can be transmitted backwards and adversely affect encapsulated organs such as the kidneys. Primary objective To investigate the association between systemic venous congestion, as estimated by Venous Excess Ultrasound (VExUS), and the occurrence of acute kidney injury (AKI) in children with RVD following congenital heart surgery. Secondary objectives included comparing changes in VExUS scores after initiating treatment for RVD and venous congestion. Methods and results This was a prospective observational study in children with RVD. The VExUS study was performed on day 1, day 2, and day 3 and categorized as VExUS-1, VExUS-2, and VExUS-3. Among 43 patients with RVD and dilated inferior vena cava, 19/43 (44%), 10/43 (23%), and 12/43 (28%) were VExUS-2 and VExUS-3, respectively. There was an association between severe RVD and elevated pulmonary artery systolic pressures and a VExUS score >2. A significant association was observed between central venous pressure (CVP) measurements and VExUS. Among 31 patients with a high VExUS score >2, 18 (58%) had AKI. Additionally, improvement in CVP and fluid balance was associated with improving VExUS scores following targeted treatment for RVD. Conclusion VExUS serves as a valuable bedside tool for diagnosing and grading venous congestion through ultrasound Doppler. An elevated VExUS score was associated with the occurrence of AKI, and among the components of VExUS, portal vein pulsatility may be useful as a predictor of AKI. How to cite this article Natraj R, Bhaskaran AK, Rola P, Haycock K, Siuba MTT, Ranjit S. Venous Congestion Assessed by Venous Excess Ultrasound (VExUS) and Acute Kidney Injury in Children with Right Ventricular Dysfunction. Indian J Crit Care Med 2024;28(5):447-452.
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Affiliation(s)
- Rajeswari Natraj
- Pediatric Intensive Care Unit and Cardiothoracic Services, Apollo Children's Hospital, Chennai, Tamil Nadu, India
| | | | - Philippe Rola
- Intensive Care Unit, Santa Cabrini Hospital, CEMTL; Intensive Care Unit, University of Montreal, Montreal, Canada
| | - Korbin Haycock
- Emergency Department, Riverside University Health System Medical Center, Moreno Valley, California, Loma Linda, United States
| | - Matthew TT Siuba
- Intensive Care Unit, Department of Critical Care Medicine, Integrated Hospital Care, Cleveland, Ohio, United States
| | - Suchitra Ranjit
- Department of Pediatric Intensive Care Unit, Apollo Children's Hospital, Chennai, Tamil Nadu, India
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Ramírez-Guerrero G, Ronco C, Lorenzin A, Brendolan A, Sgarabotto L, Zanella M, Reis T. Development of a new miniaturized system for ultrafiltration. Heart Fail Rev 2024; 29:615-630. [PMID: 38289525 DOI: 10.1007/s10741-024-10384-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/09/2024] [Indexed: 04/23/2024]
Abstract
Acute decompensated heart failure and fluid overload are the most common causes of hospitalization in heart failure patients, and often, they contribute to disease progression. Initial treatment encompasses intravenous diuretics although there might be a percentual of patients refractory to this pharmacological approach. New technologies have been developed to perform extracorporeal ultrafiltration in fluid overloaded patients. Current equipment allows to perform ultrafiltration in most hospital and acute care settings. Extracorporeal ultrafiltration is then prescribed and conducted by specialized teams, and fluid removal is planned to restore a status of hydration close to normal. Recent clinical trials and European and North American practice guidelines suggest that ultrafiltration is indicated for patients with refractory congestion not responding to medical therapy. Close interaction between nephrologists and cardiologists may be the key to a collaborative therapeutic effort in heart failure patients. Further studies are today suggesting that wearable technologies might become available soon to treat patients in ambulatory and de-hospitalized settings. These new technologies may help to cope with the increasing demand for the care of chronic heart failure patients. Herein, we provide a state-of-the-art review on extracorporeal ultrafiltration and describe the steps in the development of a new miniaturized system for ultrafiltration, called AD1 (Artificial Diuresis).
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Affiliation(s)
- Gonzalo Ramírez-Guerrero
- International Renal Research Institute of Vicenza (IRRIV), Vicenza, Italy
- Nephrology and Dialysis Unit, Carlos Van Buren Hospital, Valparaíso, Chile
- Departamento de Medicina Interna, Universidad de Valparaíso, Valparaíso, Chile
| | - Claudio Ronco
- International Renal Research Institute of Vicenza (IRRIV), Vicenza, Italy.
- Department of Nephrology, Dialysis and Kidney Transplantation, San Bortolo Hospital, Vicenza, Italy.
- Department of Medicine (DIMED), Università degli Studi di Padova, Padua, Italy.
| | - Anna Lorenzin
- International Renal Research Institute of Vicenza (IRRIV), Vicenza, Italy
- Department of Nephrology, Dialysis and Kidney Transplantation, San Bortolo Hospital, Vicenza, Italy
| | - Alessandra Brendolan
- International Renal Research Institute of Vicenza (IRRIV), Vicenza, Italy
- Department of Nephrology, Dialysis and Kidney Transplantation, San Bortolo Hospital, Vicenza, Italy
| | - Luca Sgarabotto
- International Renal Research Institute of Vicenza (IRRIV), Vicenza, Italy
- Department of Nephrology, Dialysis and Kidney Transplantation, San Bortolo Hospital, Vicenza, Italy
- Department of Medicine (DIMED), Università degli Studi di Padova, Padua, Italy
| | - Monica Zanella
- International Renal Research Institute of Vicenza (IRRIV), Vicenza, Italy
- Department of Nephrology, Dialysis and Kidney Transplantation, San Bortolo Hospital, Vicenza, Italy
| | - Thiago Reis
- International Renal Research Institute of Vicenza (IRRIV), Vicenza, Italy
- Laboratory of Molecular Pharmacology, Faculty of Health Sciences, University of Brasília, Brasília, Brazil
- Department of Nephrology and Kidney Transplantation, Fenix Group, Sao Paulo, Brazil
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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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Liu L, Shang L, Zhuang Y, Su X, Li X, Sun Y, Long B. Exploration of factors affecting hemodynamic stability following pheochromocytoma resection - cohort study. Front Endocrinol (Lausanne) 2024; 15:1336128. [PMID: 38650714 PMCID: PMC11033385 DOI: 10.3389/fendo.2024.1336128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 03/25/2024] [Indexed: 04/25/2024] Open
Abstract
Purpose Surgery is the only way to cure pheochromocytoma; however, postoperative hemodynamic instability is one of the main causes of serious complications and even death. This study's findings provide some guidance for improved clinical management. Patients and methods This study was to investigate the factors leading to postoperative hemodynamic instability in the postoperative pathology indicated pheochromocytoma from May 2016 to May 2022. They were divided into two groups according to whether vasoactive drugs were used for a median number of days or more postoperatively. The factors affecting the postoperative hemodynamics in the perioperative period (preoperative, intraoperative, and postoperative) were then evaluated. Results The median number of days requiring vasoactive drug support postoperatively was three in 234 patients, while 118 (50.4%) patients required vasoactive drug support for three days or more postoperatively. The results of the multivariate analysis indicated more preoperative colloid use (odds ratio [OR]=1.834, confidence interval [CI]:1.265-2.659, P=0.001), intraoperative use of vasoactive drug (OR=4.174, CI:1.882-9.258, P<0.001), and more postoperative crystalloid solution input per unit of body weight per day (ml/kg/d) (OR=1.087, CI:1.062-1.112, P<0.001) were risk factors for predicting postoperative hemodynamic instability. The optimal cutoff point of postoperative crystalloid use were 42.37 ml/kg/d. Conclusion Hemodynamic instability is a key issue for consideration in the perioperative period of pheochromocytoma. The amount of preoperative colloid use, the need for intraoperative vasoactive drugs, and postoperative crystalloid solution are risk factors for predicting postoperative hemodynamic instability (registration number: ChiCT2300071166).
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Affiliation(s)
| | | | | | | | | | | | - Bo Long
- Department of Anesthesiology, Shengjing Hospital of China Medical University, Shenyang, China
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8
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Martos-Benítez FD, Burgos-Aragüez D, García-Mesa L, Orama-Requejo V, Cárdenas-González RC, Michelena-Piedra JC, Izquierdo-Castañeda J, Sánchez-de-la-Rosa E, Corrales-González O. Fluid balance, biomarkers of renal function and mortality in critically ill patients with AKI diagnosed before, or within 24 h of intensive care unit admission: a prospective study. J Nephrol 2024; 37:439-449. [PMID: 38189864 DOI: 10.1007/s40620-023-01829-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 11/08/2023] [Indexed: 01/09/2024]
Abstract
BACKGROUND To evaluate fluid balance, biomarkers of renal function and its relation to mortality in patients with acute kidney injury (AKI) diagnosed before, or within 24 h of intensive care unit admission. METHODS A prospective cohort study considered 773 critically ill patients observed over six years. Pre-intensive care unit-onset AKI was defined as AKI diagnosed before, or within 24 h of intensive care unit admission. Body weight-adjusted fluid balance and fluid balance-adjusted biomarkers of renal function were measured daily for the first three days of intensive care unit admission. Primary outcome was mortality in the intensive care unit. RESULTS Prevalence of pre-intensive care unit-onset AKI was 55.1%, of which 55.6% of cases were hospital-acquired and 44.4% were community-acquired. Fluid balance was higher in AKI patients than in non-AKI patients (p < 0.001) and had a negative correlation with urine output (p < 0.01). Positive fluid balance and biomarkers of renal function were independently related to mortality. Multivariate analysis identified the following AKI-related variables associated with increased mortality: (1) In AKI patients: type 1 cardiorenal syndrome (OR 2.00), intra-abdominal hypertension (OR 1.71), AKI stage 3 (OR 2.15) and increase in AKI stage (OR 4.99); 2) In patients with community-acquired AKI: type 1 cardiorenal syndrome (OR 5.16), AKI stage 2 (OR 2.72), AKI stage 3 (OR 4.95) and renal replacement therapy (OR 3.05); and 3) In patients with hospital-acquired AKI: intra-abdominal hypertension (OR 2.31) and increase in AKI stage (OR 4.51). CONCLUSIONS In patients with pre-intensive care unit-onset AKI, positive fluid balance is associated with worse renal outcomes. Positive fluid balance and decline in biomarkers of renal function are related to increased mortality, thus in this subpopulation of critically ill patients, positive fluid balance is not recommended and renal function must be closely monitored.
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Affiliation(s)
- Frank Daniel Martos-Benítez
- Intensive Care Unit, National Institute of Neurology and Neurosurgery, 29 St. and D St., Vedado, Plaza, 10400, Havana, Cuba.
| | - Dailé Burgos-Aragüez
- Intensive Care Unit-8, Hermanos Ameijeiras Hospital, San Lázaro St., Centro Havana, 10200, Havana, Cuba
| | - Liselotte García-Mesa
- Intensive Care Unit-8, Hermanos Ameijeiras Hospital, San Lázaro St., Centro Havana, 10200, Havana, Cuba
| | | | | | - Juan Carlos Michelena-Piedra
- Intensive Care Unit, National Institute of Neurology and Neurosurgery, 29 St. and D St., Vedado, Plaza, 10400, Havana, Cuba
| | - Judet Izquierdo-Castañeda
- Intensive Care Unit, National Institute of Neurology and Neurosurgery, 29 St. and D St., Vedado, Plaza, 10400, Havana, Cuba
| | - Ernesto Sánchez-de-la-Rosa
- Intensive Care Unit, National Institute of Neurology and Neurosurgery, 29 St. and D St., Vedado, Plaza, 10400, Havana, Cuba
| | - Olivia Corrales-González
- Intensive Care Unit, National Institute of Neurology and Neurosurgery, 29 St. and D St., Vedado, Plaza, 10400, Havana, Cuba
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Martínez-Camacho MÁ, Jones-Baro RA, Gómez-González A, Lugo-García DS, Astorga PCG, Melo-Villalobos A, Gonzalez-Rodriguez BK, Pérez-Calatayud ÁA. Prolonged intensive care: muscular functional, and nutritional insights from the COVID-19 pandemic. Acute Crit Care 2024; 39:47-60. [PMID: 38303585 PMCID: PMC11002617 DOI: 10.4266/acc.2023.01284] [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: 10/10/2023] [Revised: 10/27/2023] [Accepted: 10/31/2023] [Indexed: 02/03/2024] Open
Abstract
During the coronavirus disease 2019 (COVID-19) pandemic, clinical staff learned how to manage patients enduring extended stays in an intensive care unit (ICU). COVID-19 patients requiring critical care in an ICU face a high risk of experiencing prolonged intensive care (PIC). The use of invasive mechanical ventilation in individuals with severe acute respiratory distress syndrome can cause numerous complications that influence both short-term and long-term morbidity and mortality. Those risks underscore the importance of proactively addressing functional complications. Mitigating secondary complications unrelated to the primary pathology of admission is imperative in minimizing the risk of PIC. Therefore, incorporating strategies to do that into daily ICU practice for both COVID-19 patients and those critically ill from other conditions is significantly important.
