1
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Meyhoff TS, Granholm A, Hjortrup PB, Sivapalan P, Lange T, Laake JH, Cronhjort M, Jakob SM, Cecconi M, Nalos M, Ostermann M, Malbrain MLNG, Møller MH, Perner A. Albumin use in patients with septic shock-Post-hoc analyses of an international randomised fluid trial. Acta Anaesthesiol Scand 2024; 68:372-384. [PMID: 37975538 DOI: 10.1111/aas.14359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 10/13/2023] [Accepted: 10/25/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Albumin administration is suggested in patients with sepsis and septic shock who have received large volumes of crystalloids. Given lack of firm evidence, clinical practice variation may exist. To address this, we investigated if patient characteristics or trial site were associated with albumin use in septic shock. METHODS We conducted a post-hoc study of the CLASSIC international, randomised clinical trial of fluid volumes in septic shock. Associations between selected baseline variables and trial site with albumin use during ICU stay were assessed in Cox models considering death, ICU discharge, and loss-to-follow-up as competing events. Baseline variables were first assessed individually, adjusted for treatment allocation (restrictive vs. standard IV fluid), and then adjusted for allocation and the other baseline variables. Site was assessed in a model adjusted for allocation and baseline variables. RESULTS We analysed 1541 of 1554 patients randomised in CLASSIC (99.2%). During ICU stay, 36.3% of patients in the restrictive-fluid group and 52.6% in the standard-fluid group received albumin. Gastrointestinal focus of infection and higher doses of norepinephrine were most strongly associated with albumin use (subgroup with highest quartile of norepinephrine doses, hazard ratio (HR) 2.58, 95% CI 1.89 to 3.53). HRs for associations between site and albumin use ranged from 0.11 (95% CI 0.05 to 0.26) to 1.70 (95% CI 1.06 to 2.74); test for overall effect of site: p < .001. CONCLUSIONS In adults with septic shock, gastrointestinal focus of infection and higher doses of norepinephrine at baseline were associated with albumin use, which also varied substantially between sites.
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Affiliation(s)
- Tine Sylvest Meyhoff
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Anders Granholm
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Peter Buhl Hjortrup
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
- Department of Cardiothoracic Anaesthesia and Intensive Care, The Heart Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Praleene Sivapalan
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Theis Lange
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - Jon Henrik Laake
- Department of Anaesthesiology and Intensive Care Medicine, Rikshospitalet, Oslo University Hospital, Norway
- Division of Emergencies and Critical Care, Rikshospitalet, Oslo University Hospital, Norway
| | - Maria Cronhjort
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
| | | | - Maurizio Cecconi
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
- Department of Anaesthesia and Intensive Care Medicine, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Marek Nalos
- Medical Intensive Care Unit 1, Interni klinika, Fakultni Nemocnice, Plzen, Czech Republic
| | - Marlies Ostermann
- Department of Intensive Care, Guy's and St Thomas' Hospital, London, UK
| | - Manu L N G Malbrain
- Department of Intensive Care Medicine, University Hospital Brussels (UZB), Jette, Belgium
- First Department of Anaesthesiology and Intensive Therapy, Medical University of Lublin, Lublin, Poland
| | - Morten Hylander Møller
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Anders Perner
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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2
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Schortgen F, Tabra Osorio C, Carpentier D, Henry M, Beuret P, Lacave G, Simon G, Blanchard PY, Gobe T, Guillon A, Bitker L, Duhommet G, Quenot JP, Le Meur M, Jochmans S, Dubouloz F, Mainguy N, Saletes J, Creutin T, Nicolas P, Senay J, Berthelot AL, Rizk D, Tran Van D, Riviere A, Heili-Frades SB, Nunes J, Robquin N, Lhotellier S, Ledochowski S, Guénégou-Arnoux A, Constan A. Fluid Intake in Critically Ill Patients: The "Save Useless Fluids For Intensive Resuscitation" Multicenter Prospective Cohort Study. Crit Care Med 2024; 52:258-267. [PMID: 37909832 DOI: 10.1097/ccm.0000000000006091] [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: 11/03/2023]
Abstract
OBJECTIVES Patients at risk of adverse effects related to positive fluid balance could benefit from fluid intake optimization. Less attention is paid to nonresuscitation fluids. We aim to evaluate the heterogeneity of fluid intake at the initial phase of resuscitation. DESIGN Prospective multicenter cohort study. SETTING Thirty ICUs across France and one in Spain. PATIENTS Patients requiring vasopressors and/or invasive mechanical ventilation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS All fluids administered by vascular or enteral lines were recorded over 24 hours following admission and were classified in four main groups according to their predefined indication: fluids having a well-documented homeostasis goal (resuscitation fluids, rehydration, blood products, and nutrition), drug carriers, maintenance fluids, and fluids for technical needs. Models of regression were constructed to determine fluid intake predicted by patient characteristics. Centers were classified according to tertiles of fluid intake. The cohort included 296 patients. The median total volume of fluids was 3546 mL (interquartile range, 2441-4955 mL), with fluids indisputably required for body fluid homeostasis representing 36% of this total. Saline, glucose-containing high chloride crystalloids, and balanced crystalloids represented 43%, 27%, and 16% of total volume, respectively. Whatever the class of fluids, center of inclusion was the strongest factor associated with volumes. Compared with the first tertile, the difference between the volume predicted by patient characteristics and the volume given was +1.2 ± 2.0 L in tertile 2 and +3.0 ± 2.8 L in tertile 3. CONCLUSIONS Fluids indisputably required for body fluid homeostasis represent the minority of fluid intake during the 24 hours after ICU admission. Center effect is the strongest factor associated with the volume of fluids. Heterogeneity in practices suggests that optimal strategies for volume and goals of common fluids administration need to be developed.
