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1
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Willam C, Herbst L. [The ROSE concept: modern fluid management in intensive care medicine]. Med Klin Intensivmed Notfmed 2024; 119:634-639. [PMID: 39382684 DOI: 10.1007/s00063-024-01193-1] [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: 03/22/2024] [Accepted: 09/09/2024] [Indexed: 10/10/2024]
Abstract
The ROSE concept, which is the acronym of resuscitation, optimization, stabilization and evacuation, describes the phases of fluid therapy, based on the pathophysiology of septic shock. During the first two phases, aggressive fluid therapy that is guided by clinical and hemodynamic parameters is mandatory. During the stabilization phase, recovery from shock and microcirculatory injury occurs, which enables the depletion of fluid overload in the fourth and final phase. Ultimately, euvolemia needs to be regained, which reverts interstitial edema and organ dysfunction.
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Affiliation(s)
- Carsten Willam
- Medizinische Klinik 4, Universitätsklinikum Erlangen, Ulmenweg 18, 91054, Erlangen, Deutschland.
| | - Larissa Herbst
- Medizinische Klinik 4, Universitätsklinikum Erlangen, Ulmenweg 18, 91054, Erlangen, Deutschland.
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2
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Ostermann M, Awdishu L, Legrand M. Using diuretic therapy in the critically ill patient. Intensive Care Med 2024; 50:1331-1334. [PMID: 38695931 DOI: 10.1007/s00134-024-07441-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Accepted: 04/06/2024] [Indexed: 08/09/2024]
Affiliation(s)
- Marlies Ostermann
- Department of Intensive Care, King's College London, Guy's & St Thomas' Hospital, London, UK.
| | - Linda Awdishu
- Division of Clinical Pharmacy, University of California, San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences, La Jolla, USA
| | - Matthieu Legrand
- Department of Anesthesia and Peri-Operative Care, Division of Critical Care Medicine, University of California San Francisco, San Francisco, USA
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3
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Nadim MK, Kellum JA, Forni L, Francoz C, Asrani SK, Ostermann M, Allegretti AS, Neyra JA, Olson JC, Piano S, VanWagner LB, Verna EC, Akcan-Arikan A, Angeli P, Belcher JM, Biggins SW, Deep A, Garcia-Tsao G, Genyk YS, Gines P, Kamath PS, Kane-Gill SL, Kaushik M, Lumlertgul N, Macedo E, Maiwall R, Marciano S, Pichler RH, Ronco C, Tandon P, Velez JCQ, Mehta RL, Durand F. Acute kidney injury in patients with cirrhosis: Acute Disease Quality Initiative (ADQI) and International Club of Ascites (ICA) joint multidisciplinary consensus meeting. J Hepatol 2024; 81:163-183. [PMID: 38527522 PMCID: PMC11193657 DOI: 10.1016/j.jhep.2024.03.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 02/28/2024] [Accepted: 03/07/2024] [Indexed: 03/27/2024]
Abstract
Patients with cirrhosis are prone to developing acute kidney injury (AKI), a complication associated with a markedly increased in-hospital morbidity and mortality, along with a risk of progression to chronic kidney disease. Whereas patients with cirrhosis are at increased risk of developing any phenotype of AKI, hepatorenal syndrome (HRS), a specific form of AKI (HRS-AKI) in patients with advanced cirrhosis and ascites, carries an especially high mortality risk. Early recognition of HRS-AKI is crucial since administration of splanchnic vasoconstrictors may reverse the AKI and serve as a bridge to liver transplantation, the only curative option. In 2023, a joint meeting of the International Club of Ascites (ICA) and the Acute Disease Quality Initiative (ADQI) was convened to develop new diagnostic criteria for HRS-AKI, to provide graded recommendations for the work-up, management and post-discharge follow-up of patients with cirrhosis and AKI, and to highlight priorities for further research.
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Affiliation(s)
- Mitra K Nadim
- Division of Nephrology and Hypertension, Keck School of Medicine, University of Southern California, Los Angeles, USA
| | - John A Kellum
- Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Lui Forni
- School of Medicine, University of Surrey and Critical Care Unit, Royal Surrey Hospital Guildford UK
| | - Claire Francoz
- Hepatology & Liver Intensive Care, Hospital Beaujon, Clichy, Paris, France
| | | | - Marlies Ostermann
- King's College London, Guy's & St Thomas' Hospital, Department of Critical Care, London, UK
| | - Andrew S Allegretti
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Javier A Neyra
- Division of Nephrology, Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Jody C Olson
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
| | - Salvatore Piano
- Unit of Internal Medicine and Hepatology, Department of Medicine - DIMED, University and Hospital of Padova, Padova, Italy
| | - Lisa B VanWagner
- Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Elizabeth C Verna
- Division of Digestive and Liver Diseases, Columbia University, New York, NY, USA
| | - Ayse Akcan-Arikan
- Department of Pediatrics, Divisions of Critical Care Medicine and Nephrology, Baylor College of Medicine, Houston, TX, USA
| | - Paolo Angeli
- Unit of Internal Medicine and Hepatology, University and Teaching Hospital of Padua, Italy
| | - Justin M Belcher
- Section of Nephrology, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA; VA Connecticut Healthcare System, West Haven, CT, USA
| | - Scott W Biggins
- Division of Gastroenterology, Department of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Akash Deep
- Pediatric Intensive Care Unit, King's College Hospital, London, UK
| | - Guadalupe Garcia-Tsao
- Digestive Diseases Section, Yale University School of Medicine, New Haven, CT, USA; VA Connecticut Healthcare System, West Haven, CT, USA
| | - Yuri S Genyk
- Division of Abdominal Organ Transplantation and Hepatobiliary Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA; Division of Abdominal Organ Transplantation at Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Pere Gines
- Liver Unit, Hospital Clínic de Barcelona, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi-Sunyer and Ciber de Enfermedades Hepàticas y Digestivas, Barcelona, Catalonia, Spain
| | - Patrick S Kamath
- Division of Gastroenterology and Hepatology Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Sandra L Kane-Gill
- Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, USA
| | - Manish Kaushik
- Department of Renal Medicine, Singapore General Hospital, Singapore
| | - Nuttha Lumlertgul
- Excellence Centre in Critical Care Nephrology and Division of Nephrology, Faculty of Medicine, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Etienne Macedo
- Division of Nephrology, Department of Medicine, University of California San Diego, CA, USA
| | - Rakhi Maiwall
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | | | - Raimund H Pichler
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, WA, USA
| | - Claudio Ronco
- International Renal Research Institute of Vicenza, Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Vicenza-Italy
| | - Puneeta Tandon
- Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Alberta, Canada
| | - Juan-Carlos Q Velez
- Department of Nephrology, Ochsner Health, New Orleans, LA, USA; Ochsner Clinical School, The University of Queensland, Brisbane, QLD, Australia
| | - Ravindra L Mehta
- Division of Nephrology-Hypertension, Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - François Durand
- Hepatology & Liver Intensive Care, Hospital Beaujon, Clichy, Paris, France; University Paris Cité, Paris, France.