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Affiliation(s)
| | - Robert Alexander Jones-Baro
- Department of Critical Care Rehabilitation, Hospital General de México “Dr. Eduardo Liceaga”, Mexico City, Mexico
| | - Alberto Gómez-González
- Department of Critical Care Rehabilitation, Hospital General de México “Dr. Eduardo Liceaga”, Mexico City, Mexico
| | - Dalia Sahian Lugo-García
- Department of Critical Care Rehabilitation, Hospital General de México “Dr. Eduardo Liceaga”, Mexico City, Mexico
| | | | - Andrea Melo-Villalobos
- Department of Critical Care Rehabilitation, Hospital General de México “Dr. Eduardo Liceaga”, Mexico City, Mexico
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Nikravan S, Bughrara N, Klick J, Lanspa MJ, Rapoport L, Díaz-Gomez J. An Echocardiographic Approach for the Management of Shock: The Subcostal to Apical, Respiratory to Parasternal-Cardiac to Respiratory, Aortic to Stomach Protocol. Semin Ultrasound CT MR 2024; 45:74-83. [PMID: 38065314 DOI: 10.1053/j.sult.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/13/2024]
Abstract
Point of care ultrasound has become an integral part of critical care medicine, particularly for recognizing shock etiologies and guiding management. Most of the current ultrasonography guided shock protocols have been tailored towards a qualitative assessment of patients on presentation with shock. Unfortunately, the evolving nature of shock, particularly in the face of resuscitation and physiologic changes, demands a more sophisticated approach. This manuscript serves to present a comprehensive algorithm called the transthoracic Subcostal To Apical, Respiratory to paraSternal and transesophageal Cardiac to Respiratory, Aortic to StomacH ultrasonographic evaluations for the assessment of shock. This protocol is better suited for the critically ill patient in its ability to move beyond pattern recognition and focus on monitoring shock states from their presentation through their evolution. Not only is importance placed on the sequence of the exam, but also the identification of signs of chronic disease, the early incorporation of pulmonary evaluation, and the role for transesophageal imaging in critically ill patients with difficult surface imaging. Given the broad capabilities of bedside ultrasound, the Subcostal To Apical, Respiratory to paraSternal-Cardiac to Respiratory, Aortic to StomacH protocol serves as a multifaceted algorithm allowing for a nuanced and dynamic approach for the resuscitation of critically ill patients in shock.
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Affiliation(s)
| | | | - John Klick
- University of Vermont Medical Center, Burlington, VT
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11
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Alevroudis I, Kotoulas SC, Tzikas S, Vassilikos V. Congestion in Heart Failure: From the Secret of a Mummy to Today's Novel Diagnostic and Therapeutic Approaches: A Comprehensive Review. J Clin Med 2023; 13:12. [PMID: 38202020 PMCID: PMC10779505 DOI: 10.3390/jcm13010012] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 12/04/2023] [Accepted: 12/14/2023] [Indexed: 01/12/2024] Open
Abstract
This review paper presents a review of the evolution of this disease throughout the centuries, describes and summarizes the pathophysiologic mechanisms, briefly discusses the mechanism of action of diuretics, presents their role in decongesting heart failure in patients, and reveals the data behind ultrafiltration in the management of acutely or chronically decompensated heart failure (ADHF), focusing on all the available data and advancements in this field. Acutely decompensated heart failure (ADHF) presents a critical clinical condition characterized by worsening symptoms and signs of heart failure, necessitating prompt intervention to alleviate congestion and improve cardiac function. Diuretics have traditionally been the mainstay for managing fluid overload in ADHF. Mounting evidence suggests that due to numerous causes, such as coexisting renal failure or chronic use of loop diuretics, an increasing rate of diuretic resistance is noticed and needs to be addressed. There has been a series of trials that combined diuretics of different categories without the expected results. Emerging evidence suggests that ultrafiltration may offer an alternative or adjunctive approach.
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Affiliation(s)
- Ioannis Alevroudis
- Third Department of Cardiology, Ippokratio General Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece (V.V.)
- Intensive Care Medicine Clinic, Ippokratio General Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece;
| | | | - Stergios Tzikas
- Third Department of Cardiology, Ippokratio General Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece (V.V.)
| | - Vassilios Vassilikos
- Third Department of Cardiology, Ippokratio General Hospital, Aristotle University of Thessaloniki, 54642 Thessaloniki, Greece (V.V.)
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12
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Beni CE, Arbabi S, Robinson BRH, O'Keefe GE. Early Fluid is Less Fluid: Comparing Early Versus Late Resuscitation in Severely Injured Trauma Patients. RESEARCH SQUARE 2023:rs.3.rs-3409172. [PMID: 37886568 PMCID: PMC10602071 DOI: 10.21203/rs.3.rs-3409172/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
Background We aimed to characterize the temporal trends of crystalloid resuscitation in severely injured trauma patients after intensive care unit (ICU) admission. Using 500 mL/hr of crystalloid in the first 6 hours of ICU admission to distinguish early versus late resuscitation, we hypothesized early resuscitation was associated with less volume by 48 hours and better outcomes compared with late resuscitation. Methods We performed a retrospective review of the trauma registry of a high-volume level 1 academic trauma center to examine adult trauma patients admitted to the ICU (2016-2019) with: with initial serum lactate ≥ 4 mmol/dL, elevated lactate (≥ 2 mmol/L) at ICU admission, and lactate normalization within 48 hours. We analyzed patient and injury characteristics, and the first 48 hours of ICU course. The primary outcome was ICU length of stay (LOS); secondary outcomes included ventilator days, acute kidney injury (AKI), and in-hospital death. We compared subjects who received early resuscitation to those received late resuscitation using unadjusted methods and multivariable regression models. Results We analyzed 333 subjects. The late resuscitation group received less volume over the first 24 hours, but surpassed the early group by 48 hours (5.5 vs 4.1L, p ≤ 0.001). The late group had longer ICU LOS (9 vs 5 days, p ≤ 0.001) and ventilator days (5 vs 2 days, p ≤ 0.001), and higher incidence of AKI (38% vs 11%, p ≤ 0.001). On multivariable regression, late resuscitation remained associated with longer ICU LOS and ventilator days, and higher odds of AKI after adjusting for important confounders. Conclusions After hemostasis, crystalloid can play an important role in restoration of organ perfusion. Delaying resuscitation is associated with both receipt of higher volumes of crystalloid by 48 hours and worse outcomes compared to early resuscitation. Judicious crystalloid given early in ICU admission could improve outcomes in the severely injured.
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13
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Koch EB, Madsen JM, Wichmann S, Bestle MH, Itenov TS. Bioimpedance and Duration of Organ Dysfunction in Septic Shock-A Prospective Observational Study. J Intensive Care Med 2023; 38:966-974. [PMID: 37186782 DOI: 10.1177/08850666231175819] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Abstract
Rationale: Bioimpedance may be a useful tool to guide fluid treatment and avoid organ dysfunction related to fluid overload. Objective: We examined the correlation between bioimpedance and organ dysfunction in patients with septic shock. Methods: Prospective observational study of adult intensive care unit patients fulfilling the sepsis-3 criteria. Bioimpedance was measured using a body composition monitor (BCM) and BioScan Touch i8 (MBS). We measured impedance at inclusion and after 24 h and reported the impedance, change in impedance, bioimpedance-derived fluid balance, and changes in bioimpedance-derived fluid balance. Organ markers on respiratory, circulatory, and kidney function and overall disease severity were ascertained on days 1-7. The effect of bioimpedance on the change in organ function was assessed by mixed effects linear models. We considered P < .01 as significant. Measurements and Main Results: Forty-nine patients were included. None of the single baseline measurements or derived fluid balances were associated with the course of organ dysfunction. Changes in impedance were associated with the course of overall disease severity (P < .001; with MBS), and with changes in noradrenaline dose (P < .001; with MBS) and fluid balance (P < .001; with BCM). The changes in bioimpedance-derived fluid balance were associated with changes in noradrenaline dose (P < .001; with BCM), cumulative fluid balances (P < .001; with MBS), and lactate concentrations (P < .001; with BCM). Conclusions: Changes in bioimpedance were correlated with the duration of overall organ failure, circulatory failure, and fluid status. Single measurements of bioimpedance were not associated with any changes in organ dysfunction.
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Affiliation(s)
- Ellen Bjerre Koch
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital-North Zealand, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Janne M Madsen
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital-North Zealand, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Sine Wichmann
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital-North Zealand, Copenhagen, Denmark
| | - Morten H Bestle
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital-North Zealand, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Theis S Itenov
- Department of Anaesthesia and Intensive Care, Copenhagen University Hospital-North Zealand, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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14
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de Carvalho EB, Battaglini D, Robba C, Malbrain MLNG, Pelosi P, Rocco PRM, Silva PL. Fluid management strategies and their interaction with mechanical ventilation: from experimental studies to clinical practice. Intensive Care Med Exp 2023; 11:44. [PMID: 37474816 PMCID: PMC10359242 DOI: 10.1186/s40635-023-00526-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 05/31/2023] [Indexed: 07/22/2023] Open
Abstract
Patients on mechanical ventilation may receive intravenous fluids via restrictive or liberal fluid management. A clear and objective differentiation between restrictive and liberal fluid management strategies is lacking in the literature. The liberal approach has been described as involving fluid rates ranging from 1.2 to 12 times higher than the restrictive approach. A restrictive fluid management may lead to hypoperfusion and distal organ damage, and a liberal fluid strategy may result in endothelial shear stress and glycocalyx damage, cardiovascular complications, lung edema, and distal organ dysfunction. The association between fluid and mechanical ventilation strategies and how they interact toward ventilator-induced lung injury (VILI) could potentiate the damage. For instance, the combination of a liberal fluids and pressure-support ventilation, but not pressure control ventilation, may lead to further lung damage in experimental models of acute lung injury. Moreover, under liberal fluid management, the application of high positive end-expiratory pressure (PEEP) or an abrupt decrease in PEEP yielded higher endothelial cell damage in the lungs. Nevertheless, the translational aspects of these findings are scarce. The aim of this narrative review is to provide better understanding of the interaction between different fluid and ventilation strategies and how these interactions may affect lung and distal organs. The weaning phase of mechanical ventilation and the deresuscitation phase are not explored in this review.
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Affiliation(s)
- Eduardo Butturini de Carvalho
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
- University of Vassouras, Rio de Janeiro, Brazil
| | | | - Chiara Robba
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Manu L. N. G. Malbrain
- First Department of Anesthesiology and Intensive Therapy, Medical University of Lublin, Lublin, Poland
- International Fluid Academy, Lovenjoel, Belgium
| | - Paolo Pelosi
- IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Patricia Rieken Macedo Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Pedro Leme Silva
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Biophysics Institute, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
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15
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Schnaubelt S, Eibensteiner F, Oppenauer J, Tihanyi D, Neymayer M, Brock R, Kornfehl A, Veigl C, Al Jalali V, Anders S, Steinlechner B, Domanovits H, Sulzgruber P. Hemodynamic and Rhythmologic Effects of Push-Dose Landiolol in Critical Care-A Retrospective Cross-Sectional Study. Pharmaceuticals (Basel) 2023; 16:134. [PMID: 37259286 PMCID: PMC9967759 DOI: 10.3390/ph16020134] [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: 12/24/2022] [Revised: 01/06/2023] [Accepted: 01/10/2023] [Indexed: 08/30/2023] Open
Abstract
BACKGROUND The highly β1-selective beta-blocker Landiolol is known to facilitate efficient and safe rate control in non-compensatory tachycardia or dysrhythmia when administered continuously. However, efficacy and safety data of the also-available bolus formulation in critically ill patients are scarce. METHODS We conducted a retrospective cross-sectional study on a real-life cohort of critical care patients, who had been treated with push-dose Landiolol due to sudden-onset non-compensatory supraventricular tachycardia. Continuous hemodynamic data had been acquired via invasive blood pressure monitoring. RESULTS Thirty patients and 49 bolus applications were analyzed. Successful heart rate control was accomplished in 20 (41%) cases, rhythm control was achieved in 13 (27%) episodes, and 16 (33%) applications showed no effect. Overall, the heart rate was significantly lower (145 (130-150) vs. 105 (100-125) bpm, p < 0.001) in a 90 min post-application observational period in all subgroups. The median changes in blood pressure after the bolus application did not reach clinical significance. Compared with the ventilation settings before the bolus application, the respiratory settings including the required FiO2 after the bolus application did not differ significantly. No serious adverse events were seen. CONCLUSIONS Push-dose Landiolol was safe and effective in critically ill ICU patients. No clinically relevant impact on blood pressure was noted.