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Affiliation(s)
- Frédérique Schortgen
- Réanimation et surveillance continue adulte, Centre hospitalier intercommunal, Créteil, France
| | - Cécilia Tabra Osorio
- Réanimation et surveillance continue adulte, Centre hospitalier intercommunal, Créteil, France
| | - Dorothée Carpentier
- Department of Medical Intensive Care, Rouen University Hospital, Rouen, France
| | - Matthieu Henry
- Médecine Intensive Réanimation, Centre hospitalier départemental Vendée, La Roche-sur-Yon, France
| | - Pascal Beuret
- Réanimation et Soins continus, Centre Hospitalier, Roanne, France
| | - Guillaume Lacave
- Réanimation médico-chirurgicale, Centre Hospitalier de Versailles, Le Chesnay, France
| | - Georges Simon
- Réanimation polyvalente, Centre hospitalier, Troyes, France
| | - Pierre-Yves Blanchard
- Médecine Intensive et Réanimation, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Hôpital Tenon, Paris, France
| | - Tiphanie Gobe
- Réanimation médicale, Centre Hospitalier Universitaire de Rennes-Hôpital Pontchaillou, Rennes, France
| | - Antoine Guillon
- Intensive Care Unit, Tours University Hospital, Research Center for Respiratory Diseases, INSERM U1100, University of Tours, Tours, France
| | - Laurent Bitker
- Médecine Intensive-Réanimation, Hôpital de la Croix Rousse, Hospices Civils de Lyon, Lyon, France
- Université Claude Bernard Lyon 1, Lyon, France
- Université Lyon, INSA-Lyon, Université Claude Bernard Lyon 1, CNRS, Inserm, CREATIS UMR 5220, U1294, Villeurbanne, France
| | - Guillaume Duhommet
- Unité Réanimation Polyvalente, Centre Hospitalier Public du Cotentin, Cherbourg-en-Cotentin, France
| | - Jean-Pierre Quenot
- Department of Intensive Care, Burgundy University Hospital, Dijon, France
- Lipness Team, INSERM Research Center LNC-UMR1231 and LabEx LipSTIC, University of Burgundy, Dijon, France
- INSERM CIC 1432, Clinical Epidemiology, University of Burgundy, Dijon, France
| | - Matthieu Le Meur
- Service de Réanimation, Groupe Hospitalier Nord Essonne, Longjumeau, France
| | - Sébastien Jochmans
- Service de Médecine Intensive-Réanimation et Unité de Recherche Clinique, Groupe Hospitalier Sud Ile-de-France, Melun, France
| | - Fabrice Dubouloz
- Réanimation des urgences, Hôpitaux universitaires de Marseille Timone, Marseille, France
| | - Nolwenn Mainguy
- Réanimation polyvalente, Centre hospitalier Bretagne Atlantique, Vannes, France
| | - Josselin Saletes
- Service de Réanimation Médico-Chirurgicale et USC, Centre hospitalier, Le Mans, France
| | - Thibault Creutin
- Service de médecine intensive-réanimation, Hôpitaux Universitaires APHP-Paris-Saclay, Le Kremlin-Bicêtre, France
| | - Pierre Nicolas
- Médecine Intensive Réanimation, CHU Grenoble-Alpes, La Tronche, France
| | - Julien Senay
- Service de réanimation polyvalente, Hôpital Foch, Suresnes, France
| | | | - Delphine Rizk
- Service de Médecine Intensive-Réanimation, Groupe Hospitalier Pitié Salpêtrière APHP-Sorbonne Université, Paris, France
| | - David Tran Van
- Réanimation polyvalente, Hôpital d'Instruction des Armées Robert Picqué, Villenave d'Ornon, France
| | - Audrey Riviere
- Réanimation Polyvalente, CHU de La Réunion, Saint Pierre, France
| | - Sarah Beatrice Heili-Frades
- Intermediate Respiratory Care Unit, University Hospital Jiménez Díaz Quirón Health Foundation of Madrid, Madrid, Spain
| | - Justine Nunes
- Réanimation adultes, Centre Hospitalier Sud Francilien, Corbeil-Essonnes, France
| | - Nadine Robquin
- Médecine Intensive Réanimation, Centre hospitalier intercommunal, Villeneuve St Georges, France
| | | | | | - Armelle Guénégou-Arnoux
- Université Paris Cité, AP-HP, Hôpital européen Georges Pompidou, Unité de Recherche Clinique, Centre d'Investigation Clinique 1418 Épidémiologie Clinique, INSERM, Inria, HeKA, Paris, France
| | - Adrien Constan
- Réanimation et surveillance continue adulte, Centre hospitalier intercommunal, Créteil, France
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Meyhoff TS, Hjortrup PB, Hammond N. Fluid Therapy in the ICU-Useful or Useless Practices? Crit Care Med 2024; 52:350-353. [PMID: 38240518 DOI: 10.1097/ccm.0000000000006108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
Affiliation(s)
- Tine Sylvest Meyhoff
- Department of Intensive Care, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
| | - Peter Buhl Hjortrup
- Collaboration for Research in Intensive Care (CRIC), Copenhagen, Denmark
- Department of Cardiothoracic Anaesthesia and Intensive Care, The Heart Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Naomi Hammond
- The George Institute for Global Health, University of New South Wales, Sydney, NSW, Australia
- Malcolm Fisher Department of Intensive Care, Royal North Shore Hospital, Sydney, NSW, Australia
