Prevalence and risk factors of hemodynamic instability associated with preload-dependence during continuous renal replacement therapy in a prospective observational cohort of critically ill patients

Incidence and associated factors for hypotension during continuous renal replacement therapy in critically ill patients

AIMS

This work aimed to analyse retrospective data on hypotension incidence and associated factors among patients requiring continuous renal replacement therapy.

BACKGROUND

The incidence and risk factors of continuous renal replacement therapy-related hypotension have not been adequately explored.

DESIGN

The study was designed as a retrospective analysis.

METHODS

Patients who required continuous renal replacement therapy in the ICU between January 2017 and June 2021 were reviewed. The multivariate logistic regression model was used to determine the associated factors of hypotension.

RESULTS

Hypotension occurred in 242 out of 885 circuits (27.3%) among 140 patients. The logistic regression analysis identified seven factors associated with the occurrence of hypotension during CRRT: serum albumin (OR = 0.969, 95%CI: 0.934-0.999), serum calcium (OR = 0.514, 95%CI: 0.345-0.905), CO2CP (OR = 0.933, 95%CI: 0.897-0.971), use of vasopressors (OR = 5.731, 95%CI: 4.023-8.165), hypotension before CRRT initiation (OR = 2.779, 95%CI:1.238-6.242), age (OR = 1.016, 95%CI: 1.005-1.027), and fluid removal rate (OR = 1.002, 95%CI: 1.001-1.003).

CONCLUSIONS

Hypotension frequently occurs in patients receiving continuous renal replacement therapy, especially in the early stages. Multiple factors can be associated with cardiac output or peripheral resistance changes, including excessive ultrafiltration, vasopressors, serum albumin and serum calcium levels, and carbon dioxide combining power.

Knowledge, attitude, practice, needs, and implementation status of intensive care unit staff toward continuous renal replacement therapy: a survey of 66 hospitals in central and South China

BACKGROUND

Continuous renal replacement therapy (CRRT) is a commonly utilized form of renal replacement therapy (RRT) in the intensive care unit (ICU). A specialized CRRT team (SCT, composed of physicians and nurses) engage playing pivotal roles in administering CRRT, but there is paucity of evidence-based research on joint training and management strategies. This study armed to evaluate the knowledge, attitude, and practice (KAP) of ICU staff toward CRRT, and to identify education pathways, needs, and the current status of CRRT implementation.

METHODS

This study was performed from February 6 to March 20, 2023. A self-made structured questionnaire was used for data collection. Descriptive statistics, T-tests, Analysis of variance (ANOVA), multiple linear regression, and Pearson correlation coefficient tests (α = 0.05) were employed.

RESULTS

A total of 405 ICU staff from 66 hospitals in Central and South China participated in this study, yielding 395 valid questionnaires. The mean knowledge score was 51.46 ± 5.96 (61.8% scored highly). The mean attitude score was 58.71 ± 2.19 (73.9% scored highly). The mean practice score was 18.15 ± 0.98 (85.1% scored highly). Multiple linear regression analysis indicated that gender, age, years of CRRT practice, ICU category, and CRRT specialist panel membership independently affected the knowledge score; Educational level, years of CRRT practice, and CRRT specialist panel membership independently affected the attitude score; Education level and teaching hospital employment independently affected the practice score. The most effective method for ICU staff to undergo training and daily work experience is within the department.

CONCLUSION

ICU staff exhibit good knowledge, a positive attitude and appropriately practiced CRRT. Extended CRRT practice time in CRRT, further training in a general ICU or teaching hospital, joining a CRRT specialist panel, and upgraded education can improve CRRT professional level. Considering the convenience of training programs will enhance ICU staff participation. Training should focus on basic CRRT principles, liquid management, and alarm handling.

Fluid Balance in Continuous Renal Replacement Therapy: Prescribing, Delivering, and Review

BACKGROUND

Historically IV and enteral fluids given during acute kidney injury (AKI) were restricted before the introduction of continuous renal replacement therapies (CRRTs) when more liberal fluids improved nutrition for the critically ill. However, fluid accumulation can occur when higher volumes each day are not considered in the fluid balance prescribing and the NET ultrafiltration (NUF) volume target.

KEY MESSAGES

The delivered hours of CRRT each day are vital for achievement of fluid balance and time off therapy makes the task more challenging. Clinicians inexperienced with CRRT make this aspect of AKI management a focus of rounding with senior oversight, clear communication, and "precision" a clinical target. Sepsis-associated AKI can be a complex patient where resuscitation and admission days are with a positive fluid load and replacement mind set. Subsequent days in ICU requires fluid regulation, removal, with a comprehensive multilayered assessment before prescribing the daily fluid balance target and the required hourly NET plasma water removal rate (NUF rate). Future machines may include advanced software, new alarms - display metrics, messages and association with machine learning and "AKI models" for setting, monitoring, and guaranteeing fluid removal. This could also link to current hardware such as on-line blood volume assessment with continuous haematocrit measurement.

SUMMARY

Fluid balance in the acutely ill is a challenge where forecasting and prediction are necessary. NUF rate and volume each hour should be tracked and adjusted to achieve the daily target. This requires human and machine connections.