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Affiliation(s)
- Sebastian Schnaubelt
- Department of Emergency Medicine, Medical University of Vienna, 1090 Vienna, Austria
| | - Felix Eibensteiner
- Department of Emergency Medicine, Medical University of Vienna, 1090 Vienna, Austria
| | - Julia Oppenauer
- Department of Emergency Medicine, Medical University of Vienna, 1090 Vienna, Austria
| | - Daniel Tihanyi
- Department of Pulmonology, Clinic Penzing, Vienna Healthcare Group, 1140 Vienna, Austria
| | - Marco Neymayer
- Department of Emergency Medicine, Medical University of Vienna, 1090 Vienna, Austria
| | - Roman Brock
- Department of Emergency Medicine, Medical University of Vienna, 1090 Vienna, Austria
| | - Andrea Kornfehl
- Department of Emergency Medicine, Medical University of Vienna, 1090 Vienna, Austria
| | - Christoph Veigl
- Department of Emergency Medicine, Medical University of Vienna, 1090 Vienna, Austria
| | - Valentin Al Jalali
- Department of Clinical Pharmacology, Medical University of Vienna, 1090 Vienna, Austria
| | - Sonja Anders
- Department of Pulmonology, Clinic Penzing, Vienna Healthcare Group, 1140 Vienna, Austria
| | - Barbara Steinlechner
- Department of Anaesthesia, Intensive Cate Medicine and Pain Medicine, Medical University of Vienna, 1090 Vienna, Austria
| | - Hans Domanovits
- Department of Emergency Medicine, Medical University of Vienna, 1090 Vienna, Austria
| | - Patrick Sulzgruber
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria
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Donati PA, Villalta C, Lisa T, Fravega R, Cordero IS, Tunesi M, Guevara JM, Otero PE. Echocardiographic indicators of fluid responsiveness in hospitalized dogs with compromised hemodynamics and tissue hypoperfusion. J Vet Emerg Crit Care (San Antonio) 2023; 33:22-28. [PMID: 36125168 DOI: 10.1111/vec.13255] [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: 04/07/2021] [Revised: 08/17/2021] [Accepted: 09/11/2021] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To evaluate the accuracy of selected echocardiographic variables used to predict fluid responsiveness in hospitalized dogs with compromised hemodynamics and tissue hypoperfusion. DESIGN Diagnostic test study in a prospective cohort of hospitalized dogs. SETTING Veterinary referral clinics. ANIMALS Forty-four hospitalized dogs with compromised hemodynamics and tissue hypoperfusion were utilized in this study. INTERVENTIONS Echocardiographic examination before and after fluid replacement with 30 ml/kg of lactated Ringer's solution. MEASUREMENTS AND MAIN RESULTS Pre-fluid replacement measurements of velocity of transmitral E wave (E-peak), the left ventricular end-diastolic internal diameter normalized to body weight (LVIDdN), and the left ventricular end-systolic internal diameter normalized to body weight (LVIDsN) were significantly lower in fluid-responsive patients compared with nonresponders (P < 0.001). The area under the receiver operating characteristic curve (AUROC) with its 95% confidence interval (CI) for each significant predictor was as follows: E-peak 0.907 (0.776-1.000, P < 0.001) and LVIDdN 0.919 (0.801-1.000, P < 0.001). The predictive capacity of LVIDsN was not significantly better than chance (AUROC, 0.753; 95% CI, 0.472-1.000, P = 0.078). A significant negative linear correlation was observed between the percentage of increase in velocity-time integral after expansion and the echocardiographic variables LVIDdN (rs = -0.452, P = 0.023) and E-peak (rs = -0.396, P = 0.008) pre-fluid replacement. The intraobserver and interobserver variability was very low (<5 %) for all measurements. CONCLUSIONS In this study using critically ill dogs with compromised hemodynamics and tissue hypoperfusion, pre-fluid replacement measurements of LVIDdN and E-peak adequately predict fluid responsiveness. Because a small number of fluid nonresponders were involved in the present study (11.4%), further studies that include larger numbers of fluid-nonresponsive animals are required.
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Affiliation(s)
- Pablo A Donati
- Facultad de Ciencias Veterinarias, Cátedra de Anestesiología y Algiología, Universidad de Buenos Aires, Buenos Aires, Argentina.,Cooperative Veterinary Intensive Care Unit (UCICOOP), Buenos Aires, Argentina
| | | | - Tarragona Lisa
- Facultad de Ciencias Veterinarias, Cátedra de Anestesiología y Algiología, Universidad de Buenos Aires, Buenos Aires, Argentina
| | - Rodrigo Fravega
- Internal Medicine Service, Hospital Veterinario de Santiago, Santiago, Chile
| | | | - Marcela Tunesi
- Cooperative Veterinary Intensive Care Unit (UCICOOP), Buenos Aires, Argentina
| | - Juan Manuel Guevara
- Cooperative Veterinary Intensive Care Unit (UCICOOP), Buenos Aires, Argentina
| | - Pablo E Otero
- Facultad de Ciencias Veterinarias, Cátedra de Anestesiología y Algiología, Universidad de Buenos Aires, Buenos Aires, Argentina
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Wang JL, Xiang BX, Song XL, Que RM, Zuo XC, Xie YL. Prevalence of polymyxin-induced nephrotoxicity and its predictors in critically ill adult patients: A meta-analysis. World J Clin Cases 2022; 10:11466-11485. [PMID: 36387815 PMCID: PMC9649555 DOI: 10.12998/wjcc.v10.i31.11466] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 09/15/2022] [Accepted: 09/23/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Polymyxin-induced nephrotoxicity is a major safety concern in clinical practice due to long-term adverse outcomes and high mortality.
AIM To conducted a systematic review and meta-analysis of the prevalence and potential predictors of polymyxin-induced nephrotoxicity in adult intensive care unit (ICU) patients.
METHODS PubMed, EMBASE, the Cochrane Library and Reference Citation Analysis database were searched for relevant studies from inception through May 30, 2022. The pooled prevalence of polymyxin-induced nephrotoxicity and pooled risk ratios of associated factors were analysed using a random-effects or fixed-effects model by Stata SE ver. 12.1. Additionally, subgroup analyses and meta-regression were conducted to assess heterogeneity.
RESULTS A total of 89 studies involving 12234 critically ill adult patients were included in the meta-analysis. The overall pooled incidence of polymyxin-induced nephrotoxicity was 34.8%. The pooled prevalence of colistin-induced nephrotoxicity was not higher than that of polymyxin B (PMB)-induced nephrotoxicity. The subgroup analyses showed that nephrotoxicity was significantly associated with dosing interval, nephrotoxicity criteria, age, publication year, study quality and sample size, which were confirmed in the univariable meta-regression analysis. Nephrotoxicity was significantly increased when the total daily dose was divided into 2 doses but not 3 or 4 doses. Furthermore, older age, the presence of sepsis or septic shock, hypoalbuminemia, and concomitant vancomycin or vasopressor use were independent risk factors for polymyxin-induced nephrotoxicity, while an elevated baseline glomerular filtration rate was a protective factor against colistin-induced nephrotoxicity.
CONCLUSION Our findings indicated that the incidence of polymyxin-induced nephrotoxicity among ICU patients was high. It emphasizes the importance of additional efforts to manage ICU patients receiving polymyxins to decrease the risk of adverse outcomes.
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Affiliation(s)
- Jiang-Lin Wang
- Department of Pharmacy, The Third Xiangya Hospital of Central South University, Changsha 410013, Hunan Province, China
| | - Bi-Xiao Xiang
- Department of Pharmacy, The Third Xiangya Hospital of Central South University, Changsha 410013, Hunan Province, China
| | - Xiao-Li Song
- Department of Pharmacy, Sanya Central Hospital, Sanya 572000, Hainan Province, China
| | - Rui-Man Que
- Department of Pharmacy, The Third Xiangya Hospital of Central South University, Changsha 410013, Hunan Province, China
| | - Xiao-Cong Zuo
- Department of Pharmacy, The Third Xiangya Hospital of Central South University, Changsha 410013, Hunan Province, China
| | - Yue-Liang Xie
- Department of Pharmacy, The Third Xiangya Hospital of Central South University, Changsha 410013, Hunan Province, China
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18
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Murugan R, Kazory A, Sgarabotto L, Ronco C. Fluid Overload and Precision Net Ultrafiltration in Critically Ill Patients. Cardiorenal Med 2022; 13:9-18. [PMID: 36202071 PMCID: PMC10076441 DOI: 10.1159/000527390] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 09/19/2022] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Fluid overload is present in two-thirds of critically ill patients with acute kidney injury and is associated with morbidity, mortality, and increased healthcare resource utilization. Kidney replacement therapy (KRT) is frequently used for net fluid removal (i.e., net ultrafiltration [UFNET]) in patients with severe oliguric acute kidney injury. However, ultrafiltration has considerable risks associated with it, and there is a need for newer technology to perform ultrafiltration safely and to improve outcomes. SUMMARY Caring for a critically ill patient with oliguric acute kidney injury and fluid overload is one of the most challenging problems. Although diuretics are the first-line treatment for management of fluid overload, diuretic resistance is common. Various clinical practice guidelines support fluid removal using ultrafiltration during KRT. Emerging evidence from observational studies in critically ill patients suggests that both slow and fast rates of net fluid removal during continuous kidney replacement therapy are associated with increased mortality compared with moderate UFNET rates. In addition, fast UFNET rates are associated with an increased risk of cardiac arrhythmias. Randomized trials are required to examine whether moderate UFNET rates are associated with a reduced risk of hemodynamic instability, organ injury, and improved outcomes in critically ill patients. There is a need for newer technology for fluid removal in patients who do not meet traditional criteria for initiation of KRT. Emerging newer and miniaturized ultrafiltration devices may address an unmet clinical need. KEY MESSAGES Among critically ill patients with acute kidney injury and fluid overload requiring continuous kidney replacement therapy, use of higher and slower UFNET rates compared with moderate UFNET rates might be associated with poor outcomes. Newer minimally invasive technologies may allow for safe and efficient UFNET in patients with acute kidney injury who do not meet criteria for initiation of KRT.
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Affiliation(s)
- Raghavan Murugan
- The Program for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Amir Kazory
- Division of Nephrology, Hypertension, and Renal Transplantation, University of Florida, Gainesville, Florida, USA
| | - Luca Sgarabotto
- Department of Medicine, Nephrology, Dialysis and Transplantation Unit, University of Padova, Italy
| | - Claudio Ronco
- Department of Medicine, University of Padova, International Renal Research Institute of Vicenza and Department of Clinical Nephrology, San Bortolo Hospital, Vicenza, Italy
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19
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Zhu S, Zhang Y, Qiao W, Wang Y, Xie Y, Zhang X, Wu C, Wang G, Li Y, Dong N, Xie M, Zhang L. Incremental value of preoperative right ventricular function in predicting moderate to severe acute kidney injury after heart transplantation. Front Cardiovasc Med 2022; 9:931517. [PMID: 36017097 PMCID: PMC9398196 DOI: 10.3389/fcvm.2022.931517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 07/18/2022] [Indexed: 11/21/2022] Open
Abstract
Background Acute kidney injury (AKI) commonly occurs after heart transplantation (HTx), but its association with preoperative right ventricular (RV) function remains unknown. Consequently, we aimed to determine the predictive value of preoperative RV function for moderate to severe AKI after HTx. Materials and methods From 1 January 2016 to 31 December 2019, all the consecutive HTx recipients in our center were enrolled and analyzed for the occurrence of postoperative AKI staged by the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Conventional RV function parameters, including RV fractional area change (RVFAC) and tricuspid annular plane systolic excursion (TAPSE), were obtained. The primary endpoint was moderate to severe AKI (the KDIGO stage 2 or 3). The secondary endpoints included the impact of AKI on intensive care unit (ICU) mortality, in-hospital mortality, and 1-year mortality. Results A total of 273 HTx recipients were included in the study. Postoperative AKI occurred in 209 (77%) patients, including 122 (45%) patients in stage 1 AKI, 49 (18%) patients in stage 2 AKI, and 38 (14%) patients in stage 3 AKI. Patients with higher AKI stage had lower baseline estimated glomerular filtration rate (eGFR), more frequent diabetes, higher right atrial pressure (RAP), longer cardiopulmonary bypass (CPB) duration, more perioperative red blood cell (RBC) transfusions, and worse preoperative RV function. A multivariate logistic regression model incorporating previous diabetes mellitus [odds ratio (OR): 2.21; 95% CI: 1.06–4.61; P = 0.035], baseline eGFR (OR: 0.99; 95% CI: 0.97–0.10; P = 0.037), RAP (OR: 1.05; 95% CI: 1.00–1.10; P = 0.041), perioperative RBC (OR: 1.18; 95% CI: 1.08–1.28; P < 0.001), and TAPSE (OR: 0.84; 95% CI: 0.79–0.91; P < 0.001) was established to diagnose moderate to severe AKI more accurately [the area under the curve (AUC) = 79.8%; Akaike information criterion: 274]. Conclusion Preoperative RV function parameters provide additional predicting value over clinical and hemodynamic parameters, which are imperative for risk stratification in patients with HTx at higher risk of AKI.
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Affiliation(s)
- Shuangshuang Zhu
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Yanting Zhang
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Weihua Qiao
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yixuan Wang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yuji Xie
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Xin Zhang
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Chun Wu
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Guohua Wang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yuman Li
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Nianguo Dong
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- *Correspondence: Nianguo Dong,
| | - Mingxing Xie
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
- Mingxing Xie,
| | - Li Zhang
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
- Li Zhang,
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20
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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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21
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Jung S, Kim J, Lee J, Choi SY, Joo HJ, Koo BN. Effects of the Type of Intraoperative Fluid in Living Donor Kidney Transplantation: A Single-Center Retrospective Cohort Study. Yonsei Med J 2022; 63:380-388. [PMID: 35352890 PMCID: PMC8965431 DOI: 10.3349/ymj.2022.63.4.380] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 11/23/2021] [Accepted: 12/11/2021] [Indexed: 11/27/2022] Open
Abstract
PURPOSE Perioperative fluid management in kidney transplant recipients is crucial to supporting the fluid, acid-base, and electrolyte balance required for graft perfusion. However, the choice of intraoperative crystalloids in kidney transplantation remains controversial. We conducted a single-center retrospective cohort study to evaluate the impact of intraoperative fluids on acid-base and electrolyte balance and graft outcomes. MATERIALS AND METHODS We included 282 living donor kidney transplant recipients from January 2010 to December 2017. Patients were classified into two groups based on the type of intraoperative crystalloids used (157 patients in the half saline group and 125 patients in the balanced crystalloid solutions group, Plasma-lyte). RESULTS Compared with the half saline group, the Plasma-lyte group showed less metabolic acidosis and hyponatremia during surgery. Hyperkalemia incidence was not significantly different between the two groups. Changes in postoperative graft function assessed by blood urea nitrogen and creatinine were significantly different between the two groups. Patients in the Plasma-lyte group exhibited consistently higher glomerular filtration rates than those in the half saline group at 1 month and 1 year after transplantation after adjusting for demographic differences. CONCLUSION Intraoperative Plasma-lyte can lead to more favorable results in terms of acid-base balance during kidney transplantation. Patients who received Plasma-lyte showed superior postoperative graft function at 1 month and 1 year after transplantation. Further studies are needed to evaluate the superiority of intraoperative Plasma-lyte over other types of crystalloids in relation to graft outcomes.