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Kristine Jessen M, Drescher Petersen A, Kirkegaard H. Effect of Out-Of-Hour Admission on Fluid Treatment of Emergency Department Patients with Suspected Infection; a Multicenter Post-Hoc Analysis. ARCHIVES OF ACADEMIC EMERGENCY MEDICINE 2023; 11:e21. [PMID: 36919142 PMCID: PMC10008217 DOI: 10.22037/aaem.v11i1.1839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 03/16/2023]
Abstract
Introduction Sepsis is a life-threatening and common cause of Emergency department (ED) referrals. Out-of-hour staffing is limited in ED, which may potentially affect fluid administration. This study aimed to investigate fluid volume variation in out-of-hour vs. routine-hour admissions. Methods The present study is a post-hoc analysis of a multicentre, prospective, observational study investigating fluid administration in ED patients with suspected infection, from Jan 20th - March 2nd, 2020. Patient groups were "routine-hours" (RH): weekdays 07:00-18:59 or "out-of-hours" (OOH): weekdays 19:00-06:59 or Friday 19:00-Monday 06:59. Primary outcome was 24-hour total fluid volumes (oral + intravenous (IV)). Secondary outcomes were total fluids 0-6 hours, oral fluids 0-6 and 0-24 hours, and IV fluids 0-6 and 0-24 hours. Linear regression adjusted for site and illness severity was used. Results 734 patients had suspected infection; 449 were admitted during RH and 287 during OOH. Mean (95% CI) total 24-hour fluid volumes were equal in simple infection and sepsis regardless of admission time: Simple infection RH: 3640 (3410 - 3871) ml and OOH: 3681 (3451 - 3913) ml. Sepsis RH: 3671 (3443;3898) ml and OOH: 3896 (3542;4250) ml. Oral fluids 0-6h were reduced in simple infection and sepsis among OOH vs. RH. Sepsis patients received more 0-6-hour IV fluid when admitted OOH vs. RH. There were no associations between admission time and 0-24-hour oral or IV volumes in simple infection or sepsis. Conclusion Admission time did not have an association with 24-hour total fluid volumes. Sepsis patients admitted during OOH received more 0-6-hour IV fluids than RH patients, and simple infection and sepsis patients received less oral fluid in 0-6 hours if admitted during OOH vs. RH.
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Affiliation(s)
- Marie Kristine Jessen
- Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark.,Department of Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Anna Drescher Petersen
- Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark
| | - Hans Kirkegaard
- Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Aarhus, Denmark.,Department of Emergency Medicine, Aarhus University Hospital, Aarhus, Denmark
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Jessen MK, Andersen LW, Thomsen MH, Kristensen P, Hayeri W, Hassel RE, Messerschmidt TG, Sølling CG, Perner A, Petersen JAK, Kirkegaard H. Restrictive fluids versus standard care in adults with sepsis in the emergency department (REFACED): A multicenter, randomized feasibility trial. Acad Emerg Med 2022; 29:1172-1184. [PMID: 35652491 PMCID: PMC9804491 DOI: 10.1111/acem.14546] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 05/22/2022] [Accepted: 05/27/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Fluid treatment in sepsis is a challenge and clinical equipoise exists regarding intravenous (IV) volumes. We aimed to determine whether a 24-h protocol restricting IV fluid was feasible in adult patients with sepsis without shock presenting to the emergency department (ED). METHODS The REFACED Sepsis trial is an investigator-initiated, multicenter, randomized, open-label, feasibility trial, assigning sepsis patients without shock to 24 h of restrictive, crystal IV fluid administration or standard care. In the IV fluid restriction group fluid boluses were only permitted if predefined criteria for hypoperfusion occurred. Standard care was at the discretion of the treating team. The primary outcome was total IV crystalloid fluid volumes at 24 h after randomization. Secondary outcomes included total fluid volumes, feasibility measures, and patient-centered outcomes. RESULTS We included 123 patients (restrictive 61 patients and standard care 62 patients) in the primary analysis. A total of 32% (95% confidence interval [CI] 28%-37%) of eligible patients meeting all inclusion criteria and no exclusion criteria were included. At 24 h, the mean (±SD) IV crystalloid fluid volumes were 562 (±1076) ml versus 1370 (±1438) ml in the restrictive versus standard care group (mean difference -801 ml, 95% CI -1257 to -345 ml, p = 0.001). Protocol violations occurred in 21 (34%) patients in the fluid-restrictive group. There were no differences between groups in adverse events, use of mechanical ventilation or vasopressors, acute kidney failure, length of stay, or mortality. CONCLUSIONS A protocol restricting IV crystalloid fluids in ED patients with sepsis reduced 24-h fluid volumes compared to standard care. A future trial powered toward patient-centered outcomes appears feasible.