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4
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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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5
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Baldwin IC, McKaige A. Fluid Balance in Continuous Renal Replacement Therapy: Prescribing, Delivering, and Review. Blood Purif 2024; 53:533-540. [PMID: 38377974 DOI: 10.1159/000537928] [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: 07/27/2023] [Accepted: 02/15/2024] [Indexed: 02/22/2024]
Abstract
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.
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Affiliation(s)
- Ian Charles Baldwin
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Amy McKaige
- Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
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Sanfilippo F, Messina A, Scolletta S, Bignami E, Morelli A, Cecconi M, Landoni G, Romagnoli S. The "CHEOPS" bundle for the management of Left Ventricular Diastolic Dysfunction in critically ill patients: an experts' opinion. Anaesth Crit Care Pain Med 2023; 42:101283. [PMID: 37516408 DOI: 10.1016/j.accpm.2023.101283] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 07/18/2023] [Accepted: 07/19/2023] [Indexed: 07/31/2023]
Abstract
The impact of left ventricular (LV) diastolic dysfunction (DD) on the outcome of patients with heart failure was established over three decades ago. Nevertheless, the relevance of LVDD for critically ill patients admitted to the intensive care unit has seen growing interest recently, and LVDD is associated with poor prognosis. Whilst an assessment of LV diastolic function is desirable in critically ill patients, treatment options for LVDD are very limited, and pharmacological possibilities to rapidly optimize diastolic function have not been found yet. Hence, a proactive approach might have a substantial role in improving the outcomes of these patients. Recalling historical Egyptian parallelism suggesting that Doppler echocardiography has been the "Rosetta stone" to decipher the study of LV diastolic function, we developed a potentially useful acronym for physicians at the bedside to optimize the management of critically ill patients with LVDD with the application of the bundle. We summarized the bundle under the acronym of the famous ancient Egyptian pharaoh CHEOPS: Chest Ultrasound, combining information from echocardiography and lung ultrasound; HEmodynamics assessment, with careful evaluation of heart rate and rhythm, as well as afterload and vasoactive drugs; OPtimization of mechanical ventilation and pulmonary circulation, considering the effects of positive end-expiratory pressure on both right and left heart function; Stabilization, with cautious fluid administration and prompt fluid removal whenever judged safe and valuable. Notably, the CHEOPS bundle represents experts' opinion and are not targeted at the initial resuscitation phase but rather for the optimization and subsequent period of critical illness.
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Affiliation(s)
- Filippo Sanfilippo
- Department of Anaesthesia and Intensive Care, A.O.U. Policlinico-San Marco, Catania, Italy; Department of General Surgery and Medico-Surgical Specialties, School of Anaesthesia and Intensive Care, University of Catania, Catania, Italy.
| | - Antonio Messina
- Department of Anesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center IRCCS, 20089, Rozzano, Milan, Italy.
| | - Sabino Scolletta
- Anesthesia and Intensive Care Unit, University Hospital of Siena, University of Siena, Siena, Italy.
| | - Elena Bignami
- Anesthesiology, Critical Care and Pain Medicine Division, Department of Medicine and Surgery, University of Parma, Parma, Italy.
| | - Andrea Morelli
- Department Clinical Internal, Anesthesiological and Cardiovascular Sciences, University of Rome, "La Sapienza", Policlinico Umberto Primo, Roma, Italy.
| | - Maurizio Cecconi
- Department of Anesthesia and Intensive Care Medicine, Humanitas Clinical and Research Center IRCCS, 20089, Rozzano, Milan, Italy.
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Faculty of Medicine, Vita-Salute San Raffaele University, Milan, Italy.
| | - Stefano Romagnoli
- Department of Health Science, Section of Anaesthesia and Intensive Care, University of Florence, Department of Anetshesia and Critical Care, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy.
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7
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Murugan R, Kashani K, Palevsky PM. Precision net ultrafiltration dosing in continuous kidney replacement therapy: a practical approach. Intensive Care Med Exp 2023; 11:83. [PMID: 38015332 PMCID: PMC10684837 DOI: 10.1186/s40635-023-00566-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 11/17/2023] [Indexed: 11/29/2023] Open
Affiliation(s)
- Raghavan Murugan
- The Program for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America.
- The Center for Research, Investigation, and Systems Modeling of Acute Illness (CRISMA), Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America.
| | - Kianoush Kashani
- Division of Nephrology and Hypertension, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, United States of America
| | - Paul M Palevsky
- The Program for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
- Renal and Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, United States of America
- Kidney Medicine Section, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, United States of America
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8
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Ostermann M, Ankawi G, Cantaluppi V, Madarasu R, Dolan K, Husain-Syed F, Kashani K, Mehta R, Prowle J, Reis T, Rimmelé T, Zarbock A, Kellum JA, Ronco C. Nomenclature of Extracorporeal Blood Purification Therapies for Acute Indications: The Nomenclature Standardization Conference. Blood Purif 2023; 53:358-372. [PMID: 38038238 DOI: 10.1159/000533468] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 07/28/2023] [Indexed: 12/02/2023]
Abstract
The development of new extracorporeal blood purification (EBP) techniques has led to increased application in clinical practice but also inconsistencies in nomenclature and misunderstanding. In November 2022, an international consensus conference was held to establish consensus on the terminology of EBP therapies. It was agreed to define EBP therapies as techniques that use an extracorporeal circuit to remove and/or modulate circulating substances to achieve physiological homeostasis, including support of the function of specific organs and/or detoxification. Specific acute EBP techniques include renal replacement therapy, isolated ultrafiltration, hemoadsorption, and plasma therapies, all of which can be applied in isolation and combination. This paper summarizes the proposed nomenclature of EBP therapies and serves as a framework for clinical practice and future research.