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Affiliation(s)
- Seungho Jung
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Jeongmin Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Juhan Lee
- Department of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Su Youn Choi
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Hye Ji Joo
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Bon-Nyeo Koo
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea.
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22
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Venkataraman R, Kellum JA. Evaluation and Treatment of Acute Oliguria. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00018-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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23
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Zhang L, Xu F, Han D, Huang T, Li S, Yin H, Lyu J. Influence of the trajectory of the urine output for 24 h on the occurrence of AKI in patients with sepsis in intensive care unit. J Transl Med 2021; 19:518. [PMID: 34930308 PMCID: PMC8686667 DOI: 10.1186/s12967-021-03190-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 12/09/2021] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Sepsis-associated acute kidney injury (S-AKI) is a common and life-threatening complication in hospitalized and critically ill patients. This condition is an independent cause of death. This study was performed to investigate the correlation between the trajectory of urine output within 24 h and S-AKI. METHODS Patients with sepsis were studied retrospectively based on the Medical Information Mart for Intensive Care IV. Latent growth mixture modeling was used to classify the trajectory of urine output changes within 24 h of sepsis diagnosis. The outcome of this study is AKI that occurs 24 h after sepsis. Cox proportional hazard model, Fine-Gray subdistribution proportional hazard model, and doubly robust estimation method were used to explore the risk of AKI in patients with different trajectory classes. RESULTS A total of 9869 sepsis patients were included in this study, and their 24-h urine output trajectories were divided into five classes. The Cox proportional hazard model showed that compared with class 1, the HR (95% CI) values for classes 3, 4, and 5 were 1.460 (1.137-1.875), 1.532 (1.197-1.961), and 2.232 (1.795-2.774), respectively. Competing risk model and doubly robust estimation methods reached similar results. CONCLUSIONS The trajectory of urine output within 24 h of sepsis patients has a certain impact on the occurrence of AKI. Therefore, in the early treatment of sepsis, close attention should be paid to changes in the patient's urine output to prevent the occurrence of S-AKI.
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Affiliation(s)
- Luming Zhang
- Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangzhou, 510630, Guangdong Province, People's Republic of China.,Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, 510630, Guangdong Province, People's Republic of China
| | - Fengshuo Xu
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, 510630, Guangdong Province, People's Republic of China.,School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, China
| | - Didi Han
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, 510630, Guangdong Province, People's Republic of China.,School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, Shaanxi, China
| | - Tao Huang
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, 510630, Guangdong Province, People's Republic of China
| | - Shaojin Li
- Department of Orthopaedics, The First Affiliated Hospital of Jinan University, Guangzhou, Guangdong Province, China
| | - Haiyan Yin
- Intensive Care Unit, The First Affiliated Hospital of Jinan University, Guangzhou, 510630, Guangdong Province, People's Republic of China.
| | - Jun Lyu
- Department of Clinical Research, The First Affiliated Hospital of Jinan University, Guangzhou, 510630, Guangdong Province, People's Republic of China.
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24
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Beni CE, Arbabi S, Robinson BRH, O'Keefe GE. Acute intensive care unit resuscitation of severely injured trauma patients: Do we need a new strategy? J Trauma Acute Care Surg 2021; 91:1010-1017. [PMID: 34347741 PMCID: PMC9009679 DOI: 10.1097/ta.0000000000003373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Unlike recent advances in blood product resuscitation, intravenous crystalloid (IVF) use after intensive care unit (ICU) admission in hemorrhagic shock has received less attention and current recommendations are based on limited evidence. To address this knowledge gap, we aimed to determine associations between IVF administration during acute ICU resuscitation and outcomes. We hypothesized that larger IVF volumes are associated with worse outcomes. METHODS We linked our trauma registry with electronic health record data (2012-2015) to identify adults with an initial lactate level of ≥4 mmol/L and documented lactate normalization (≤2 mmol/L), excluding those with isolated head Abbreviated Injury Scale score ≥3. We focused on the period from ICU admission to lactate normalization, analyzing duration, volume of IVF, and proportion of volume as 1-L boluses. We used linear regression to determine associations with ICU length of stay and duration of mechanical ventilation in survivors, and logistic regression to identify associations with acute kidney injury and home discharge while adjusting for important covariates. RESULTS We included 337 subjects. Median time to lactate normalization was 15 hours (interquartile range, 7-25 hours), and median IVF volume was 3.7 L (interquartile range, 1.5-6.4 L). The fourfold difference between the upper and lower quartiles of both duration and volume remained after stratifying by injury severity. Hourly volumes tapered over time but persistently aggregated at 0.5 and 1 L, with 167 subjects receiving at least one 0.5-L bolus for 6 hours after ICU admission. Administration of larger volumes was associated with longer ICU length of stay and duration of mechanical ventilation, as well as acute kidney injury. CONCLUSION There is substantial variation in volume administered during acute ICU resuscitation, both absolutely and temporally, despite accounting for injury severity. Administration of larger volumes during acute ICU resuscitation is associated with worse outcomes. There is an opportunity to improve outcomes by further investigating and standardizing this important phase of care. LEVEL OF EVIDENCE Therapeutic/care management, level IV.
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Affiliation(s)
- Catherine E Beni
- From the Department of Surgery (C.E.B., S.A., B.R.H.R., G.E.O.) and Harborview Injury Prevention and Research Center (S.A., B.R.H.R., G.E.O.), Harborview Medical Center, University of Washington, Seattle, Washington
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25
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Soares H, Moita R, Maneira P, Gonçalves A, Gomes A, Flor-de-Lima F, Costa S, Soares P, Pissarra S, Rocha G, Silva J, Clemente F, Pinto H, Guimarães H. Nephrotoxicity in Neonates. Neoreviews 2021; 22:e506-e520. [PMID: 34341158 DOI: 10.1542/neo.22-8-e506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Acute kidney injury (AKI) is classified based on prerenal, intrinsic, and postrenal causes. In the newborn, AKI can occur after an insult during the prenatal, perinatal, or postnatal period. AKI is usually an underrecognized condition and its true incidence is unknown. AKI may result from the administration of a number of different nephrotoxic medications, which are often used concurrently in critically ill neonates, exponentially increasing the risk of renal injury. Drug toxicity may also compromise the formation and development of nephrons, and this is particularly important in preterm infants, who have incomplete nephrogenesis. Little is known about the pharmacokinetics and pharmacodynamics of different medications used in neonates, especially for the most immature infant, and the use of most medications in this population is off label. Strategies to prevent AKI include the avoidance of hypotension, hypovolemia, fluid imbalances, hypoxia, and sepsis as well as judicious use of nephrotoxic medications. Treatment strategies aim to maintain fluids and electrolytic and acid-base homeostasis, along with an adequate nutritional status. Neonates are especially prone to long-term sequelae of AKI and benefit from long-term follow-up. This review summarizes the most relevant aspects of nephrotoxicity in neonates and describes the prevention, treatment, and follow-up of AKI in neonates.
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Affiliation(s)
- Henrique Soares
- Neonatal Intensive Care Unit, Neonatology Department.,Department of Gynecology-Obstetrics and Pediatrics, Faculty of Medicine of Porto University, Porto, Portugal
| | - Rita Moita
- Neonatal Intensive Care Unit, Neonatology Department.,Department of Gynecology-Obstetrics and Pediatrics, Faculty of Medicine of Porto University, Porto, Portugal
| | - Pedro Maneira
- Neonatal Intensive Care Unit, Neonatology Department
| | | | - Ana Gomes
- Neonatal Intensive Care Unit, Neonatology Department.,Department of Gynecology-Obstetrics and Pediatrics, Faculty of Medicine of Porto University, Porto, Portugal
| | - Filipa Flor-de-Lima
- Neonatal Intensive Care Unit, Neonatology Department.,Department of Gynecology-Obstetrics and Pediatrics, Faculty of Medicine of Porto University, Porto, Portugal
| | - Sandra Costa
- Neonatal Intensive Care Unit, Neonatology Department.,Department of Gynecology-Obstetrics and Pediatrics, Faculty of Medicine of Porto University, Porto, Portugal
| | - Paulo Soares
- Neonatal Intensive Care Unit, Neonatology Department
| | - Susana Pissarra
- Neonatal Intensive Care Unit, Neonatology Department.,Department of Gynecology-Obstetrics and Pediatrics, Faculty of Medicine of Porto University, Porto, Portugal
| | - Gustavo Rocha
- Neonatal Intensive Care Unit, Neonatology Department.,Department of Gynecology-Obstetrics and Pediatrics, Faculty of Medicine of Porto University, Porto, Portugal
| | - Jorge Silva
- Neonatal Intensive Care Unit, Neonatology Department.,Department of Gynecology-Obstetrics and Pediatrics, Faculty of Medicine of Porto University, Porto, Portugal
| | - Fátima Clemente
- Neonatal Intensive Care Unit, Neonatology Department.,Department of Gynecology-Obstetrics and Pediatrics, Faculty of Medicine of Porto University, Porto, Portugal
| | - Helena Pinto
- Neonatal Intensive Care Unit, Neonatology Department.,Pediatrics Nephrology Unit, Pediatric Department, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Hercília Guimarães
- Department of Gynecology-Obstetrics and Pediatrics, Faculty of Medicine of Porto University, Porto, Portugal
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26
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Chávez-Íñiguez JS, Maggiani-Aguilera P, Pérez-Flores C, Claure-Del Granado R, De la Torre-Quiroga AE, Martínez-Gallardo González A, Navarro-Blackaller G, Medina-González R, Raimann JG, Yanowsky-Escatell FG, García-García G. Nephrologist Interventions to Avoid Kidney Replacement Therapy in Acute Kidney Injury. Kidney Blood Press Res 2021; 46:629-638. [PMID: 34315155 DOI: 10.1159/000517615] [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: 03/26/2021] [Accepted: 06/04/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Based on the pathophysiology of acute kidney injury (AKI), it is plausible that certain early interventions by the nephrologist could influence its trajectory. In this study, we investigated the impact of 5 early nephrology interventions on starting kidney replacement therapy (KRT), AKI progression, and death. METHODS In a prospective cohort at the Hospital Civil of Guadalajara, we followed up for 10 days AKI patients in whom a nephrology consultation was requested. We analyzed 5 early interventions of the nephrology team (fluid adjustment, nephrotoxic withdrawal, antibiotic dose adjustment, nutritional adjustment, and removal of hyperchloremic solutions) after the propensity score and multivariate analysis for the risk of starting KRT (primary objective), AKI progression to stage 3, and death (secondary objectives). RESULTS From 2017 to 2020, we analyzed 288 AKI patients. The mean age was 55.3 years, 60.7% were male, AKI KDIGO stage 3 was present in 50.5% of them, sepsis was the main etiology 50.3%, and 72 (25%) patients started KRT. The overall survival was 84.4%. Fluid adjustment was the only intervention associated with a decreased risk for starting KRT (odds ratio [OR]: 0.58, 95% confidence interval [CI]: 0.48-0.70, and p ≤ 0.001) and AKI progression to stage 3 (OR: 0.59, 95% CI: 0.49-0.71, and p ≤ 0.001). Receiving vasopressors and KRT were associated with mortality. None of the interventions studied was associated with reducing the risk of death. CONCLUSIONS In this prospective cohort study of AKI patients, we found for the first time that early nephrologist intervention and fluid prescription adjustment were associated with lower risk of starting KRT and progression to AKI stage 3.
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Affiliation(s)
- Jonathan S Chávez-Íñiguez
- Nephrology Service, Civil Hospital of Guadalajara Fray Antonio Alcalde, Guadalajara, Mexico.,University of Guadalajara Health Sciences Center, Guadalajara, Mexico
| | - Pablo Maggiani-Aguilera
- Nephrology Service, Civil Hospital of Guadalajara Fray Antonio Alcalde, Guadalajara, Mexico.,University of Guadalajara Health Sciences Center, Guadalajara, Mexico
| | - Christian Pérez-Flores
- Nephrology Service, Civil Hospital of Guadalajara Fray Antonio Alcalde, Guadalajara, Mexico.,University of Guadalajara Health Sciences Center, Guadalajara, Mexico
| | - Rolando Claure-Del Granado
- Division of Nephrology, Hospital Obrero #2 - C.N.S., Cochabamba, Bolivia.,Universidad Mayor de San Simon, School of Medicine, Cochabamba, Bolivia
| | - Andrés E De la Torre-Quiroga
- Nephrology Service, Civil Hospital of Guadalajara Fray Antonio Alcalde, Guadalajara, Mexico.,University of Guadalajara Health Sciences Center, Guadalajara, Mexico
| | - Alejandro Martínez-Gallardo González
- Nephrology Service, Civil Hospital of Guadalajara Fray Antonio Alcalde, Guadalajara, Mexico.,University of Guadalajara Health Sciences Center, Guadalajara, Mexico
| | - Guillermo Navarro-Blackaller
- Nephrology Service, Civil Hospital of Guadalajara Fray Antonio Alcalde, Guadalajara, Mexico.,University of Guadalajara Health Sciences Center, Guadalajara, Mexico
| | - Ramón Medina-González
- Nephrology Service, Civil Hospital of Guadalajara Fray Antonio Alcalde, Guadalajara, Mexico
| | | | | | - Guillermo García-García
- Nephrology Service, Civil Hospital of Guadalajara Fray Antonio Alcalde, Guadalajara, Mexico.,University of Guadalajara Health Sciences Center, Guadalajara, Mexico
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27
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Karpavičiūtė J, Skarupskienė I, Balčiuvienė V, Vaičiūnienė R, Žiginskienė E, Bumblytė IA. Assessment of Fluid Status by Bioimpedance Analysis and Central Venous Pressure Measurement and Their Association with the Outcomes of Severe Acute Kidney Injury. ACTA ACUST UNITED AC 2021; 57:medicina57060518. [PMID: 34067299 PMCID: PMC8224573 DOI: 10.3390/medicina57060518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2021] [Revised: 05/12/2021] [Accepted: 05/19/2021] [Indexed: 11/19/2022]
Abstract
Background and Objectives: Fluid disbalance is associated with adverse outcomes in critically ill patients with acute kidney injury (AKI). In this study, we intended to assess fluid status using bioimpedance analysis (BIA) and central venous pressure (CVP) measurement and to evaluate the association between hyperhydration and hypervolemia with the outcomes of severe AKI. Materials and Methods: A prospective study was conducted in the Hospital of the Lithuanian University of Health Sciences Kauno Klinikos. Forty-seven patients treated at the Intensive Care Unit (ICU) with severe AKI and a need for renal replacement therapy (RRT) were examined. The hydration level was evaluated according to the ratio of extracellular water to total body water (ECW/TBW) of bioimpedance analysis and volemia was measured according to CVP. All of the patients were tested before the first hemodialysis (HD) procedure. Hyperhydration was defined as ECW/TBW > 0.39 and hypervolemia as CVP > 12 cm H2O. Results: According to bioimpedance analysis, 72.3% (n = 34) of patients were hyperhydrated. According to CVP, only 51.1% (n = 24) of the patients were hypervolemic. Interestingly, 69.6% of hypovolemic/normovolemic patients were also hyperhydrated. Of all study patients, 57.4% (n = 27) died, in 29.8% (n = 14) the kidney function improved, and in 12.8% (n = 6) the demand for RRT remained after in-patient treatment. A tendency of higher mortality in hyperhydrated patients was observed, but no association between hypervolemia and outcomes of severe AKI was established. Conclusions: Three-fourths of the patients with severe AKI were hyperhydrated based on bioimpedance analysis. However, according to CVP, only half of these patients were hypervolemic. A tendency of higher mortality in hyperhydrated patients was observed.