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Affiliation(s)
- Marie K. Jessen
- Department of Clinical Medicine, Research Center for Emergency MedicineAarhus University and Aarhus University HospitalAarhusDenmark,Department of Emergency MedicineAarhus University HospitalAarhusDenmark
| | - Lars W. Andersen
- Department of Clinical Medicine, Research Center for Emergency MedicineAarhus University and Aarhus University HospitalAarhusDenmark,Department of Anesthesiology and Intensive CareAarhus University HospitalAarhusDenmark,Prehospital Emergency Medical ServicesCentral Denmark RegionAarhusDenmark
| | - Marie‐Louise H. Thomsen
- Department of Clinical Medicine, Research Center for Emergency MedicineAarhus University and Aarhus University HospitalAarhusDenmark,Department of Emergency MedicineAarhus University HospitalAarhusDenmark
| | - Peter Kristensen
- Department of Emergency MedicineRegional Hospital ViborgViborgDenmark
| | - Wazhma Hayeri
- Department of Emergency MedicineRegional Hospital RandersRandersDenmark
| | - Ranva E. Hassel
- Department of Emergency MedicineAarhus University HospitalAarhusDenmark
| | | | | | - Anders Perner
- Department of Intensive CareCopenhagen University Hospital, RigshospitaletCopenhagenDenmark
| | - Jens Aage K. Petersen
- Department of Anesthesiology and Intensive CareAarhus University HospitalAarhusDenmark
| | - Hans Kirkegaard
- Department of Clinical Medicine, Research Center for Emergency MedicineAarhus University and Aarhus University HospitalAarhusDenmark,Department of Emergency MedicineAarhus University HospitalAarhusDenmark,Prehospital Emergency Medical ServicesCentral Denmark RegionAarhusDenmark
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6
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Jessen MK, Andersen LW, Thomsen MLH, Kristensen P, Hayeri W, Hassel RE, Perner A, Petersen JAK, Kirkegaard H. Restrictive Fluid Administration vs. Standard of Care in Emergency Department Sepsis Patients (REFACED Sepsis)-protocol for a multicenter, randomized, clinical, proof-of-concept trial. Pilot Feasibility Stud 2022; 8:75. [PMID: 35351214 PMCID: PMC8962933 DOI: 10.1186/s40814-022-01034-y] [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: 12/05/2021] [Accepted: 03/17/2022] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Intravenous fluids are often used in the treatment of sepsis. The better strategy regarding fluid volume is debated, but preliminary data in patients with septic shock or sepsis-related hypotension favor restrictive fluid administration. We describe the protocol and statistical analysis plan for the Restrictive Fluid Administration vs. Standard of Care in Emergency Department Sepsis Patients (REFACED Sepsis)-a multicenter, randomized clinical proof-of-concept trial. The aim of the REFACED Sepsis trial is to test if a restrictive intravenous fluid protocol in emergency department patients with sepsis without shock is feasible and decreases the intravenous fluid volume administered in comparison to standard care. METHODS This is an investigator-initiated, multicenter, randomized, parallel-group, open-labeled, feasibility trial investigating volumes of crystalloid fluid within 24 h in 124 patients with sepsis without shock enrolled at three emergency departments in the Central Denmark Region. Patients are allocated to two different intravenous fluid regimens: a restrictive approach using four trigger criteria for fluid administration vs. standard care. The primary, feasibility outcome is total intravenous, crystalloid fluid volume within 24 h, and key secondary outcomes include protocol violations, total fluids (intravenous and oral) within 24 h, and serious adverse reactions and suspected unexpected serious adverse reactions. Status: The trial started in November 2021, and the last patient is anticipated to be included in January 2022. DISCUSSION Sepsis is very common in emergency department patients and fluid administration is very frequently administered in these patients. However, the evidence to guide fluid administration is very sparse. This feasibility trial will be the foundation for a potential future large-scale trial investigating restrictive vs. standard fluid administration in patients with sepsis. TRIAL REGISTRATION EudraCT number: 2021-000224-35 (date: 2021 May 03), ClinicalTrials.gov number: NCT05076435 (date: 2021 October 13), Committee on Health Research Ethics - Central Denmark Region: 1-10-72-163-21 (date: 2021 June 28).