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Affiliation(s)
- Marlies Ostermann
- Department of Critical Care and Nephrology, Guy's and St Thomas' Hospital, London, UK
| | - Ghada Ankawi
- Department of Internal Medicine and Nephrology, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Vincenzo Cantaluppi
- Nephrology and Kidney Transplantation Unit, Department of Translational Medicine, University of Piemonte Orientale, "Maggiore della Carità" University Hospital, Novara, Italy
| | - Rajasekara Madarasu
- Department of Nephrology, Star Hospitals, Renown Clinical Services, Hyderabad, India
| | - Kristin Dolan
- Department of Paediatrics, Mercy Children's Hospital Kansas City, Kansas City, Kansas, USA
| | - Faeq Husain-Syed
- Department of Internal Medicine II, University Hospital Giessen and Marburg, Justus-Liebig-University Giessen, Giessen, Germany
| | - Kianoush Kashani
- Division of Nephrology and Hypertension, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Ravindra Mehta
- Department of Medicine, University of California San Diego, La Jolla, California, USA
| | - John Prowle
- Faculty of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Thiago Reis
- Department of Nephrology and Kidney Transplantation, Fenix Group, São Paulo, Brazil
- Laboratory of Molecular Pharmacology, University of Brasília, Brasília, Brazil
- Division of Nephrology, Syrian-Lebanese Hospital, São Paulo, Brazil
| | - Thomas Rimmelé
- Department of Anaesthesiology and Critical Care Medicine, Edouard Herriot Hospital, Hospices Civils de Lyon, Lyon, France
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - John A Kellum
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - 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
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9
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Messmer A, Pietsch U, Siegemund M, Buehler P, Waskowski J, Müller M, Uehlinger DE, Hollinger A, Filipovic M, Berger D, Schefold JC, Pfortmueller CA. Protocolised early de-resuscitation in septic shock (REDUCE): protocol for a randomised controlled multicentre feasibility trial. BMJ Open 2023; 13:e074847. [PMID: 37734896 PMCID: PMC11148668 DOI: 10.1136/bmjopen-2023-074847] [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] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND Fluid overload is associated with excess mortality in septic shock. Current approaches to reduce fluid overload include restrictive administration of fluid or active removal of accumulated fluid. However, evidence on active fluid removal is scarce. The aim of this study is to assess the efficacy and feasibility of an early de-resuscitation protocol in patients with septic shock. METHODS All patients admitted to the intensive care unit (ICU) with a septic shock are screened, and eligible patients will be randomised in a 1:1 ratio to intervention or standard of care. INTERVENTION Fluid management will be performed according to the REDUCE protocol, where resuscitation fluid will be restricted to patients showing signs of poor tissue perfusion. After the lactate has peaked, the patient is deemed stable and assessed for active de-resuscitation (signs of fluid overload). The primary objective of this study is the proportion of patients with a negative cumulative fluid balance at day 3 after ICU. Secondary objectives are cumulative fluid balances throughout the ICU stay, number of patients with fluid overload, feasibility and safety outcomes and patient-centred outcomes. The primary outcome will be assessed by a logistic regression model adjusting for the stratification variables (trial site and chronic renal failure) in the intention-to-treat population. ETHICS AND DISSEMINATION The study was approved by the respective ethical committees (No 2020-02197). The results of the REDUCE trial will be published in an international peer-reviewed medical journal regardless of the results. TRIAL REGISTRATION NUMBER ClinicalTrials.gov, NCT04931485.
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Affiliation(s)
- Anna Messmer
- Intensive Care Medicine, Inselspital, Bern University Hospital, Bern University, Bern, Switzerland
| | - Urs Pietsch
- Department of operative Intensive Care Medicine, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - Martin Siegemund
- Intensive Care Unit, Department of Acute Medicine, University Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Philipp Buehler
- Department of Intensive Care Medicine, Cantonal Hospital Winterthu, Winterthur, Switzerland
| | - Jan Waskowski
- Intensive Care Medicine, Inselspital, Bern University Hospital, Bern University, Bern, Switzerland
| | - Martin Müller
- Department of Emergency Medicine, Inselspital, Bern University Hospital, Bern University, Bern, Switzerland
| | - Dominik E Uehlinger
- Department of Nephrology and Hypertension, Inselspital, Bern University Hospital, Bern University, Bern, Switzerland
| | - Alexa Hollinger
- Intensive Care Unit, Department of Acute Medicine, University Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - Miodrag Filipovic
- Department of operative Intensive Care Medicine, Cantonal Hospital St. Gallen, St. Gallen, Switzerland
| | - David Berger
- Intensive Care Medicine, Inselspital, Bern University Hospital, Bern University, Bern, Switzerland
| | - Joerg C Schefold
- Intensive Care Medicine, Inselspital, Bern University Hospital, Bern University, Bern, Switzerland
| | - Carmen A Pfortmueller
- Intensive Care Medicine, Inselspital, Bern University Hospital, Bern University, Bern, Switzerland
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10
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Murugan R, Chang CCH, Raza M, Nikravangolsefid N, Huang DT, Palevsky PM, Kashani K. Restrictive versus Liberal Rate of Extracorporeal Volume Removal Evaluation in Acute Kidney Injury (RELIEVE-AKI): a pilot clinical trial protocol. BMJ Open 2023; 13:e075960. [PMID: 37419639 PMCID: PMC10335418 DOI: 10.1136/bmjopen-2023-075960] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 06/21/2023] [Indexed: 07/09/2023] Open
Abstract
INTRODUCTION Observational studies have linked slower and faster net ultrafiltration (UFNET) rates during kidney replacement therapy (KRT) with mortality in critically ill patients with acute kidney injury (AKI) and fluid overload. To inform the design of a larger randomised trial of patient-centered outcomes, we conduct a feasibility study to examine restrictive and liberal approaches to UFNET during continuous KRT (CKRT). METHODS AND ANALYSIS This study is an investigator-initiated, unblinded, 2-arm, comparative-effectiveness, stepped-wedged, cluster randomised trial among 112 critically ill patients with AKI treated with CKRT in 10 intensive care units (ICUs) across 2 hospital systems. In the first 6 months, all ICUs started with a liberal UFNET rate strategy. Thereafter, one ICU is randomised to the restrictive UFNET rate strategy every 2 months. In the liberal group, the UFNET rate is maintained between 2.0 and 5.0 mL/kg/hour; in the restrictive group, the UFNET rate is maintained between 0.5 and 1.5 mL/kg/hour. The three coprimary feasibility outcomes are (1) between-group separation in mean delivered UFNET rates; (2) protocol adherence; and (3) patient recruitment rate. Secondary outcomes include daily and cumulative fluid balance, KRT and mechanical ventilation duration, organ failure-free days, ICU and hospital length of stay, hospital mortality and KRT dependence at hospital discharge. Safety endpoints include haemodynamics, electrolyte imbalance, CKRT circuit issues, organ dysfunction related to fluid overload, secondary infections and thrombotic and haematological complications. ETHICS AND DISSEMINATION The University of Pittsburgh Human Research Protection Office approved the study, and an independent Data and Safety Monitoring Board monitors the study. A grant from the United States National Institute of Diabetes and Digestive and Kidney Diseases sponsors the study. The trial results will be submitted for publication in peer-reviewed journals and presented at scientific conferences. TRIAL REGISTRATION NUMBER This trial has been prospectively registered with clinicaltrials.gov (NCT05306964). Protocol version identifier and date: 1.5; 13 June 2023.