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Affiliation(s)
- Justina Karpavičiūtė
- Department of Nephrology, Medical Academy, Lithuanian University of Health Sciences, Eivenių 2, LT-50161 Kaunas, Lithuania; (I.S.); (R.V.); (E.Ž.); (I.A.B.)
- Correspondence:
| | - Inga Skarupskienė
- Department of Nephrology, Medical Academy, Lithuanian University of Health Sciences, Eivenių 2, LT-50161 Kaunas, Lithuania; (I.S.); (R.V.); (E.Ž.); (I.A.B.)
- Hospital of Lithuanian University of Health Sciences, Eivenių 2, LT-50161 Kaunas, Lithuania;
| | - Vilma Balčiuvienė
- Hospital of Lithuanian University of Health Sciences, Eivenių 2, LT-50161 Kaunas, Lithuania;
| | - Rūta Vaičiūnienė
- Department of Nephrology, Medical Academy, Lithuanian University of Health Sciences, Eivenių 2, LT-50161 Kaunas, Lithuania; (I.S.); (R.V.); (E.Ž.); (I.A.B.)
- Hospital of Lithuanian University of Health Sciences, Eivenių 2, LT-50161 Kaunas, Lithuania;
| | - Edita Žiginskienė
- Department of Nephrology, Medical Academy, Lithuanian University of Health Sciences, Eivenių 2, LT-50161 Kaunas, Lithuania; (I.S.); (R.V.); (E.Ž.); (I.A.B.)
- Hospital of Lithuanian University of Health Sciences, Eivenių 2, LT-50161 Kaunas, Lithuania;
| | - Inga Arūnė Bumblytė
- Department of Nephrology, Medical Academy, Lithuanian University of Health Sciences, Eivenių 2, LT-50161 Kaunas, Lithuania; (I.S.); (R.V.); (E.Ž.); (I.A.B.)
- Hospital of Lithuanian University of Health Sciences, Eivenių 2, LT-50161 Kaunas, Lithuania;
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28
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Kohli M, Garg N, Sindwani G, Tempe D, Pamecha V, Pasupuleti SSR. Effect of positive cumulative fluid balance on postoperative complications after living donor liver transplantation: A retrospective analysis. Indian J Anaesth 2021; 65:383-389. [PMID: 34211196 PMCID: PMC8202804 DOI: 10.4103/ija.ija_1457_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Revised: 01/02/2021] [Accepted: 03/02/2021] [Indexed: 12/14/2022] Open
Abstract
Background and Aims: Fluid administration during liver transplant (LT) surgery is controversial. Although adverse outcomes following positive intraoperative fluid balance have been reported, studies presenting the influence of cumulative postoperative fluid balance (CFB) on complications following LT are sparse. Patients with chronic liver disease tend to receive more fluid during and after surgery due to their unique physiological disease state. The aim of this study was to evaluate the influence of 48-hour CFB on the development of acute kidney injury (AKI) and pulmonary complications on day 4 after live donor LT. Methods: This retrospective study included 230 patients undergoing live donor LT. The effect of CFB on day 2 on AKI and pulmonary complications was analysed. Chi-square test, Fisher's exact test, samples t-test, Mann-Whitney U-test were used. Results: Bivariate analysis showed a lower graft vs recipient weight ratio (GRWR), sepsis (P < 0.001) and a higher 48-hour CFB after surgery significantly increased the development of AKI. For pulmonary complications, higher Model for End- stage Liver Disease-Na(MELD-Na) score, higher peak arterial lactate, higher 48-hour CFB (P = 0.016) and sepsis (P = 0.003) were found to be statistically significant. Upon multivariate analysis, CFB at 48 hours was significantly higher in patients suffering from pulmonary complications, and GRWR and sepsis were significant for AKI. For every one litre increase in CFB on day 2, the odds of pulmonary complications increased by 37%. Conclusion: A more positive CFB on day 2 increased the development of pulmonary complications and lower GRWR and sepsis increased the development of AKI.
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Affiliation(s)
- Megha Kohli
- Department of Anaesthesia, Institute of Liver and Biliary Sciences, Delhi, India
| | - Neha Garg
- Department of Anaesthesia, Institute of Liver and Biliary Sciences, Delhi, India
| | - Gaurav Sindwani
- Department of Anaesthesia, Institute of Liver and Biliary Sciences, Delhi, India
| | - Deepak Tempe
- Department of Anaesthesia, Institute of Liver and Biliary Sciences, Delhi, India
| | - Viniyendra Pamecha
- Department of Liver Transplant and Hepatobiliary Surgery, Institute of Liver and Biliary Sciences, Delhi, India
| | - Samba Siva Rao Pasupuleti
- Department of Statistics, Mizoram University (A Central University), Pachhunga University College Campus, Aizawl, Mizoram, India
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29
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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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30
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Lin J, Ji XJ, Wang AY, Liu JF, Liu P, Zhang M, Qi ZL, Guo DC, Bellomo R, Bagshaw SM, Wald R, Gallagher M, Duan ML. Timing of continuous renal replacement therapy in severe acute kidney injury patients with fluid overload: A retrospective cohort study. J Crit Care 2021; 64:226-236. [PMID: 34034218 DOI: 10.1016/j.jcrc.2021.04.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Revised: 04/29/2021] [Accepted: 04/30/2021] [Indexed: 01/20/2023]
Abstract
PURPOSE We aimed to evaluate the association of early versus late initiation of Continuous renal replacement therapy (CRRT) with mortality in patients with fluid overload. METHODS This was a retrospective cohort study of patients with fluid overload (FO) treated with CRRT due to severe acute kidney injury (AKI) between January 2015 and December 2017 in a mixed medical intensive care unit of a teaching hospital in Beijing, China. Patients were divided into early (≤15 h) and late (>15 h) groups based on the median time from ICU admission to CRRT initiation. The primary outcome was all-cause mortality at day 60. Multivariable Cox model analysis was used for analysis. RESULTS The study patients were male predominant (84/150) with a mean age of 64.8 ± 16.7 years. The median FO value before CRRT initiation was 10.1% [6.2-16.1%]. The 60-day mortality rates in the early vs the late CRRT groups were 53.9% and 73%, respectively. On multivariable Cox modelling, the late initiation of CRRT was independently associated with an increased risk of death at 60 days (HR 1.75, 95% CI 1.11-2.74, p = 0.015). CONCLUSIONS Early initiation of CRRT was independently associated with survival benefits in severe AKI patients with fluid overload.
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Affiliation(s)
- J Lin
- Department of Critical Care Medicine, Beijing Friendship Hospital, Capital Medical University, China
| | - X J Ji
- Department of Critical Care Medicine, Beijing Friendship Hospital, Capital Medical University, China
| | - A Y Wang
- The George Institute for Global Health, Newtown, Australia; Concord Clinical School, The University of Sydney, Australia; Department of Renal Medicine, Concord Repatriation General Hospital, Australia.
| | - J F Liu
- Department of Critical Care Medicine, Beijing Friendship Hospital, Capital Medical University, China
| | - P Liu
- Department of Critical Care Medicine, Beijing Friendship Hospital, Capital Medical University, China
| | - M Zhang
- Department of Critical Care Medicine, Beijing Friendship Hospital, Capital Medical University, China
| | - Z L Qi
- Department of Critical Care Medicine, Beijing Friendship Hospital, Capital Medical University, China
| | - D C Guo
- Department of Critical Care Medicine, Beijing Friendship Hospital, Capital Medical University, China
| | - R Bellomo
- The George Institute for Global Health, Newtown, Australia; Department of Intensive Care, Austin Hospital, Australia
| | - S M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - R Wald
- Division of Nephrology, St. Michael's Hospital, University of Toronto, Li Ka Shing Knowledge Institute, Toronto, ON, Canada
| | - M Gallagher
- The George Institute for Global Health, Newtown, Australia; Concord Clinical School, The University of Sydney, Australia; Department of Renal Medicine, Concord Repatriation General Hospital, Australia
| | - M L Duan
- Department of Critical Care Medicine, Beijing Friendship Hospital, Capital Medical University, China.
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31
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Felice VB, Lisboa TC, Souza LVD, Sell LC, Friedman G. Hemodynamically stable oliguric patients usually do not respond to fluid challenge. Rev Bras Ter Intensiva 2021; 32:564-570. [PMID: 33470358 PMCID: PMC7853676 DOI: 10.5935/0103-507x.20200094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 05/20/2020] [Indexed: 11/20/2022] Open
Abstract
Objective To evaluate renal responsiveness in oliguric critically ill patients after a fluid challenge. Methods We conducted a prospective observational study in one university intensive care unit. Patients with urine output < 0.5mL/kg/h for 3 hours with a mean arterial pressure > 60mmHg received a fluid challenge. We examined renal fluid responsiveness (defined as urine output > 0.5mL/kg/h for 3 hours) after fluid challenge. Results Forty-two patients (age 67 ± 13 years; APACHE II score 16 ± 6) were evaluated. Patient characteristics were similar between renal responders and renal nonresponders. Thirteen patients (31%) were renal responders. Hemodynamic or perfusion parameters were not different between those who did and those who did not increase urine output before the fluid challenge. The areas under the receiver operating characteristic curves were calculated for mean arterial pressure, heart rate, creatinine, urea, creatinine clearance, urea/creatinine ratio and lactate before the fluid challenge. None of these parameters were sensitive or specific enough to predict reversal of oliguria. Conclusion After achieving hemodynamic stability, oliguric patients did not increase urine output after a fluid challenge. Systemic hemodynamic, perfusion or renal parameters were weak predictors of urine responsiveness. Our results suggest that volume replacement to correct oliguria in patients without obvious hypovolemia should be done with caution.
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Affiliation(s)
- Vinicius Brenner Felice
- Unidade Central de Terapia Intensiva, Complexo Hospitalar Santa Casa de Porto Alegre - Porto Alegre (RS), Brasil.,Programa de Pós-Graduação em Ciências Pneumológicas, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
| | - Thiago Costa Lisboa
- Unidade de Terapia Intensiva, Hospital de Clínicas de Porto Alegre, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil.,Rede Institucional de Pesquisa e Inovação em Terapia Intensiva, Complexo Hospitalar Santa Casa de Porto Alegre - Porto Alegre (RS), Brasil
| | - Lucas Vieira de Souza
- Unidade Central de Terapia Intensiva, Complexo Hospitalar Santa Casa de Porto Alegre - Porto Alegre (RS), Brasil
| | - Luana Canevese Sell
- Unidade Central de Terapia Intensiva, Complexo Hospitalar Santa Casa de Porto Alegre - Porto Alegre (RS), Brasil
| | - Gilberto Friedman
- Unidade Central de Terapia Intensiva, Complexo Hospitalar Santa Casa de Porto Alegre - Porto Alegre (RS), Brasil.,Unidade de Terapia Intensiva, Hospital de Clínicas de Porto Alegre, Faculdade de Medicina, Universidade Federal do Rio Grande do Sul - Porto Alegre (RS), Brasil
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Wagenlehner F, Lucenteforte E, Pea F, Soriano A, Tavoschi L, Steele VR, Henriksen AS, Longshaw C, Manissero D, Pecini R, Pogue JM. Systematic review on estimated rates of nephrotoxicity and neurotoxicity in patients treated with polymyxins. Clin Microbiol Infect 2021; 27:S1198-743X(20)30764-3. [PMID: 33359542 DOI: 10.1016/j.cmi.2020.12.009] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Revised: 11/03/2020] [Accepted: 12/10/2020] [Indexed: 12/27/2022]
Abstract
BACKGROUND Nephrotoxicity and neurotoxicity are commonly associated with polymyxin treatment; however, the emergence of multidrug-resistant Gram-negative bacteria with limited therapeutic options has resulted in increased use of polymyxins. OBJECTIVES To determine the rates of nephrotoxicity and neurotoxicity during polymyxin treatment and whether any factors influence these. DATA SOURCES Medline, Embase and Cochrane Library databases were searched on 2 January 2020. STUDY ELIGIBILITY CRITERIA Studies reporting nephrotoxicity and/or neurotoxicity rates in patients with infections treated with polymyxins were included. Reviews, meta-analyses and reports not in English were excluded. PARTICIPANTS Patients hospitalized with infections treated with systemic or inhaled polymyxins were included. For comparative analyses, patients treated with non-polymyxin-based regimens were also included. METHODS Meta-analyses were performed using a random-effects model; subgroup meta-analyses were conducted where data permitted using a mixed-effects model. RESULTS In total, 237 reports of randomized controlled trials, cohort and case-control studies were eligible for inclusion; most were single-arm observational studies. Nephrotoxic events in 35,569 patients receiving polymyxins were analysed. Overall nephrotoxicity rate was 0.282 (95% confidence interval (CI) 0.259-0.307). When excluding studies where >50% of patients received inhaled-only polymyxin treatment or nephrotoxicity assessment was by methods other than internationally recognized criteria (RIFLE, KDIGO or AKIN), the nephrotoxicity rate was 0.391 (95% CI 0.364-0.419). The odds of nephrotoxicity were greater with polymyxin therapies compared to non-polymyxin-based regimens (odds ratio 2.23 (95% CI 1.58-3.15); p < 0.001). Meta-analyses showed a significant effect of polymyxin type, dose, patient age, number of concomitant nephrotoxins and use of diuretics, glycopeptides or vasopressors on the rate of nephrotoxicity. Polymyxin therapies were not associated with a significantly different rate of neurotoxicity than non-polymyxin-based regimens (p 0.051). The overall rate of neurotoxicity during polymyxin therapy was 0.030 (95% CI 0.020-0.043). CONCLUSIONS Polymyxins are associated with a higher risk of nephrotoxicity than non-polymyxin-based regimens.