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Affiliation(s)
- Marie Kristine Jessen
- Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, J103, DK-8200, Aarhus N, Denmark. .,Department of Emergency Medicine, Aarhus University Hospital, Aarhus N, Denmark.
| | - Lars Wiuff Andersen
- Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, J103, DK-8200, Aarhus N, Denmark.,Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus N, Denmark.,Prehospital Emergency Medical Services, Central Denmark Region, Aarhus N, Denmark
| | | | - Peter Kristensen
- Department of Emergency Medicine, Regional Hospital Viborg, Viborg, Denmark
| | - Wazhma Hayeri
- Department of Emergency Medicine, Regional Hospital Randers, Randers, Denmark
| | | | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | | | - Hans Kirkegaard
- Research Center for Emergency Medicine, Department of Clinical Medicine, Aarhus University and Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, J103, DK-8200, Aarhus N, Denmark.,Prehospital Emergency Medical Services, Central Denmark Region, Aarhus N, Denmark
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7
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Jessen MK, Andersen LW, Thomsen MH, Jensen ME, Kirk ME, Kildegaard S, Petersen P, Mohey R, Madsen AH, Perner A, Kølsen Petersen JA, Kirkegaard H. Twenty-four-hour fluid administration in emergency department patients with suspected infection: A multicenter, prospective, observational study. Acta Anaesthesiol Scand 2021; 65:1122-1142. [PMID: 33964019 DOI: 10.1111/aas.13848] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 04/15/2021] [Accepted: 04/17/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND To describe 24-hour fluid administration in emergency department (ED) patients with suspected infection. METHODS A prospective, multicenter, observational study conducted in three Danish hospitals, January 20 to March 2, 2020. We included consecutive adult ED patients with suspected infection (drawing of blood culture and/or intravenous antibiotic administration within 6 hours of admission). Oral and intravenous fluids were registered for 24 hours. PRIMARY OUTCOME 24-hour total fluid volume. We used linear regression to investigate patient and disease characteristics' effect on 24-hour fluids and to estimate the proportion of the variance in fluid administration explained by potential predictors. RESULTS 734 patients had 24-hour fluids available: 387 patients had simple infection, 339 sepsis, eight septic shock. Mean total 24-hour fluid volumes were 3656 mL (standard deviation [SD]:1675), 3762 mL (SD: 1839), and 6080 mL (SD: 3978) for the groups, respectively. Fluid volumes varied markedly. Increasing age (mean difference [MD]: 60-79 years: -470 mL [95% CI: -789, -150], +80 years; -974 mL [95% CI: -1307, -640]), do-not-resuscitate orders (MD: -466 mL [95% CI: -797, -135]), and preexisting atrial fibrillation (MD: -367 mL [95% CI: -661, -72) were associated with less fluid. Systolic blood pressure < 100 mmHg (MD: 1182 mL [95% CI: 820, 1543]), mean arterial pressure < 65 mmHg (MD: 1317 mL [95% CI: 770, 1864]), lactate ≥ 2 mmol/L (MD: 655 mL [95% CI: 306, 1005]), heart rate > 120 min (MD: 566 [95% CI: 169, 962]), low (MD: 1963 mL [95% CI: 813, 3112]) and high temperature (MD: 489 mL [95% CI: 234, 742]), SOFA score > 5 (MD: 1005 mL [95% CI: 501, 510]), and new-onset atrial fibrillation (MD: 498 mL [95% CI: 30, 965]) were associated with more fluid. Clinical variables explained 37% of fluid variation among patients. CONCLUSIONS Patients with simple infection and sepsis received equal fluid volumes. Fluid volumes varied markedly, a variation that was partly explained by clinical characteristics.
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Affiliation(s)
- Marie K. Jessen
- Research Center for Emergency Medicine Department of Clinical Medicine Aarhus University and Aarhus University Hospital Aarhus Denmark
- Department of Emergency Medicine Aarhus University Hospital Aarhus Denmark
| | - Lars W. Andersen
- Research Center for Emergency Medicine Department of Clinical Medicine Aarhus University and Aarhus University Hospital Aarhus Denmark
- Department of Anesthesiology and Intensive Care Aarhus University Hospital Aarhus Denmark
- Prehospital Emergency Medical Services Central Denmark Region Aarhus Denmark
| | - Marie‐Louise H. Thomsen
- Research Center for Emergency Medicine Department of Clinical Medicine Aarhus University and Aarhus University Hospital Aarhus Denmark
- Department of Emergency Medicine Aarhus University Hospital Aarhus Denmark
| | - Marie E. Jensen
- Research Center for Emergency Medicine Department of Clinical Medicine Aarhus University and Aarhus University Hospital Aarhus Denmark
| | - Mathilde E. Kirk
- Research Center for Emergency Medicine Department of Clinical Medicine Aarhus University and Aarhus University Hospital Aarhus Denmark
| | - Sofie Kildegaard
- Department of Emergency Medicine Regional Hospital Randers Randers Denmark
- Department of Anesthesiology and Intensive Care Regional Hospital Randers Randers Denmark
| | - Poul Petersen
- Department of Emergency Medicine Regional Hospital Herning Herning Denmark
| | - Rajesh Mohey