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Affiliation(s)
- Raghavan Murugan
- Program for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Chung-Chou H Chang
- Biostatistics and Data Management Core, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Maham Raza
- Multidisciplinary Acute Care Research Organization, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Nasrin Nikravangolsefid
- Division of Nephrology and Hypertension, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, New York, USA
| | - David T Huang
- Multidisciplinary Acute Care Research Organization, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Paul M Palevsky
- Renal and Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
- Kidney Medicine Section, VA Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
| | - Kianoush Kashani
- Division of Nephrology and Hypertension, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, New York, USA
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11
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Messmer AS, Dill T, Müller M, Pfortmueller CA. Active fluid de-resuscitation in critically ill patients with septic shock: A systematic review and meta-analysis. Eur J Intern Med 2023; 109:89-96. [PMID: 36635127 DOI: 10.1016/j.ejim.2023.01.009] [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] [Received: 05/18/2022] [Revised: 01/01/2023] [Accepted: 01/05/2023] [Indexed: 01/12/2023]
Abstract
PURPOSE To evaluate the impact of active fluid de-resuscitation on mortality in critically ill patients with septic shock. METHODS A systematic search was performed on PubMed, EmBase, and the Cochrane Library databases. Trials investigating active fluid de-resuscitation and reporting data on mortality in patients with septic shock were eligible. The primary objective was the impact of active de-resuscitation in patients with septic shock on short-term mortality. Secondary outcomes were whether de-resuscitation lead to a fluid separation, and the impact of de-resuscitation on patient-centred outcomes. RESULTS Thirteen trials (8,030 patients) were included in the systematic review, whereof 5 randomised-controlled trials (RCTs) were included in the meta-analysis. None of the RCTs showed a reduction in mortality with active de-resuscitation measures (relative risk (RR) 1.12 [95%-CI 0.84 - 1.48]). Fluid separation was achieved by two RCTs. Evidence from non-randomised trials suggests a mortality benefit with de-resuscitation strategies and indicates a trend towards a more negative fluid balance. Patient-centred outcomes were not influenced in the RCTs, and only one non-randomised trial revealed an impact on the duration of mechanical ventilation and renal replacement requirement (RRT). CONCLUSION We found no evidence for superiority of active fluid de-resuscitation compared to usual care regarding mortality, fluid balance or patient-centred outcomes in patients with septic shock. Current evidence is limited by the lack of high-quality RCTs in patients with septic shock, the small sample sizes and the heterogeneity of the applied de-resuscitation techniques. In addition, validity of the majority of RCTs is compromised by their inability to achieve fluid separation.
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Affiliation(s)
- Anna S Messmer
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Tatjana Dill
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Martin Müller
- Department of Emergency Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Carmen A Pfortmueller
- Department of Intensive Care Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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12
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Affiliation(s)
- Mitra K Nadim
- From the Division of Nephrology and Hypertension, Keck School of Medicine, University of Southern California, Los Angeles (M.K.N.); and the Section of Digestive Diseases, Yale University School of Medicine, New Haven, and the Section of Digestive Diseases, Veterans Affairs Connecticut Healthcare System, West Haven - both in Connecticut (G.G.-T.)
| | - Guadalupe Garcia-Tsao
- From the Division of Nephrology and Hypertension, Keck School of Medicine, University of Southern California, Los Angeles (M.K.N.); and the Section of Digestive Diseases, Yale University School of Medicine, New Haven, and the Section of Digestive Diseases, Veterans Affairs Connecticut Healthcare System, West Haven - both in Connecticut (G.G.-T.)
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13
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Reis T, Ronco F, Ostermann M. Diuretics and Ultrafiltration in Heart Failure. Cardiorenal Med 2023; 13:56-65. [PMID: 36630939 DOI: 10.1159/000529068] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Accepted: 12/15/2022] [Indexed: 01/12/2023] Open
Abstract
Fluid overload is a risk factor for increased morbidity and mortality, especially in patients with heart disease. The treatment options are limited to diuretics and mechanical fluid removal using ultrafiltration or renal replacement therapy. This paper provides an overview of the challenges of managing fluid overload, outlines the risks and benefits of different pharmacological options and extracorporeal techniques, and provides guidance for clinical practice.
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Affiliation(s)
- Thiago Reis
- Division of Kidney Transplantation, D'Or Institute for Research and Education (IDOR), DF Star Hospital, Brasília, Brazil
- Laboratory of Molecular Pharmacology, Faculty of Health Sciences, University of Brasília, Asa Norte, Campus Darcy Ribeiro, Brasília, Brazil
| | - Federico Ronco
- Interventional Cardiology, Ospedale dell'Angelo, Mestre, Venezia, Italy
| | - Marlies Ostermann
- Department of Critical Care and Nephrology, King's College London, Guy's and St Thomas' Hospital, London, UK
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14
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Polz M, Bergmoser K, Horn M, Schörghuber M, Lozanović J, Rienmüller T, Baumgartner C. A system theory based digital model for predicting the cumulative fluid balance course in intensive care patients. Front Physiol 2023; 14:1101966. [PMID: 37123264 PMCID: PMC10133509 DOI: 10.3389/fphys.2023.1101966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 04/04/2023] [Indexed: 05/02/2023] Open
Abstract
Background: Surgical interventions can cause severe fluid imbalances in patients undergoing cardiac surgery, affecting length of hospital stay and survival. Therefore, appropriate management of daily fluid goals is a key element of postoperative intensive care in these patients. Because fluid balance is influenced by a complex interplay of patient-, surgery- and intensive care unit (ICU)-specific factors, fluid prediction is difficult and often inaccurate. Methods: A novel system theory based digital model for cumulative fluid balance (CFB) prediction is presented using recorded patient fluid data as the sole parameter source by applying the concept of a transfer function. Using a retrospective dataset of n = 618 cardiac intensive care patients, patient-individual models were created and evaluated. RMSE analyses and error calculations were performed for reasonable combinations of model estimation periods and clinically relevant prediction horizons for CFB. Results: Our models have shown that a clinically relevant time horizon for CFB prediction with the combination of 48 h estimation time and 8-16 h prediction time achieves high accuracy. With an 8-h prediction time, nearly 50% of CFB predictions are within ±0.5 L, and 77% are still within the clinically acceptable range of ±1.0 L. Conclusion: Our study has provided a promising proof of principle and may form the basis for further efforts in the development of computational models for fluid prediction that do not require large datasets for training and validation, as is the case with machine learning or AI-based models. The adaptive transfer function approach allows estimation of CFB course on a dynamically changing patient fluid balance system by simulating the response to the current fluid management regime, providing a useful digital tool for clinicians in daily intensive care.