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Affiliation(s)
- Florian Wagenlehner
- Clinic for Urology, Pediatric Urology and Andrology, Justus-Liebig-University, Giessen, Germany
| | - Ersilia Lucenteforte
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Federico Pea
- Department of Medicine, University of Udine and Institute of Clinical Pharmacology, SM Misericordia University Hospital, ASUIUD, Udine, Italy
| | - Alex Soriano
- Infectious Diseases Department, Hospital Clínic of Barcelona, University of Barcelona IDIBAPS, Barcelona, Spain
| | - Lara Tavoschi
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | | | | | | | - Davide Manissero
- University College of London, Institute for Global Health, London, UK
| | | | - Jason M Pogue
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI, USA.
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Gordin E, Gordin D, Viitanen S, Szlosek D, Coyne M, Farace G, Murphy R, Quinn J, Yerramilli M, Yerramilli M, Spillmann T. Urinary clusterin and cystatin B as biomarkers of tubular injury in dogs following envenomation by the European adder. Res Vet Sci 2020; 134:12-18. [PMID: 33278755 DOI: 10.1016/j.rvsc.2020.11.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 10/14/2020] [Accepted: 11/22/2020] [Indexed: 12/20/2022]
Abstract
Diagnosing acute kidney injury remains a challenge since the established renal biomarkers, serum creatinine (sCr) and symmetric dimethylarginine (SDMA) reflect glomerular function and not tubular injury. Sensitive tubular markers such as urinary clusterin (uClust) and cystatin B (uCysB) have been proposed to detect AKI at an earlier stage. Since envenomation by the European adder (Vipera berus berus) could serve as a spontaneous disease model of AKI we investigated these new biomarkers in affected dogs. Concentrations of uClust and uCysB as well as sCr and SDMA were analyzed retrospectively in stored samples from 26 dogs with snake envenomation and 13 healthy controls. Higher concentrations of uClust (P < 0.012) and uCysB (P < 0.001) were observed in the snake-envenomed group. Normalization of uClust and uCysB to urinary creatinine did not alter the results. No differences were observed in sCr and SDMA between the snake-envenomed group and the healthy control group. Spearman rank correlation analysis revealed a strong association of uClust with uCysB in the snake-envenomed dogs (r = 0.75 P < 0.001) but not in the healthy controls. The high percentage of snake-envenomed dogs with increased uClust and uCysB concentrations in the absence of increased sCr and SDMA suggests renal tubular injury in the affected dogs. Larger prospective case-controlled studies are warranted to evaluate the clinical utility and prognostic value of these biomarkers.
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Affiliation(s)
- E Gordin
- Faculty of Veterinary Medicine, Department of Equine and Small Animal Medicine, Internal Medicine Section, University of Helsinki, P.O. Box 57, 00014 University of Helsinki, Finland.
| | - D Gordin
- Abdominal Center Nephrology, Helsinki University Hospital, Folkhälsan Research Center, University of Helsinki, Helsinki, Finland
| | - S Viitanen
- Faculty of Veterinary Medicine, Department of Equine and Small Animal Medicine, Internal Medicine Section, University of Helsinki, P.O. Box 57, 00014 University of Helsinki, Finland
| | - D Szlosek
- IDEXX Laboratories, Inc., One IDEXX Drive, Westbrook, ME 04092, United States
| | - M Coyne
- IDEXX Laboratories, Inc., One IDEXX Drive, Westbrook, ME 04092, United States
| | - G Farace
- IDEXX Laboratories, Inc., One IDEXX Drive, Westbrook, ME 04092, United States
| | - R Murphy
- IDEXX Laboratories, Inc., One IDEXX Drive, Westbrook, ME 04092, United States
| | - J Quinn
- IDEXX Laboratories, Inc., One IDEXX Drive, Westbrook, ME 04092, United States
| | - Ma Yerramilli
- IDEXX Laboratories, Inc., One IDEXX Drive, Westbrook, ME 04092, United States
| | - Mu Yerramilli
- IDEXX Laboratories, Inc., One IDEXX Drive, Westbrook, ME 04092, United States
| | - T Spillmann
- Faculty of Veterinary Medicine, Department of Equine and Small Animal Medicine, Internal Medicine Section, University of Helsinki, P.O. Box 57, 00014 University of Helsinki, Finland
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Joannes-Boyau O, Roquilly A, Constantin JM, Duracher-Gout C, Dahyot-Fizelier C, Langeron O, Legrand M, Mirek S, Mongardon N, Mrozek S, Muller L, Orban JC, Virat A, Leone M. Choice of fluid for critically ill patients: An overview of specific situations. Anaesth Crit Care Pain Med 2020; 39:837-845. [PMID: 33091593 DOI: 10.1016/j.accpm.2020.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Olivier Joannes-Boyau
- Service d'Anesthésie-Réanimation Sud, Centre Médico-Chirurgical Magellan, Centre Hospitalier Universitaire (CHU) de Bordeaux, 33000 Bordeaux, France.
| | - Antoine Roquilly
- CHU Nantes, Université de Nantes, Pôle Anesthésie-Réanimation, Service d'Anesthésie Réanimation Chirurgicale, Hôtel Dieu, 44093 Nantes, France
| | - Jean-Michel Constantin
- Sorbonne University, GRC 29, AP-HP, DMU DREAM, Department of Anesthesiology and Critical Care, Pitié-Salpêtrière Hospital, 75013 Paris, France
| | - Caroline Duracher-Gout
- Département d'Anesthésie Réanimation Chirurgicale et SAMU de Paris, Université René Descartes Paris, 75006 Paris Cedex, France
| | - Claire Dahyot-Fizelier
- Anaesthesia and Intensive Care, University Hospital of Poitiers, Poitiers, France. INSERM UMR1070 - Pharmacology of Anti-infective Agents, University of Poitiers, 86000 Poitiers, France
| | - Olivier Langeron
- Service d'Anesthésie-Réanimation, Hôpital Henri Mondor Assistance Publique - Hôpitaux de Paris Université Paris-Est, 94 Créteil, France
| | - Matthieu Legrand
- Department of Anaesthesia and Perioperative Care, University of California, 500 Parnassus Avenue, San Francisco, USA
| | - Sébastien Mirek
- Service d'Anesthésie Réanimation, CHU Dijon, 21000 Dijon Cedex, France
| | - Nicolas Mongardon
- Service d'Anesthésie-Réanimation, Hôpital Henri Mondor Assistance Publique - Hôpitaux de Paris Université Paris-Est, 94 Créteil, France
| | - Ségolène Mrozek
- Département d'Anesthésie-Réanimation, CHU Toulouse, Hôpital Pierre Paul Riquet, 31000 Toulouse, France
| | - Laurent Muller
- Service des réanimations et Surveillance Continue, Pôle Anesthésie Réanimation Douleur Urgences, CHU Nîmes Caremeau, Place Du Pr Debré, 30000 Nîmes, France
| | | | - Antoine Virat
- Clinique Pont De Chaume, 330, Avenue Marcel Unal, 82000 Montauban, France
| | - Marc Leone
- Aix Marseille Université, Assistance Publique Hôpitaux de Marseille, Service d'Anesthésie et de Réanimation, Hôpital Nord, 13005 Marseille, France
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Donati PA, Guevara JM, Ardiles V, Guillemi EC, Londoño L, Dubin A. Caudal vena cava collapsibility index as a tool to predict fluid responsiveness in dogs. J Vet Emerg Crit Care (San Antonio) 2020; 30:677-686. [PMID: 33063922 DOI: 10.1111/vec.13009] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Revised: 02/03/2019] [Accepted: 03/09/2020] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To evaluate the use of the caudal vena cava collapsibility index (CVCCI) as a predictor of fluid responsiveness in hospitalized, critically ill dogs with hemodynamic or tissue perfusion abnormalities. DESIGN Retrospective observational study. SETTING Private referral center. ANIMALS Twenty-seven critically ill, spontaneously breathing dogs with compromised hemodynamics or tissue hypoperfusion. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The electronic medical records were searched for dogs admitted for any cause, from August 2016 to December 2017. We included dogs with ultrasound measurements of: CVCCI, performed at baseline; and velocity time integral (VTI) of the subaortic blood flow, carried out before and after a fluid load. CVCCI was estimated as: (maximum diameter-minimum diameter/maximum diameter) × 100. Dogs in which VTI increased ≥15% were considered fluid responders. The CVCCI accurately predicted fluid responsiveness with an area under the receiver operating characteristic curve of 0.96 (95% CI, 0.88 to 1.00). The optimal cut-off of CVCCI that better discriminated between fluid responders and nonresponders was 27%, with 100.0% sensitivity and 83.3% specificity. At baseline, fluid responders had lower VTI (5.48 [4.26 to 7.40] vs 10.61 [7.38 to 13.23] cm, P = 0.004) than nonresponders. The basal maximum diameter of the caudal vena cava adjusted to body weight was not different between responders and nonresponders (0.050 [0.030 to 0.100] vs 0.079 [0.067 to 0.140] cm/kg, P = 0.339). The increase in VTI was related to basal CVCCI (R = 0.60, P = 0.001). Bland-Altman analysis showed narrow 95% limits of agreement between measurements of CVCCI and VTI performed by different observers or by the same observer. CONCLUSIONS The results of this small cohort study suggest that CVCCI can accurately predict fluid responsiveness in critically ill dogs with perfusion abnormalities. Further research is necessary to extrapolate these results to larger populations of hospitalized dogs.
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Affiliation(s)
- Pablo A Donati
- Cooperative Veterinary Intensive Care Unit, Buenos Aires, Argentina
| | - Juan M Guevara
- Cooperative Veterinary Intensive Care Unit, Buenos Aires, Argentina
| | - Victoria Ardiles
- General Surgery Service, Surgery Department, Non-sponsored Research Area, Research Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | - Leonel Londoño
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, Florida
| | - Arnaldo Dubin
- Chair of Applied Pharmacology, Faculty of Medical Sciences, National University of La Plata, La Plata, Argentina
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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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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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38
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Zhang S, Ma J, An R, Liu L, Li J, Fang Z, Wang Q, Ma Q, Shen X. Effect of cumulative fluid balance on acute kidney injury and patient outcomes after orthotopic liver transplantation: A retrospective cohort study. Nephrology (Carlton) 2020; 25:700-707. [PMID: 32105370 DOI: 10.1111/nep.13702] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Revised: 11/26/2019] [Accepted: 01/29/2020] [Indexed: 12/20/2022]
Abstract
AIM Acute kidney injury (AKI) is a serious complication following orthotopic liver transplantation (OLT) and it affects long-term patient survival. The aims of this study were to identify the effects of cumulative fluid balance (FB) on early post-OLT AKI and adverse outcomes and to construct a model to predict AKI. METHODS We retrospectively analysed 146 adult patients who underwent OLT. AKI severity was classified according to the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Univariate and multivariate logistic regression analyses were used to evaluate the association between cumulative FB and post-OLT AKI. The Kaplan-Meier method was used to estimate the survival rate. RESULTS Within the perioperative period of 72 hours, 50% (66/132) of patients developed AKI, with 36 (54%), 16 (24%) and 14 (21%) patients having AKI stages 1, 2 and 3, respectively. The cumulative FB was the risk factors for post-OLT AKI (odds ratio [OR], 1.011; 95% confidence interval [CI], 1.156~6.001; P = .021). Preoperative albumin was a protective factor for post-OLT AKI (OR, 0.309; 95% CI, 0.140~0.731; P = .007). The AKI group requires renal replacement therapy (RRT) more (15.2% vs 0%, P = .001) and associated with postoperative complications (56% vs 28.8%, P = .003). The complication-free survival was lower in the AKI group ([11.90 vs 18.74] months, χ2 = 9.60, P = .002). CONCLUSION Cumulative FB within 72 hours is associated with post-OLT AKI and requires RRT. Cumulative FB impacts the long-term complication-free survival of the recipients.