- Department of Internal Medicine Regional Hospital Herning Herning Denmark
| | - Anders H. Madsen
- Department of Abdominal Surgery Regional Hospital Herning Herning Denmark
| | - Anders Perner
- Department of Intensive Care, Rigshospitalet University of Copenhagen Copenhagen Denmark
| | | | - Hans Kirkegaard
- Research Center for Emergency Medicine Department of Clinical Medicine Aarhus University and Aarhus University Hospital Aarhus Denmark
- Department of Emergency Medicine Aarhus University Hospital Aarhus Denmark
- Prehospital Emergency Medical Services Central Denmark Region Aarhus Denmark
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8
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Meyhoff TS, Møller MH, Hjortrup PB, Cronhjort M, Perner A, Wetterslev J. Lower vs Higher Fluid Volumes During Initial Management of Sepsis: A Systematic Review With Meta-Analysis and Trial Sequential Analysis. Chest 2020; 157:1478-1496. [PMID: 31982391 DOI: 10.1016/j.chest.2019.11.050] [Citation(s) in RCA: 65] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Revised: 11/05/2019] [Accepted: 11/25/2019] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVE IV fluids are recommended during the initial management of sepsis, but the quality of evidence is low, and clinical equipoise exists. We aimed to assess patient-important benefits and harms of lower vs higher fluid volumes in adult patients with sepsis. METHODS We conducted a systematic review with meta-analysis and trial sequential analysis (TSA) of randomized clinical trials of IV fluid volume separation in adult patients with sepsis. We adhered to our published protocol; the Cochrane handbook; the Preferred Reporting Items for Systematic Reviews and Meta-Analyses; and the Grading of Recommendations Assessment, Development and Evaluation statements. The primary outcomes were all-cause mortality, serious adverse events (SAEs), and quality of life. RESULTS We included nine trials (n = 637); all were published after 2015 and had an overall high risk of bias. We found no statistically significant difference between lower vs higher fluid volumes in all-cause mortality (relative risk [RR], 0.87; 95% CI, 0.69-1.10; I2 = 0%; TSA-adjusted CI, 0.34-2.22) or SAEs (RR, 0.91; 95% CI, 0.78-1.05; I2 = 0%; TSA-adjusted CI, 0.68-1.21). No trials reported on quality of life. We did not find differences in the secondary or exploratory outcomes. The quality of evidence was very low across all outcomes. CONCLUSIONS In this systematic review, we found very low quantity and quality of evidence supporting the decision on the volumes of IV fluid therapy in adults with sepsis. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT03668236; URL: www.clinicaltrials.gov.
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Affiliation(s)
- Tine Sylvest Meyhoff
- Department of Intensive Care, Copenhagen, Denmark; Collaboration for Research in Intensive Care, Copenhagen, Denmark.
| | - Morten Hylander Møller
- Department of Intensive Care, Copenhagen, Denmark; Collaboration for Research in Intensive Care, Copenhagen, Denmark
| | - Peter Buhl Hjortrup
- Department of Intensive Care, Copenhagen, Denmark; Collaboration for Research in Intensive Care, Copenhagen, Denmark
| | - Maria Cronhjort
- Karolinska Institutet, Department of Clinical Science and Education, Södersjukhuset, Section of Anaesthesia and Intensive Care, Sweden
| | - Anders Perner
- Department of Intensive Care, Copenhagen, Denmark; Collaboration for Research in Intensive Care, Copenhagen, Denmark
| | - Jørn Wetterslev
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark; Collaboration for Research in Intensive Care, Copenhagen, Denmark
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9
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Abstract
PURPOSE OF REVIEW Continuous renal replacement therapy (CRRT) is now the mainstay of renal organ support in the critically ill. As our understanding of CRRT delivery and its impact on patient outcomes improves there is a focus on researching the potential benefits of tailored, patient-specific treatments to meet dynamic needs. RECENT FINDINGS The most up-to-date studies investigating aspects of CRRT prescription that can be individualized: CRRT dose, timing, fluid management, membrane selection, anticoagulation and vascular access are reviewed. The use of different doses of CRRT lack conventional high-quality evidence and importantly studies reveal variation in assessment of dose delivery. Research reveals conflicting evidence for clinicians in distinguishing which patients will benefit from 'watchful waiting' vs. early initiation of CRRT. Both dynamic CRRT dosing and precision fluid management using CRRT are difficult to investigate and currently only observational data supports individualization of prescriptions. Similarly, individualization of membrane choice is largely experimental. SUMMARY Clinicians have limited evidence to individualize the prescription of CRRT. To develop this, we need to understand the requirements for renal support for individual patients, such as electrolyte imbalance, fluid overload or clearance of systemic inflammatory mediators to allow us to target these abnormalities in appropriately designed randomized trials.