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Affiliation(s)
- Mathias Polz
- Institute of Health Care Engineering with European Testing Center of Medical Devices, Graz University of Technology, Graz, STM, Austria
| | - Katharina Bergmoser
- Institute of Health Care Engineering with European Testing Center of Medical Devices, Graz University of Technology, Graz, STM, Austria
- CBmed Center for Biomarker Research in Medicine, Graz, STM, Austria
| | - Martin Horn
- Institute of Automation and Control, Graz University of Technology, Graz, STM, Austria
| | - Michael Schörghuber
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, STM, Austria
| | - Jasmina Lozanović
- Institute of Health Care Engineering with European Testing Center of Medical Devices, Graz University of Technology, Graz, STM, Austria
| | - Theresa Rienmüller
- Institute of Health Care Engineering with European Testing Center of Medical Devices, Graz University of Technology, Graz, STM, Austria
| | - Christian Baumgartner
- Institute of Health Care Engineering with European Testing Center of Medical Devices, Graz University of Technology, Graz, STM, Austria
- *Correspondence: Christian Baumgartner,
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15
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Jacquet-Lagrèze M, Ruste M, Fornier W, Jacquemet PL, Schweizer R, Fellahi JL. Refilling and preload dependence failed to predict cardiac index decrease during fluid removal with continuous renal replacement therapy. J Nephrol 2023; 36:187-197. [PMID: 36121642 DOI: 10.1007/s40620-022-01407-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 07/14/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Fluid removal can reduce the burden of fluid overload after initial resuscitation. According to the Frank-Starling model, iatrogenic hypovolemia should induce a decrease in cardiac index. We hypothesized that inadequate refilling detected by haemoconcentration during fluid removal or an increase in cardiac index (CI) during passive leg raising (PLR) could predict CI decrease during mechanical fluid removal with continuous renal replacement therapy (CRRT). METHODS We conducted a single-centre prospective diagnostic accuracy study. The primary objective was to investigate the diagnostic performance of plasma protein concentration variations in detecting a CI decrease ≥ 12% during mechanical fluid removal. Secondary objective was to assess other predictive factors of CI change. The attending physician prescribed a fluid removal challenge consisting of a mechanical fluid removal challenge of 500 mL for one hour. Plasma protein concentration, haemoglobin level, PLR and transpulmonary thermodilution were done before and after the fluid removal challenge. RESULTS We included 69 adult patients between December 2016 and April 2020. Sixteen patients had a significant CI decrease (23% [95% CI 14-35]). Haemoconcentration and PLR before fluid removal challenge or CI trending failed to predict CI decrease. CONCLUSION Haemoconcentration variables, preload dependence status and CI trending failed to predict CI decrease during fluid removal challenge.
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Affiliation(s)
- Matthias Jacquet-Lagrèze
- Department of Anesthesiology and Intensive Care, University Hospital Louis Pradel, Hospices Civils de Lyon, 59 Boulevard Pinel, 69500, Lyon, France. .,Faculty of Medicine Lyon-Est, University Claude Bernard Lyon 1, 69373, Lyon, France. .,Laboratoire CarMeN, Inserm UMR 1060, University Claude Bernard Lyon 1, Lyon, France.
| | - Martin Ruste
- Department of Anesthesiology and Intensive Care, University Hospital Louis Pradel, Hospices Civils de Lyon, 59 Boulevard Pinel, 69500, Lyon, France.,Faculty of Medicine Lyon-Est, University Claude Bernard Lyon 1, 69373, Lyon, France
| | - William Fornier
- Department of Anesthesiology and Intensive Care, University Hospital Louis Pradel, Hospices Civils de Lyon, 59 Boulevard Pinel, 69500, Lyon, France
| | - Pierre-Louis Jacquemet
- Department of Anesthesiology and Intensive Care, University Hospital Louis Pradel, Hospices Civils de Lyon, 59 Boulevard Pinel, 69500, Lyon, France
| | - Remi Schweizer
- Department of Anesthesiology and Intensive Care, University Hospital Louis Pradel, Hospices Civils de Lyon, 59 Boulevard Pinel, 69500, Lyon, France
| | - Jean-Luc Fellahi
- Department of Anesthesiology and Intensive Care, University Hospital Louis Pradel, Hospices Civils de Lyon, 59 Boulevard Pinel, 69500, Lyon, France.,Faculty of Medicine Lyon-Est, University Claude Bernard Lyon 1, 69373, Lyon, France.,Laboratoire CarMeN, Inserm UMR 1060, University Claude Bernard Lyon 1, Lyon, France
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16
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Milne B, Gilbey T, Kunst G. Perioperative Management of the Patient at High-Risk for Cardiac Surgery-Associated Acute Kidney Injury. J Cardiothorac Vasc Anesth 2022; 36:4460-4482. [PMID: 36241503 DOI: 10.1053/j.jvca.2022.08.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 07/27/2022] [Accepted: 08/22/2022] [Indexed: 11/11/2022]
Abstract
Acute kidney injury (AKI) is one of the most common major complications of cardiac surgery, and is associated with increased morbidity and mortality. Cardiac surgery-associated AKI has a complex, multifactorial etiology, including numerous factors such as primary cardiac dysfunction, hemodynamic derangements of cardiac surgery and cardiopulmonary bypass, and the possibility of a large volume of blood transfusion. There are no truly effective pharmacologic therapies for the management of AKI, and, therefore, anesthesiologists, intensivists, and cardiac surgeons must remain vigilant and attempt to minimize the risk of developing renal dysfunction. This narrative review describes the current state of the scientific literature concerning the specific aspects of cardiac surgery-associated AKI, and presents it in a chronological fashion to aid the perioperative clinician in their approach to this high-risk patient group. The evidence was considered for risk prediction models, preoperative optimization, and the intraoperative and postoperative management of cardiac surgery patients to improve renal outcomes.