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Affiliation(s)
- Simei Zhang
- Department of Anesthesiology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Jiguang Ma
- Department of Anesthesiology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Rui An
- Department of Anesthesiology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Lin Liu
- Department of Anesthesiology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Jianpeng Li
- Department of Hepatobiliary Surgery, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Zeping Fang
- Department of Epidemiology and Biostatistics, Xi'an Jiaotong University School of Public Health, Xi'an, Shanxi Province, China
| | - Qiang Wang
- Department of Anesthesiology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Qingyong Ma
- Department of Hepatobiliary Surgery, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
| | - Xin Shen
- Department of Anesthesiology, First Affiliated Hospital, Xi'an Jiaotong University, Xi'an, China
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Abstract
BACKGROUND Fluid overload (FO) is a condition present in critical care units, and it is associated with clinical complications and worse outcomes for severe patients. OBJECTIVE The aim of this study was to verify if FO is a risk factor for mortality in critically ill patients. METHODS Retrospective study performed in a Brazilian intensive care unit, from January to March 2016, with patients older than 18 years and hospitalized for more than 24 hours. Demographic and clinical data, as well as fluid balance and overload, were analyzed to verify the risk factors for mortality. A logistic regression model was elaborated, and significance was set at P < .05. RESULTS There were 158 patients included, of which only 13 (8.2%) presented FO. Mortality was verified in individuals 30 (18.9%), of whom only 7 (23.3%) developed FO, which was lower in survivors 6 (4.9%), P = .001. In the simple regression model, the FO was significant (odds ratio [OR], 6.23; 95% confidence interval [CI], 2.04-19.53), P = .001. However, in the multiple regression model, there were significant findings only for mechanical ventilation (OR, 5.86; 95% CI, 2.10-18.12, P = .001), acute kidney injury (OR, 4.05; 95% CI, 1.53-11; P = .001), and noradrenaline (OR, 3.85; 95% CI, 1.01-9.51; P = .041); FO was not significant (OR, 3.68; 95% CI, 0.91-15.55; P = .069). CONCLUSION Fluid overload is higher in patients who died. Therefore, it was not considered a risk factor for mortality.
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Abstract
Commonest intervention in hospitalized patient is fluid therapy, and practically every critically ill patient receives fluid resuscitation. Commonest indication for fluid administration is to achieve hemodynamic stability and prevent or manage acute kidney injury (AKI). However, fluid administration is a two-edged sword, i.e., inadequate fluids give rise to hypoperfusion and organ injury and overzealous fluid therapy can give rise to fluid overload and related consequences. Though fluids are commonly given to prevent development of AKI, hypervolemia itself has the potential to cause AKI.
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Affiliation(s)
- Vijaya P Patil
- Division of Clinical Anaesthesiology, Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
| | - Bindiya G Salunke
- Division of Clinical Anaesthesiology, Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Parel, Mumbai, Maharashtra, India
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Latent Trajectories of Fluid Balance Are Associated With Outcomes in Cardiac and Aortic Surgery. Ann Thorac Surg 2019; 109:1343-1349. [PMID: 31734247 DOI: 10.1016/j.athoracsur.2019.09.068] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 08/25/2019] [Accepted: 09/16/2019] [Indexed: 01/10/2023]
Abstract
BACKGROUND Fluid overload is common in critically ill patients and is associated with worse outcomes. The trends in fluid balance have not been investigated previously. This study used trajectory analysis to investigate the impact of fluid balance trends on patients who had undergone cardiac or aortic surgery. METHODS We analyzed patients who underwent cardiac or aortic surgery between August 2005 and March 2015. We excluded patients who died within the first 72 postoperative hours or received chronic dialysis before the surgery. Trajectories of urine and input-output during the first 3 postoperative days were analyzed using a latent class growth model. The primary outcomes were any stage of acute kidney injury (AKI) by Kidney Disease Improving Global Outcomes definition and de novo dialysis. RESULTS The in-hospital mortality was 6.6% (70 of the 1063 patients included). The fluid input-output balance trajectories had better association with the primary outcome than urine output trajectories did. The risk of AKI and de novo dialysis were highest in the group with progressively positive fluid balance adjusted by preoperative body weight (AKI: adjusted odds ratio, 7.10; 95% confidence interval, 2.02-24.93; de novo dialysis: odds ratio, 4.54; 95% confidence interval, 1.12-18.38). CONCLUSIONS A progressively positive fluid balance is associated with AKI and de novo dialysis in patients undergoing cardiac or aortic surgery.
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Montomoli J, Donati A, Ince C. Acute Kidney Injury and Fluid Resuscitation in Septic Patients: Are We Protecting the Kidney? Nephron Clin Pract 2019; 143:170-173. [PMID: 31394531 DOI: 10.1159/000501748] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 06/25/2019] [Indexed: 12/20/2022] Open
Abstract
Acute kidney injury (AKI) is a common complication in critically ill patients, especially among septic patients. Sepsis and hypovolemia are the 2 most frequent etiologies of AKI in intensive care units and frequently coexist in critically ill patients. Effective fluid resuscitation is crucial for the stabilization of sepsis-induced tissue hypoperfusion or septic shock. However, the lack of a goal-directed therapy targeting kidney oxygenation prevents from optimization of the fluid therapy with regard to improvement of renal oxygen delivery and extraction. Similarly, fluid administration as all therapeutic actions carries adverse effects such as the activation of cytokines, disruption of the capillary glycocalyx, and adverse effects on kidney metabolism and oxygenation. Moreover, a positive fluid balance is associated with an increased risk of AKI and is a negative predictor for recovery of renal function. The role of fluid resuscitation on kidney injury stems from the high renal vulnerability to hypoxemic injury. Indeed, fluids have a poor oxygen solubility and hemodilution decreases blood viscosity both promoting intrarenal shunting and heterogeneity with a decreased capillary density and enhanced intrarenal cortex and medullary hypoxia. The development of physiological biomarkers that are able to detect the early development of AKI specifically aimed at the identification of renal microcirculatory dysfunctions should form a valuable contribution to monitoring therapeutic modalities.
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Affiliation(s)
- Jonathan Montomoli
- Anesthesia and Intensive Care, Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy.,Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Abele Donati
- Anesthesia and Intensive Care, Department of Biomedical Sciences and Public Health, Università Politecnica delle Marche, Ancona, Italy
| | - Can Ince
- Department of Intensive Care, Erasmus MC, University Medical Center, Rotterdam, The Netherlands,
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Feltracco P, Barbieri S, Carollo C, Bortolato A, Michieletto E, Bertacco A, Gringeri E, Cillo U. Early circulatory complications in liver transplant patients. Transplant Rev (Orlando) 2019; 33:219-230. [PMID: 31327573 DOI: 10.1016/j.trre.2019.06.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 06/28/2019] [Accepted: 06/30/2019] [Indexed: 02/06/2023]
Affiliation(s)
- Paolo Feltracco
- Department of Medicine, UO Anesthesia and Intensive Care, University of Padua, Italy.
| | - Stefania Barbieri
- Department of Medicine, UO Anesthesia and Intensive Care, University of Padua, Italy
| | - Cristiana Carollo
- Department of Medicine, UO Anesthesia and Intensive Care, University of Padua, Italy
| | - Andrea Bortolato
- Department of Medicine, UO Anesthesia and Intensive Care, University of Padua, Italy
| | - Elisa Michieletto
- Department of Medicine, UO Anesthesia and Intensive Care, University of Padua, Italy
| | - Alessandra Bertacco
- Hepatobiliary Surgery and Liver Transplant Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Italy
| | - Enrico Gringeri
- Hepatobiliary Surgery and Liver Transplant Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Italy
| | - Umberto Cillo
- Hepatobiliary Surgery and Liver Transplant Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Italy
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Panitchote A, Mehkri O, Hastings A, Hanane T, Demirjian S, Torbic H, Mireles-Cabodevila E, Krishnan S, Duggal A. Factors associated with acute kidney injury in acute respiratory distress syndrome. Ann Intensive Care 2019; 9:74. [PMID: 31264042 PMCID: PMC6603088 DOI: 10.1186/s13613-019-0552-5] [Citation(s) in RCA: 100] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Accepted: 06/24/2019] [Indexed: 12/16/2022] Open
Abstract
Background Acute kidney injury (AKI) is the most frequent extra-pulmonary organ failure in acute respiratory distress syndrome (ARDS). The objective of this study was to assess the factors associated with the development and severity of AKI in patients with ARDS.
Methods This is a retrospective cohort study of ARDS patients without acute or chronic kidney disease prior to the onset of ARDS over a 7-year period (2010–2017). AKI and severity of AKI were defined according to the Kidney Disease Improving Global Outcomes 2012 guidelines. Results Of the 634 ARDS patients, 357 patients met study criteria. A total of 244 (68.3%) patients developed AKI after ARDS onset: 60 (24.6%) had stage I AKI, 66 (27%) had stage II AKI, and 118 (48.4%) had stage III AKI. The median time of AKI onset for stage I AKI was 2 days (interquartile range, 1.5–5.5) while stage II and III AKI was 4 days. On multivariable analysis, factors associated with development of AKI were age [subdistribution hazard ratio (SHR) 1.01, 95% confidence interval (CI) 1.00–1.02], SOFA score (SHR 1.16, 95%CI 1.12–1.21), a history of diabetes mellitus (DM) (SHR 1.42, 95%CI 1.07–1.89), and arterial pH on day 1 of ARDS (SHR per 0.1 units decrease was 1.18, 95%CI 1.05–1.32). In severity of AKI, stage I AKI was associated with age (SHR 1.03, 95%CI 1.01–1.05) and serum bicarbonate on day 1 of ARDS (SHR 1.07, 95%CI 1.02–1.13). Stage II AKI was associated with age (SHR 1.03, 95%CI 1.01–1.05), serum bicarbonate on day 1 (SHR 1.12, 95%CI 1.06–1.18), SOFA score (SHR 1.19, 95%CI 1.10–1.30), history of heart failure (SHR 3.71, 95%CI 1.63–8.46), and peak airway pressure (SHR 1.04, 95%CI 1.00–1.07). Stage III AKI was associated with a higher BMI (SHR 1.02, 95%CI 1.00–1.03), a history of DM (SHR 1.79, 95%CI 1.18–2.72), SOFA score (SHR 1.29, 95%CI 1.22–1.36), and arterial pH on day 1 (SHR per 0.1 units decrease was 1.25, 95%CI 1.05–1.49). Conclusions Age, a higher severity of illness, a history of diabetes, and acidosis were associated with development of AKI in ARDS patients. Severity of AKI was further associated with BMI, history of heart failure, and peak airway pressure. Electronic supplementary material The online version of this article (10.1186/s13613-019-0552-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Anupol Panitchote
- Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA.,Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand
| | - Omar Mehkri
- Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Andrei Hastings
- Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Tarik Hanane
- Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Sevag Demirjian
- Department of Nephrology, Cleveland Clinic, Cleveland, OH, USA
| | - Heather Torbic
- Department of Pharmacology, Cleveland Clinic, Cleveland, OH, USA
| | | | - Sudhir Krishnan
- Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Abhijit Duggal
- Department of Critical Care, Respiratory Institute, Cleveland Clinic, Cleveland, OH, USA.
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Westphal M. Science and fiction in critical care: established concepts with or without evidence? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:125. [PMID: 31200737 PMCID: PMC6570636 DOI: 10.1186/s13054-019-2419-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 04/01/2019] [Indexed: 12/19/2022]
Abstract
In the absence of evidence, therapies are often based on intuition, belief, common sense or gut feeling. Over the years, some treatment strategies may become dogmas that are eventually considered as state-of-the-art and not questioned any longer. This might be a reason why there are many examples of "strange" treatments in medical history that have been applied in the absence of evidence and later abandoned for good reasons.In this article, five dogmas relevant to critical care medicine are discussed and reviewed in the light of the available evidence. Dogma #1 relates to the treatment of oliguria with fluids, diuretics, and vasopressors. In this context, it should be considered that oliguria is a symptom rather than a disease. Thus, once hypovolaemia can be excluded as the underlying reason, there is no justification for giving fluids, which may do more harm than good in euvolaemic or hypervolaemic patients. Similarly, there is no solid evidence for forcing diuresis by administering vasopressors and loop diuretics. Dogma #2 addresses the treatment of crush syndrome patients with aggressive fluid therapy using NaCl 0.9%. In fact, this treatment may aggravate renal injury by iatrogenic metabolic acidosis and subsequent renal hypoperfusion. Dogma #3 concerns the administration of NaCl 0.9% to patients undergoing kidney transplantation. Since these patients are usually characterised by hyperkalaemia, the potassium-free solution NaCl 0.9%, containing exclusively 154 mmol/l of sodium and chloride ions each, is often considered as the fluid of choice. However, large volumes of chloride-rich solutions cause hyperchloraemic acidosis in a dose-dependent manner and induce a potassium shift to the extracellular space, thereby increasing serum potassium levels. Thus, balanced electrolyte solutions are to be preferred in this setting. Dogma #4 relates to the fact that enteral nutrition is often withheld for patients with high residual gastric volume due to the theoretical risk of gastro-oesophageal reflux, potentially resulting in aspiration pneumonitis. Despite controversial discussions, there is no clinical data supporting that residual gastric volume should be generally measured, especially not in patients without a gastro-intestinal surgery and/or motility disorders. Clinical evidence rather suggests that abandoning residual gastric volume monitoring does not increase the incidence of pneumonia, but may benefit patients by facilitating adequate enteral feeding. Finally, dogma #5 is about sedating all mechanically ventilated patients because "fighting" against the respirator may cause insufficient ventilation. This concern needs to be balanced against the unwanted consequences of sedation, such as prolonged mechanical ventilation and intensive care unit length of stay as well as increased risk of delirium. Modern concepts based on adequate analgesia and moderate to no sedation appear to be more suitable.In conclusion, dogmas are still common in clinical practice. Since science rather than fiction should govern our actions in intensive care medicine, it is important to remain critical and challenge long established concepts, especially when the underlying evidence is weak or non-existing.