Proceedings of the 2022 UAB CRRT Academy: Non-Invasive Hemodynamic Monitoring to Guide Fluid Removal with CRRT and Proliferation of Extracorporeal Blood Purification Devices

In 2022, we celebrated the 15th anniversary of the University of Alabama at Birmingham (UAB) Continuous Renal Replacement Therapy (CRRT) Academy, a 2-day conference attended yearly by an international audience of over 100 nephrology, critical care, and multidisciplinary trainees and practitioners. This year, we introduce the proceedings of the UAB CRRT Academy, a yearly review of select emerging topics in the field of critical care nephrology that feature prominently in the conference. First, we review the rapidly evolving field of non-invasive hemodynamic monitoring and its potential to guide fluid removal by renal replacement therapy (RRT). We begin by summarizing the accumulating data associating fluid overload with harm in critical illness and the potential for harm from end-organ hypoperfusion caused by excessive fluid removal with RRT, underscoring the importance of accurate, dynamic assessment of volume status. We describe four applications of point-of-care ultrasound used to identify patients in need of urgent fluid removal or likely to tolerate fluid removal: lung ultrasound, inferior vena cava ultrasound, venous excess ultrasonography, and Doppler of the left ventricular outflow track to estimate stroke volume. We briefly introduce other minimally invasive hemodynamic monitoring technologies before concluding that additional prospective data are urgently needed to adapt these technologies to the specific task of fluid removal by RRT and to learn how best to integrate them into practical fluid-management strategies. Second, we focus on the growth of novel extracorporeal blood purification devices, starting with brief reviews of the inflammatory underpinnings of multiorgan dysfunction and the specific applications of pathogen, endotoxin, and/or cytokine removal and immunomodulation. Finally, we review a series of specific adsorptive technologies, several of which have seen substantial clinical use during the COVID-19 pandemic, describing their mechanisms of target removal, the limited existing data supporting their efficacy, ongoing and future studies, and the need for additional prospective trials.

Fluid balance neutralization secured by hemodynamic monitoring versus protocolized standard of care in critically ill patients requiring continuous renal replacement therapy: study protocol of the GO NEUTRAL randomized controlled trial

Background

Fluid overload is associated with worse outcome in critically ill patients requiring continuous renal replacement therapy (CRRT). Net ultrafiltration (UF_NET) allows precise control of the fluid removal but is frequently ceased due to hemodynamic instability episodes. However, approximately 50% of the hemodynamic instability episodes in ICU patients treated with CRRT are not associated with preload dependence (i.e., are not related to a decrease in cardiac preload), suggesting that volume removal is not responsible for these episodes of hemodynamic impairment. The use of advanced hemodynamic monitoring, comprising continuous cardiac output monitoring to repeatedly assess preload dependency, could allow securing UF_NET to allow fluid balance control and prevent fluid overload.

Methods

The GO NEUTRAL trial is a multicenter, open-labeled, randomized, controlled, superiority trial with parallel groups and balanced randomization with a 1:1 ratio. The trial will enroll adult patients with acute circulatory failure treated with vasopressors and severe acute kidney injury requiring CRRT who already have been equipped with a continuous cardiac output monitoring device. After informed consent, patients will be randomized into two groups. The control group will receive protocolized fluid removal with an UF_NET rate set to 0–25 ml h⁻¹ between inclusion and H72 of inclusion. The intervention group will be treated with an UF_NET rate set on the CRRT of at least 100 ml h⁻¹ between inclusion and H72 of inclusion if hemodynamically tolerated based on a protocolized hemodynamic protocol aiming to adjust UF_NET based on cardiac output, arterial lactate concentration, and preload dependence assessment by postural maneuvers, performed regularly during nursing rounds, and in case of a hemodynamic instability episode. The primary outcome of the study will be the cumulative fluid balance between inclusion and H72 of inclusion. Randomization will be generated using random block sizes and stratified based on fluid overload status at inclusion. The main outcome will be analyzed in the modified intention-to-treat population, defined as all alive patients at H72 of inclusion, based on their initial allocation group.

Discussion

We present in the present protocol all study procedures in regard to the achievement of the GO NEUTRAL trial, to prevent biased analysis of trial outcomes and improve the transparency of the trial result report. Enrollment of patients in the GO NEUTRAL trial has started on June 31, 2021, and is ongoing.

Trial registration

ClinicalTrials.gov NCT04801784. Registered on March 12, 2021, before the start of inclusion.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-022-06735-6.

Hemodynamic Monitoring in Sepsis-A Conceptual Framework of Macro- and Microcirculatory Alterations

Circulatory failure in sepsis is common and places a considerable burden on healthcare systems. It is associated with an increased likelihood of mortality, and timely recognition is a prerequisite to ensure optimum results. While there is consensus that aggressive source control, adequate antimicrobial therapy and hemodynamic management constitute crucial determinants of outcome, discussion remains about the best way to achieve each of these core principles. Sound cardiovascular support rests on tailored fluid resuscitation and vasopressor therapy. To this end, an overarching framework to improve cardiovascular dynamics has been a recurring theme in modern critical care. The object of this review is to examine the nature of one such framework that acknowledges the growing importance of adaptive hemodynamic support combining macro- and microhemodynamic variables to produce adequate tissue perfusion.