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Affiliation(s)
- Benjamin Milne
- Department of Anaesthetics and Pain Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom; National Institute of Health Research Academic Clinical Fellow, King's College London, London, United Kingdom
| | - Tom Gilbey
- Department of Anaesthetics and Pain Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom; National Institute of Health Research Academic Clinical Fellow, King's College London, London, United Kingdom
| | - Gudrun Kunst
- Department of Anaesthetics and Pain Medicine, King's College Hospital NHS Foundation Trust, London, United Kingdom; School of Cardiovascular Medicine and Metabolic Medicine and Sciences, King's College London, British Heart Foundation Centre of Excellence, Faculty of Life Sciences and Medicine, London, United Kingdom.
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17
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da Hora Passos R, Caldas JR, Ramos JGR, Dos Santos Galvão de Melo EB, Silveira MAD, Batista PBP. Prediction of hemodynamic tolerance of intermittent hemodialysis in critically ill patients: a cohort study. Sci Rep 2021; 11:23610. [PMID: 34880359 PMCID: PMC8655072 DOI: 10.1038/s41598-021-03110-4] [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: 05/19/2021] [Accepted: 11/29/2021] [Indexed: 11/24/2022] Open
Abstract
The evaluation and management of fluid balance are key challenges when caring for critically ill patients requiring renal replacement therapy. The aim of this study was to assess the ability of clinical judgment and other variables to predict the occurrence of hypotension during intermittent hemodialysis (IHD) in critically ill patients. This was a prospective, observational, single-center study involving critically ill patients undergoing IHD. The clinical judgment of hypervolemia was determined by the managing nephrologists and critical care physicians in charge of the patients on the basis of the clinical data used to calculate the ultrafiltration volume and rate for each dialysis treatment. Seventy-nine (31.9%) patients presented with hypotension during IHD. Patients were perceived as being hypervolemic in 109 (43.9%) of the cases by nephrologists and in 107 (43.1%) by intensivists. The agreement between nephrologists and intensivists was weak (kappa = 0.561). Receiver operating characteristic curve analysis yielded an AUC of 0.81 (95% CI 0.75 to 0.84; P < 0.0001), and a cutoff value of 70 mm for the vascular pedicle width (VPW) had the highest accuracy for the prediction of the absence of hypotension. The clinical judgment of hypervolemia did not predict hypotension during IHD. The high predictive ability of the VPW may assist clinicians with critical thinking.
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Affiliation(s)
- Rogerio da Hora Passos
- Critical Care Unit Hospital São Rafael, Salvador, Brazil. .,Instituto de Pesquisa e Ensino D'OR (IDOR), Salvador, Brazil.
| | - Juliana Ribeiro Caldas
- Critical Care Unit Hospital São Rafael, Salvador, Brazil.,Instituto de Pesquisa e Ensino D'OR (IDOR), Salvador, Brazil.,Universidade de Salvador- UNIFACS, Salvador, Brazil.,Escola Bahiana de Medicina e Saúde Pública- EBMSP, Salvador, Brazil
| | - Joao Gabriel Rosa Ramos
- Critical Care Unit Hospital São Rafael, Salvador, Brazil.,Instituto de Pesquisa e Ensino D'OR (IDOR), Salvador, Brazil
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18
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Wu B, Shen Y, Peng Y, Xing C, Mao H. The Association of an Early Net Ultrafiltration Rate and 28-Day Mortality in Patients Receiving Continuous Kidney Replacement Therapy. Front Med (Lausanne) 2021; 8:766557. [PMID: 34926509 PMCID: PMC8674682 DOI: 10.3389/fmed.2021.766557] [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: 08/29/2021] [Accepted: 11/04/2021] [Indexed: 11/13/2022] Open
Abstract
Background: An early net ultrafiltration (NUF) rate may be associated with prognosis in patients receiving continuous kidney replacement therapy (CKRT). In this study, we tested whether high or low early NUF rates in patients treated with CKRT were associated with increased mortality. Methods: We conducted a retrospective, observational study among all patients in the Medical Information Mart for Intensive Care IV database who received CKRT for more than 24 h within 14 days after intensive care unit admission. We defined the early (initial 48 h) NUF rate as the amount of fluid removal per hour adjusted by the patients' weight and took it as a classified variable (low rate: <1.6, moderate rate: 1.6-3.1 and high rate: > 3.1 ml/kg/h). The association between 28-day mortality and the NUF rate was analyzed by logistic regression and mediation analyses. Results: A total of 911 patients were included in our study. The median NUF rate was 2.71 (interquartile range 1.90-3.86) ml/kg/h and the 28-day mortality was 40.1%. Compared with the moderate NUF rate, the low NUF rate (adjusted odds ratio 1.56, 95% CI 1.04-2.35, p = 0.032) and high NUF rate (adjusted odds ratio 1.43, 95% CI 1.02-2.01, p = 0.040) were associated with higher 28-day mortality. The putative effect of high or low NUF rates on 28 day mortality was not direct [adjusted average direct effects (ADE) for a low NUF rate = 0.92, p = 0.064; adjusted ADE for a high NUF rate = 1.03, p = 0.096], but mediated by effects of the NUF rate on fluid balance during the same period [adjusted average causal mediation effects (ACME) 0.96, p = 0.010 for a low NUF rate; adjusted ACME 0.99, p = 0.042 for a high NUF rate]. Moreover, we found an increase trend in the NUF rate corresponding to the lowest mortality when fluid input increased. Conclusion: Compared with NUF rates between 1.6-3.1 ml/kg/h in the first 48 h of CKRT, NUF rates > 3.1 and <1.6 ml/kg/h were associated with higher mortality.
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Affiliation(s)
| | | | | | | | - Huijuan Mao
- Department of Nephrology, Jiangsu Province Hospital/The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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19
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Schley G, Willam C. ["Intravascular space contracted-tissue space expanded": interstitial edema and fluid management in intensive care medicine]. Med Klin Intensivmed Notfmed 2021; 116:665-671. [PMID: 34605939 DOI: 10.1007/s00063-021-00872-7] [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: 07/12/2021] [Accepted: 07/12/2021] [Indexed: 10/20/2022]
Abstract
In the second phase of shock therapy, we regularly find fluid overload with edema in our patients, which not only involves the skin and interstitial tissue but can also impair kidney, liver and pulmonary function. Revision of the Starling principle and new insights into physiology of the endothelial glycocalyx have important implications for fluid therapy in intensive care medicine. Determination of fluid overload and an appropriate therapy with either diuretics or ultrafiltration are the focus of "late goal-directed fluid removal" management.