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Lewis SR, Pritchard MW, Evans DJW, Butler AR, Alderson P, Smith AF, Roberts I. Colloids versus crystalloids for fluid resuscitation in critically ill people. Cochrane Database Syst Rev 2018; 8:CD000567. [PMID: 30073665 PMCID: PMC6513027 DOI: 10.1002/14651858.cd000567.pub7] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Critically ill people may lose fluid because of serious conditions, infections (e.g. sepsis), trauma, or burns, and need additional fluids urgently to prevent dehydration or kidney failure. Colloid or crystalloid solutions may be used for this purpose. Crystalloids have small molecules, are cheap, easy to use, and provide immediate fluid resuscitation, but may increase oedema. Colloids have larger molecules, cost more, and may provide swifter volume expansion in the intravascular space, but may induce allergic reactions, blood clotting disorders, and kidney failure. This is an update of a Cochrane Review last published in 2013. OBJECTIVES To assess the effect of using colloids versus crystalloids in critically ill people requiring fluid volume replacement on mortality, need for blood transfusion or renal replacement therapy (RRT), and adverse events (specifically: allergic reactions, itching, rashes). SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and two other databases on 23 February 2018. We also searched clinical trials registers. SELECTION CRITERIA We included randomised controlled trials (RCTs) and quasi-RCTs of critically ill people who required fluid volume replacement in hospital or emergency out-of-hospital settings. Participants had trauma, burns, or medical conditions such as sepsis. We excluded neonates, elective surgery and caesarean section. We compared a colloid (suspended in any crystalloid solution) versus a crystalloid (isotonic or hypertonic). DATA COLLECTION AND ANALYSIS Independently, two review authors assessed studies for inclusion, extracted data, assessed risk of bias, and synthesised findings. We assessed the certainty of evidence with GRADE. MAIN RESULTS We included 69 studies (65 RCTs, 4 quasi-RCTs) with 30,020 participants. Twenty-eight studied starch solutions, 20 dextrans, seven gelatins, and 22 albumin or fresh frozen plasma (FFP); each type of colloid was compared to crystalloids.Participants had a range of conditions typical of critical illness. Ten studies were in out-of-hospital settings. We noted risk of selection bias in some studies, and, as most studies were not prospectively registered, risk of selective outcome reporting. Fourteen studies included participants in the crystalloid group who received or may have received colloids, which might have influenced results.We compared four types of colloid (i.e. starches; dextrans; gelatins; and albumin or FFP) versus crystalloids.Starches versus crystalloidsWe found moderate-certainty evidence that there is probably little or no difference between using starches or crystalloids in mortality at: end of follow-up (risk ratio (RR) 0.97, 95% confidence interval (CI) 0.86 to 1.09; 11,177 participants; 24 studies); within 90 days (RR 1.01, 95% CI 0.90 to 1.14; 10,415 participants; 15 studies); or within 30 days (RR 0.99, 95% CI 0.90 to 1.09; 10,135 participants; 11 studies).We found moderate-certainty evidence that starches probably slightly increase the need for blood transfusion (RR 1.19, 95% CI 1.02 to 1.39; 1917 participants; 8 studies), and RRT (RR 1.30, 95% CI 1.14 to 1.48; 8527 participants; 9 studies). Very low-certainty evidence means we are uncertain whether either fluid affected adverse events: we found little or no difference in allergic reactions (RR 2.59, 95% CI 0.27 to 24.91; 7757 participants; 3 studies), fewer incidences of itching with crystalloids (RR 1.38, 95% CI 1.05 to 1.82; 6946 participants; 2 studies), and fewer incidences of rashes with crystalloids (RR 1.61, 95% CI 0.90 to 2.89; 7007 participants; 2 studies).Dextrans versus crystalloidsWe found moderate-certainty evidence that there is probably little or no difference between using dextrans or crystalloids in mortality at: end of follow-up (RR 0.99, 95% CI 0.88 to 1.11; 4736 participants; 19 studies); or within 90 days or 30 days (RR 0.99, 95% CI 0.87 to 1.12; 3353 participants; 10 studies). We are uncertain whether dextrans or crystalloids reduce the need for blood transfusion, as we found little or no difference in blood transfusions (RR 0.92, 95% CI 0.77 to 1.10; 1272 participants, 3 studies; very low-certainty evidence). We found little or no difference in allergic reactions (RR 6.00, 95% CI 0.25 to 144.93; 739 participants; 4 studies; very low-certainty evidence). No studies measured RRT.Gelatins versus crystalloidsWe found low-certainty evidence that there may be little or no difference between gelatins or crystalloids in mortality: at end of follow-up (RR 0.89, 95% CI 0.74 to 1.08; 1698 participants; 6 studies); within 90 days (RR 0.89, 95% CI 0.73 to 1.09; 1388 participants; 1 study); or within 30 days (RR 0.92, 95% CI 0.74 to 1.16; 1388 participants; 1 study). Evidence for blood transfusion was very low certainty (3 studies), with a low event rate or data not reported by intervention. Data for RRT were not reported separately for gelatins (1 study). We found little or no difference between groups in allergic reactions (very low-certainty evidence).Albumin or FFP versus crystalloidsWe found moderate-certainty evidence that there is probably little or no difference between using albumin or FFP or using crystalloids in mortality at: end of follow-up (RR 0.98, 95% CI 0.92 to 1.06; 13,047 participants; 20 studies); within 90 days (RR 0.98, 95% CI 0.92 to 1.04; 12,492 participants; 10 studies); or within 30 days (RR 0.99, 95% CI 0.93 to 1.06; 12,506 participants; 10 studies). We are uncertain whether either fluid type reduces need for blood transfusion (RR 1.31, 95% CI 0.95 to 1.80; 290 participants; 3 studies; very low-certainty evidence). Using albumin or FFP versus crystalloids may make little or no difference to the need for RRT (RR 1.11, 95% CI 0.96 to 1.27; 3028 participants; 2 studies; very low-certainty evidence), or in allergic reactions (RR 0.75, 95% CI 0.17 to 3.33; 2097 participants, 1 study; very low-certainty evidence). AUTHORS' CONCLUSIONS Using starches, dextrans, albumin or FFP (moderate-certainty evidence), or gelatins (low-certainty evidence), versus crystalloids probably makes little or no difference to mortality. Starches probably slightly increase the need for blood transfusion and RRT (moderate-certainty evidence), and albumin or FFP may make little or no difference to the need for renal replacement therapy (low-certainty evidence). Evidence for blood transfusions for dextrans, and albumin or FFP, is uncertain. Similarly, evidence for adverse events is uncertain. Certainty of evidence may improve with inclusion of three ongoing studies and seven studies awaiting classification, in future updates.