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Affiliation(s)
- Martin Westphal
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Muenster, Albert-Schweitzer-Campus 1, Building A1, 48149, Muenster, Germany. .,Fresenius Kabi AG, Else-Kröner-Str. 1, 61352, Bad Homburg, Germany.
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Abstract
Although cardiogenic shock is uncommon in the emergency department, it is associated with high mortality. Most cardiogenic shock is caused by ischemia, but nonischemic etiologies are essential to recognize. Clinicians should optimize preload, contractility, and afterload. Volume-responsive patients should be resuscitated in small aliquots, although some patients may require diuresis to improve cardiac output. Vasopressors are important to restore end-organ perfusion, and inotropes improve contractility. Intubation and positive pressure ventilation impact hemodynamics, which, depending on volume status, may be beneficial or deleterious. Knowing indications for mechanical circulatory support is important for timely consultation or transfer as indicated.
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Affiliation(s)
- Susan R Wilcox
- Division of Critical Care, Department of Emergency Medicine, Massachusetts General Hospital, Zero Emerson Place, Suite 3B, Boston, MA 02114, USA.
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47
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Rusu DM, Siriopol I, Grigoras I, Blaj M, Ciumanghel AI, Siriopol D, Nistor I, Onofriescu M, Sandu G, Cobzaru B, Scripcariu DV, Diaconu O, Covic AC. Lung Ultrasound Guided Fluid Management Protocol for the Critically Ill Patient: study protocol for a multi-centre randomized controlled trial. Trials 2019; 20:236. [PMID: 31023358 PMCID: PMC6482502 DOI: 10.1186/s13063-019-3345-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Accepted: 04/03/2019] [Indexed: 02/07/2023] Open
Abstract
Background In routine intensive care unit (ICU) practice, fluids are often administered without a safety limit, which may lead to fluid overload and decreased survival. Recently, B-lines score (BLS) has been validated as a lung ultrasound (LUS) quantification of pulmonary congestion. This suggests that LUS may provide a safety threshold to conduct fluid therapy and to avoid overhydration. However, there is no randomized study to test the utility of LUS in guiding fluid management in ICU patients by using a pre-specified BLS cut-off value as a threshold for fluid removal. Methods LUS Guided Fluid Management Protocol for the Critically Ill Patient is a prospective, multi-centre, randomized controlled trial. Five hundred ICU patients will be randomly assigned in a 1:1 ratio, to protocolized LUS-based fluid management or usual care. The trial intervention will start on ICU admission and will consist in daily assessment of BLS and triggered evacuation of excessive fluids with loop diuretics (Furosemide) when BLS ≥ 15. If rebalancing volume status with diuretics fails, forced evacuation by ultrafiltration will be used. The main endpoint is death from all causes at 28 days from randomization. The secondary outcomes are presence and time-course evolution of organ dysfunctions, ICU- and hospital length of stay, all-cause mortality at 90 days, and health economics data. Discussion If study results will show that LUS guided fluid management protocol improves outcome in ICU patients, it will be the base for other studies to refine this protocol or track those categories of critically ill patients to whom it may bring maximum benefits. Trial registration ClinicalTrials.gov, NCT03393065. Registered on 8 January 2018. Electronic supplementary material The online version of this article (10.1186/s13063-019-3345-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Daniel-Mihai Rusu
- Grigore T. Popa University of Medicine and Pharmacy, Str. Universității nr. 16, 700115, Iasi, Romania.,Anaesthesia and Intensive Care Department, Regional Institute of Oncology, Str. General Henri Mathias Berthelot 2-4, 700483, Iasi, Romania
| | - Ianis Siriopol
- Grigore T. Popa University of Medicine and Pharmacy, Str. Universității nr. 16, 700115, Iasi, Romania.,Anaesthesia and Intensive Care Department, Regional Institute of Oncology, Str. General Henri Mathias Berthelot 2-4, 700483, Iasi, Romania
| | - Ioana Grigoras
- Grigore T. Popa University of Medicine and Pharmacy, Str. Universității nr. 16, 700115, Iasi, Romania. .,Anaesthesia and Intensive Care Department, Regional Institute of Oncology, Str. General Henri Mathias Berthelot 2-4, 700483, Iasi, Romania.
| | - Mihaela Blaj
- Grigore T. Popa University of Medicine and Pharmacy, Str. Universității nr. 16, 700115, Iasi, Romania.,Anaesthesia and Intensive Care Department, Saint Spiridon University Hospital, Iasi, Romania
| | - Adi-Ionut Ciumanghel
- Grigore T. Popa University of Medicine and Pharmacy, Str. Universității nr. 16, 700115, Iasi, Romania.,Anaesthesia and Intensive Care Department, Saint Spiridon University Hospital, Iasi, Romania
| | - Dimitrie Siriopol
- Grigore T. Popa University of Medicine and Pharmacy, Str. Universității nr. 16, 700115, Iasi, Romania.,Nephrology Department, Dr. C.I. Parhon University Hospital, Iasi, Romania
| | - Ionut Nistor
- Grigore T. Popa University of Medicine and Pharmacy, Str. Universității nr. 16, 700115, Iasi, Romania.,Nephrology Department, Dr. C.I. Parhon University Hospital, Iasi, Romania
| | - Mihai Onofriescu
- Grigore T. Popa University of Medicine and Pharmacy, Str. Universității nr. 16, 700115, Iasi, Romania.,Nephrology Department, Dr. C.I. Parhon University Hospital, Iasi, Romania
| | - Gigel Sandu
- Anaesthesia and Intensive Care Department, Saint Spiridon University Hospital, Iasi, Romania
| | - Beatrice Cobzaru
- Anaesthesia and Intensive Care Department, Saint Spiridon University Hospital, Iasi, Romania
| | - Dragos Viorel Scripcariu
- Grigore T. Popa University of Medicine and Pharmacy, Str. Universității nr. 16, 700115, Iasi, Romania.,Surgery Department, Regional Institute of Oncology, Iasi, Romania
| | - Olguta Diaconu
- Grigore T. Popa University of Medicine and Pharmacy, Str. Universității nr. 16, 700115, Iasi, Romania.,Anaesthesia and Intensive Care Department, Regional Institute of Oncology, Str. General Henri Mathias Berthelot 2-4, 700483, Iasi, Romania
| | - Adrian Constantin Covic
- Grigore T. Popa University of Medicine and Pharmacy, Str. Universității nr. 16, 700115, Iasi, Romania.,Nephrology Department, Dr. C.I. Parhon University Hospital, Iasi, Romania
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Wiersema R, Koeze J, Hiemstra B, Pettilä V, Perner A, Keus F, van der Horst ICC. Associations between tricuspid annular plane systolic excursion to reflect right ventricular function and acute kidney injury in critically ill patients: a SICS-I sub-study. Ann Intensive Care 2019; 9:38. [PMID: 30868290 PMCID: PMC6419793 DOI: 10.1186/s13613-019-0513-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2018] [Accepted: 03/05/2019] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Acute kidney injury (AKI) occurs in up to 50% of all critically ill patients and hemodynamic abnormalities are assumed to contribute, but their nature and share is still unclear. We explored the associations between hemodynamic variables, including cardiac index and right ventricular function, and the occurrence of AKI in critically ill patients. METHODS In this prospective cohort study, we included all patients acutely admitted to an intensive care unit (ICU). Within 24 h after ICU admission clinical and hemodynamic variables were registered including ultrasonographic measurements of cardiac index and right ventricular function, assessed using tricuspid annular plane systolic excursion (TAPSE) and right ventricular systolic excursion (RV S'). Maximum AKI stage was assessed according to the KDIGO criteria during the first 72 h after admission. Multivariable logistic regression modeling was used including both known predictors and univariable significant predictors of AKI. Secondary outcomes were days alive outside ICU and 90-day mortality. RESULTS A total of 622 patients were included, of which 338 patients (54%) had at least AKI stage 1 within 72 h after ICU admission. In the final multivariate model higher age (OR 1.01, 95% CI 1.00-1.03, for each year), higher weight (OR 1.03 CI 1.02-1.04, for each kg), higher APACHE IV score (OR 1.02, CI 1.01-1.03, per point), lower mean arterial pressure (OR 1.02, CI 1.01-1.03, for each mmHg decrease) and lower TAPSE (OR 1.05, CI 1.02-1.09 per millimeter decrease) were all independent predictors for AKI in the final multivariate logistic regression model. Sepsis, cardiac index, RV S' and use of vasopressors were not significantly associated with AKI in our data. AKI patients had fewer days alive outside of ICU, and their mortality rate was significantly higher than those without AKI. CONCLUSIONS In our cohort of acutely admitted ICU patients, the incidence of AKI was 54%. Hemodynamic variables were significantly different between patients with and without AKI. A worse right ventricle function was associated with AKI in the final model, whereas cardiac index was not.
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Affiliation(s)
- Renske Wiersema
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Jacqueline Koeze
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Bart Hiemstra
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ville Pettilä
- Division of Intensive Care Medicine, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Anders Perner
- Department of Intensive Care 4131, Centre for Research in Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Frederik Keus
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Iwan C. C. van der Horst
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - SICS Study Group
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- 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 4131, Centre for Research in Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
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Aliyali M, Sharifpour A, Abedi S, Spahbodi F, Namarian N, Zarea A, Alizadeh A. The Ability of Polyuria in Prediction of Weaning Outcome in Critically Ill Mechanically Ventilated Patients. TANAFFOS 2019; 18:74-78. [PMID: 31423144 PMCID: PMC6690324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Accepted: 11/27/2018] [Indexed: 06/10/2023]
Abstract
BACKGROUND Fluid balance and oliguria influence outcome in critically ill patients. Although, osmotic dieresis with hypernatraemia is a predictor of mortality in critically ill patients, the purpose of this study was to demonstrate the effect of polyuria as an independent predictor on weaning outcome in mechanically ventilated patients. MATERIALS AND METHODS This retrospective, single center, cohort study was carried out at Imam Teaching Hospital Intensive Care Unit (ICU) on 263 adult mechanically ventilated patients. We collected data of these patients during the mean seven consecutive days before weaning from mechanical ventilator. Patients with polyuria (sustained urine output greater than 3000 ml/day) were compared with patients without polyuria. The primary endpoint was successful weaning and the secondary endpoints were the mechanical ventilation duration, post weaning length of ICU stay, post weaning length of hospitalization and rate of mortality. RESULTS In 93 patients with polyuria, the mean age was 45.14±19.47 years in comparison of 170 patients without polyuria with mean age of 52.9±21.37 years (P=0.004). Fluid intake, urine output and temperature were significantly higher in patients with polyuria, but there were no statistical differences in systolic and diastolic blood pressure, serum electrolytes, urea and creatinine. No significant differences were found in primary and secondary endpoints including successful weaning, post weaning length of ICU stay, post weaning hospital duration and mortality, except for duration of mechanical ventilation (P=0.014). The area under the ROC curve for variables showed only seven days mean creatinine level before weaning which may act as a predictor of successful weaning (ROCAUC=0.67, 95% CI 0.61-0.73, P=0.0002). Serum creatinine level of 0.8 provided best overall combination of sensitivity and specificity for successful weaning (sensitivity 72.22%, 95% CI 54.8-85.8; specificity 61.19%, 95% CI 54.1-68.0). CONCLUSION Polyuria cannot predict weaning outcome but maybe considered as a predictor of longer duration of mechanical ventilation and is probably associated with a subclinical renal dysfunction.
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Affiliation(s)
- Masoud Aliyali
- Internal Medicine Department, Pulmonary and Critical Care Division, Mazandaran University of Medical Sciences, Sari, Iran
| | - Ali Sharifpour
- Internal Medicine Department, Pulmonary and Critical Care Division, Mazandaran University of Medical Sciences, Sari, Iran
| | - Siavash Abedi
- Internal Medicine Department, Pulmonary and Critical Care Division, Mazandaran University of Medical Sciences, Sari, Iran
| | - Fatemeh Spahbodi
- Internal Medicine Department, Nephrology Division, Mazandaran University of Medical Sciences, Sari, Iran
| | - Narges Namarian
- Internal Medicine Department, Mazandaran University of Medical Sciences, Sari, Iran
| | - Adel Zarea
- Internal Medicine Department, Mazandaran University of Medical Sciences, Sari, Iran
| | - Ahad Alizadeh
- Internal Medicine Department, Mazandaran University of Medical Sciences, Sari, Iran
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50
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Colbert GB, Szerlip HM. Euvolemia-A critical target in the management of acute kidney injury. Semin Dial 2018; 32:30-34. [PMID: 30412310 DOI: 10.1111/sdi.12753] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
It has been clearly established that critically ill patients with sepsis require prompt fluid resuscitation. The optimal amount of fluid and when to taper this resuscitation is less clear. There is a growing evidence that fluid overload leads to acute kidney injury, and increased morbidity and mortality. A clinician's best intentions in resuscitating a patient can lead to too much of a good thing. Currently, there are several bedside tools to aid in determining a patient's response to a fluid challenge as well as in the assessment of the current volume status. Guidelines are not available on the exact rate of fluid overload removal and what medicinal or mechanical modality is most favorable. We discuss our experience and an examination of the literature on the problems with fluid overload, and how a patient may benefit from forced fluid removal.
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Affiliation(s)
- Gates B Colbert
- Department of Medicine, Division of Nephrology, Baylor University Medical Center at Dallas, Dallas, Texas
| | - Harold M Szerlip
- Department of Medicine, Division of Nephrology, Baylor University Medical Center at Dallas, Dallas, Texas
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