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Affiliation(s)
- Gunnar Schley
- Medizinische Klinik 4, Universitätsklinikum Erlangen, Ulmenweg 18, 91054, Erlangen, Deutschland.
| | - Carsten Willam
- Medizinische Klinik 4, Universitätsklinikum Erlangen, Ulmenweg 18, 91054, Erlangen, Deutschland.
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20
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Chen H, Murugan R. Survey of U.S. Critical Care Practitioners on Net Ultrafiltration Prescription and Practice among Critically Ill Patients Receiving Kidney Replacement Therapy. J Crit Care Med (Targu Mures) 2021; 7:272-282. [PMID: 34934817 PMCID: PMC8647664 DOI: 10.2478/jccm-2021-0034] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 08/24/2021] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION The current prescription and practice of net ultrafiltration among critically ill patients receiving kidney replacement therapy in the U.S. are unclear. AIM OF THE STUDY To assess the attitudes of U.S. critical care practitioners on net ultrafiltration (UFNET) prescription and practice among critically ill patients with acute kidney injury treated with kidney replacement therapy. METHODS A secondary analysis was conducted of a multinational survey of intensivists, nephrologists, advanced practice providers, and ICU and dialysis nurses practising in the U.S. RESULTS Of 1,569 respondents, 465 (29.6%) practitioners were from the U.S. Mainly were nurses and advanced practice providers (58%) and intensivists (38.2%). The median duration of practice was 8.7 (IQR, 4.2-19.4) years. Practitioners reported using continuous kidney replacement therapy (as the first modality in 60% (IQR 20%-90%) for UFNET. It was found that there was a significant variation in assessment of prescribed-to-delivered dose of UFNET, use of continuous kidney replacement therapy for UFNET, methods used to achieve UFNET, and assessment of net fluid balance during continuous kidney replacement therapy. There was also variation in interventions performed for managing hemodynamic instability, perceived barriers to UFNET, belief that early and protocol-based fluid removal is beneficial, and willingness to enroll patients in a clinical trial. CONCLUSIONS There was considerable practice variation in UFNET among critical care practitioners in the U.S., reflecting the need to generate evidence-based practice guidelines for UFNET.
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Affiliation(s)
- Huiwen Chen
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Renal and Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Raghavan Murugan
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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21
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Wang J, Wu Z, Wen Q, Wang X. Effects of CRRT on renal function and toxin clearance in patients with sepsis: a case-control study. J Int Med Res 2021; 49:3000605211042981. [PMID: 34551615 PMCID: PMC8485274 DOI: 10.1177/03000605211042981] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 08/10/2021] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE To explore the effects of continuous renal replacement therapy (CRRT) on renal function and toxin clearance in patients with sepsis and concurrent acute kidney injury (AKI). METHOD A retrospective analysis was performed using the medical records of 115 patients with sepsis and AKI. Among them, 60 patients received routine treatment (group A) and 55 patients received CRRT plus routine treatment (group B). RESULT After treatment, the clearance rates of serum creatinine, lactic acid, and urea nitrogen were significantly lower in group A than in group B. The decrease in high-sensitivity C-reactive protein and tumor necrosis factor-α levels after treatment was significantly higher in group B than in group A. For the Acute Physiology Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA) scores from the two groups, the scores were significantly lower in group B than in group A. The mortality rate within 28 days was significantly higher in group A than in group B. CONCLUSION CRRT can effectively improve the condition of patients with sepsis and AKI, promote elimination of toxins (serum creatinine, lactic acid, and urea nitrogen) from the body, and reduce the mortality rate.
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Affiliation(s)
- Jinzhong Wang
- Department of Critical Care Medicine, the Second Affiliated Hospital of Hainan Medical University, Haikou City, Hainan province, China
| | - Zhongyong Wu
- Department of Critical Care Medicine, the Second Affiliated Hospital of Hainan Medical University, Haikou City, Hainan province, China
| | - Quan Wen
- Department of Critical Care Medicine, the Second Affiliated Hospital of Hainan Medical University, Haikou City, Hainan province, China
| | - Xiaozhi Wang
- Department of Critical Care Medicine, the Second Affiliated Hospital of Hainan Medical University, Haikou City, Hainan province, China
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22
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Murugan R, Kerti SJ, Chang CCH, Gallagher M, Neto AS, Clermont G, Ronco C, Palevsky PM, Kellum JA, Bellomo R. Association between Net Ultrafiltration Rate and Renal Recovery among Critically Ill Adults with Acute Kidney Injury Receiving Continuous Renal Replacement Therapy: An Observational Cohort Study. Blood Purif 2021; 51:397-409. [PMID: 34289471 PMCID: PMC8776893 DOI: 10.1159/000517281] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 05/18/2021] [Indexed: 01/03/2023]
Abstract
INTRODUCTION Higher net ultrafiltration (UFNET) rates are associated with mortality among critically ill patients with acute kidney injury (AKI) and treated with continuous renal replacement therapy (CRRT). OBJECTIVE The aim of the study was to discover whether UFNET rates are associated with renal recovery and independence from renal replacement therapy (RRT). METHODS Retrospective cohort study using data from the Randomized Evaluation of Normal versus Augmented Level of Renal Replacement Therapy trial that enrolled 1,433 critically ill patients with AKI and treated with CRRT between December 2005 and November 2008 across 35 intensive care units in Australia and New Zealand. We examined the association between UFNET rate and time to independence from RRT by day 90 using competing risk regression after accounting for mortality. The UFNET rate was defined as the volume of fluid removed per hour adjusted for patient body weight. RESULTS AND CONCLUSIONS Median age was 67.3 (interquartile range [IQR], 57-76.3) years, 64.4% were male, median Acute Physiology and Chronic Health Evaluation-III score was 100 (IQR, 84-118), and 634 (44.2%) died by day 90. Kidney recovery occurred in 755 patients (52.7%). Using tertiles of UFNET rates, 3 groups were defined: high, >1.75; middle, 1.01-1.75; and low, <1.01 mL/kg/h. Proportion of patients alive and independent of RRT among the groups were 47.8 versus 57.2 versus 53.0%; p = 0.01. Using competing risk regression, higher UFNET rate tertile compared with middle (cause-specific hazard ratio [csHR], 0.79, 95% CI, 0.66-0.95; subdistribution hazard ratio [sHR], 0.80, 95% CI, 0.67-0.97) and lower (csHR, 0.69, 95% CI, 0.56-0.85; sHR, 0.78, 95% CI 0.64-0.95) tertiles were associated with a longer time to independence from RRT. Every 1.0 mL/kg/h increase in rate was associated with a lower probability of kidney recovery (csHR, 0.81, 95% CI, 0.74-0.89; and sHR, 0.87, 95% CI, 0.80-0.95). Using the joint model, longitudinal increases in UFNET rates were also associated with a lower renal recovery (β = -0.29, p < 0.001). UFNET rates >1.75 mL/kg/h compared with rates 1.01-1.75 and <1.01 mL/kg/h were associated with a longer duration of dependence on RRT. Randomized clinical trials are required to confirm this UFNET rate-outcome relationship.