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Affiliation(s)
- Sharon R Lewis
- Royal Lancaster InfirmaryLancaster Patient Safety Research UnitPointer Court 1, Ashton RoadLancasterUKLA1 4RP
| | - Michael W Pritchard
- Royal Lancaster InfirmaryLancaster Patient Safety Research UnitPointer Court 1, Ashton RoadLancasterUKLA1 4RP
| | - David JW Evans
- Lancaster UniversityLancaster Health HubLancasterUKLA1 4YG
| | - Andrew R Butler
- Royal Lancaster InfirmaryDepartment of AnaesthesiaLancasterUK
| | - Phil Alderson
- National Institute for Health and Care ExcellenceLevel 1A, City Tower,Piccadilly PlazaManchesterUKM1 4BD
| | - Andrew F Smith
- Royal Lancaster InfirmaryDepartment of AnaesthesiaLancasterUK
| | - Ian Roberts
- London School of Hygiene & Tropical MedicineCochrane Injuries GroupNorth CourtyardKeppel StreetLondonUKWC1E 7HT
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11
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Hjortrup PB, Haase N, Bundgaard H, Thomsen SL, Winding R, Pettilä V, Aaen A, Lodahl D, Berthelsen RE, Christensen H, Madsen MB, Winkel P, Wetterslev J, Perner A. Restricting volumes of resuscitation fluid in adults with septic shock after initial management: the CLASSIC randomised, parallel-group, multicentre feasibility trial. Intensive Care Med 2016; 42:1695-1705. [PMID: 27686349 DOI: 10.1007/s00134-016-4500-7] [Citation(s) in RCA: 255] [Impact Index Per Article: 31.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2016] [Accepted: 08/09/2016] [Indexed: 12/19/2022]
Abstract
PURPOSE We assessed the effects of a protocol restricting resuscitation fluid vs. a standard care protocol after initial resuscitation in intensive care unit (ICU) patients with septic shock. METHODS We randomised 151 adult patients with septic shock who had received initial fluid resuscitation in nine Scandinavian ICUs. In the fluid restriction group fluid boluses were permitted only if signs of severe hypoperfusion occurred, while in the standard care group fluid boluses were permitted as long as circulation continued to improve. RESULTS The co-primary outcome measures, resuscitation fluid volumes at day 5 and during ICU stay, were lower in the fluid restriction group than in the standard care group [mean differences -1.2 L (95 % confidence interval -2.0 to -0.4); p < 0.001 and -1.4 L (-2.4 to -0.4) respectively; p < 0.001]. Neither total fluid inputs and balances nor serious adverse reactions differed statistically significantly between the groups. Major protocol violations occurred in 27/75 patients in the fluid restriction group. Ischaemic events occurred in 3/75 in the fluid restriction group vs. 9/76 in the standard care group (odds ratio 0.32; 0.08-1.27; p = 0.11), worsening of acute kidney injury in 27/73 vs. 39/72 (0.46; 0.23-0.92; p = 0.03), and death by 90 days in 25/75 vs. 31/76 (0.71; 0.36-1.40; p = 0.32). CONCLUSIONS A protocol restricting resuscitation fluid successfully reduced volumes of resuscitation fluid compared with a standard care protocol in adult ICU patients with septic shock. The patient-centred outcomes all pointed towards benefit with fluid restriction, but our trial was not powered to show differences in these exploratory outcomes. TRIAL REGISTRATION NCT02079402.
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Affiliation(s)
- Peter B Hjortrup
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Nicolai Haase
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Helle Bundgaard
- Department of Intensive Care, Randers Hospital, Randers, Denmark
| | - Simon L Thomsen
- Department of Intensive Care, Aalborg University Hospital, Aalborg, Denmark
| | - Robert Winding
- Department of Intensive Care, Herning Hospital, Herning, Denmark
| | - Ville Pettilä
- Department of Intensive Care, Helsinki University Hospital, Helsinki, Finland
| | - Anne Aaen
- Department of Intensive Care, Holbæk Hospital, Holbæk, Denmark
| | - David Lodahl
- Department of Intensive Care, Holstebro Hospital, Holstebro, Denmark
| | | | - Henrik Christensen
- Department of Intensive Care, Herlev Hospital, Herlev Municipality, Denmark
| | - Martin B Madsen
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark
| | - Per Winkel
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jørn Wetterslev
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Blegdamsvej 9, 2100, Copenhagen, Denmark.
- Centre for Research in Intensive Care, Copenhagen, Denmark.
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