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Affiliation(s)
- Raghavan Murugan
- The Center for Critical Care Nephrology, CRISMA, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, 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, PA, USA
| | - Samantha J. Kerti
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Chung-Chou H. Chang
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Martin Gallagher
- The George Institute for Global Health and University of Sydney, Sydney, Australia
| | - Ary Serpa Neto
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
- Department of Intensive Care, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Gilles Clermont
- The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Claudio Ronco
- Department of Medicine, University of Padova, International Renal Research Institute of Vicenza and Department of Clinical Nephrology, San Bortolo Hospital, Vicenza, Italy
| | - Paul M. Palevsky
- The Center for Critical Care Nephrology, CRISMA, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Renal Section, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - John A. Kellum
- The Center for Critical Care Nephrology, CRISMA, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, 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, PA, USA
| | - Rinaldo Bellomo
- Department of Intensive Care Medicine, The University of Melbourne, Austin Hospital, Victoria, Australia
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23
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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: 6] [Impact Index Per Article: 1.5] [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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24
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Murugan R, Bellomo R, Palevsky PM, Kellum JA. Ultrafiltration in critically ill patients treated with kidney replacement therapy. Nat Rev Nephrol 2021; 17:262-276. [PMID: 33177700 PMCID: PMC9826716 DOI: 10.1038/s41581-020-00358-3] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/21/2020] [Indexed: 01/30/2023]
Abstract
Management of fluid overload is one of the most challenging problems in the care of critically ill patients with oliguric acute kidney injury. Various clinical practice guidelines support fluid removal using ultrafiltration during kidney replacement therapy. However, ultrafiltration is associated with considerable risks. Emerging evidence from observational studies suggests that both slow and fast rates of net fluid removal (that is, net ultrafiltration (UFNET)) 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. Experimental studies in patients with kidney failure who were treated with intermittent haemodialysis suggest that fast UFNET rates are also associated with ischaemic injury to the heart, brain, kidney and gut. The UFNET rate should be prescribed based on patient body weight in millilitres per kilogramme per hour with close monitoring of patient haemodynamics and fluid balance. Dialysate cooling and sodium modelling may prevent haemodynamic instability and facilitate large volumes of fluid removal in patients with kidney failure who are treated with intermittent haemodialysis, but the effects of this strategy on organ injury are less well studied in critically ill patients treated with continuous kidney replacement therapy. Randomized trials are required to examine whether moderate UFNET rates are associated with a reduced risk of haemodynamic instability, organ injury and improved outcomes in critically ill patients.
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Affiliation(s)
- Raghavan Murugan
- The Center for Critical Care Nephrology, CRISMA, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, 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, PA, USA.
| | - Rinaldo Bellomo
- Department of Intensive Care Medicine, The University of Melbourne, Austin Hospital, Melbourne, Victoria, Australia
| | - Paul M Palevsky
- The Center for Critical Care Nephrology, CRISMA, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - John A Kellum
- The Center for Critical Care Nephrology, CRISMA, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, 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, PA, USA
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25
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Abstract
Emerging evidence from observational studies suggests that both slower and faster net ultrafiltration rates during kidney replacement therapy are associated with increased mortality in critically ill patients with acute kidney injury and fluid overload. Faster rates are associated with ischemic organ injury. The net ultrafiltration rate should be prescribed based on patient body weight in milliliters per kilogram per hour, with close monitoring of patient hemodynamics and fluid balance. Randomized trials are required to examine whether moderate net ultrafiltration rates compared with slower and faster rates are associated with reduced risk of hemodynamic instability, organ injury, and improved outcomes.
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Affiliation(s)
- Vikram Balakumar
- Department of Critical Care Medicine, Mercy Hospitals, Springfield, MO, USA; Department of Critical Care Medicine, Center for Critical Care Nephrology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA. https://twitter.com/vikrambalakumar
| | - Raghavan Murugan
- Department of Critical Care Medicine, Center for Critical Care Nephrology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Department of Critical Care Medicine, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh School of Medicine, University of Pittsburgh, 3347 Forbes Avenue, Suite 220, Room 206, Pittsburgh, PA 15261, USA.
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26
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Prowle J, Mehta R. Fluid balance management during continuous renal replacement therapy. Semin Dial 2021; 34:440-448. [PMID: 33755249 DOI: 10.1111/sdi.12964] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 02/16/2021] [Accepted: 02/16/2021] [Indexed: 11/30/2022]
Abstract
In critically ill patients, particularly in the setting of shock and sepsis volume management frequently results in a fluid overloaded state, requiring diuresis or intervention with renal replacement therapy. Achieving appropriate volume management requires knowledge of the underlying cardiovascular pathophysiology and careful evaluation of intravascular and extravascular volume status. In the presence of a failing kidney, fluid removal is often a challenge. Continuous renal replacement therapy (CRRT) techniques offer a significant advantage over intermittent dialysis for fluid control, however, any form of RRT in the critically ill patient requires careful attention to prescription and monitoring to avoid complications. In order to utilize these therapies for their maximum potential it is necessary to understand which factors influence fluid balance and have an understanding of the principles and kinetics of fluid removal with extra-corporeal techniques.
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Affiliation(s)
- John Prowle
- William Harvey Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.,Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, London, UK.,Department of Renal and Transplant Medicine, The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Ravindra Mehta
- Division of Nephrology, Department of Medicine, University of California, San Diego, CA, USA
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27
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Abstract
Development of acute kidney injury in patients with chronic liver disease is common and portends a poor prognosis. Diagnosis remains challenging, as traditional markers, such as serum creatinine, are not reliable. Recent development of novel biomarkers may assist with this. Pathophysiology of this condition is multifactorial, relating to physiologic changes associated with portal hypertension, kidney factors, and systemic inflammatory response. Mainstay of treatment remains use of vasoconstrictors along with albumin. Recent guidelines streamline the selection of patients that will require simultaneous liver and kidney transplantation. Posttransplant kidney injury is common relating to multiple factors.
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Affiliation(s)
- Saro Khemichian
- Division of Gastroenterology/Liver, Keck School of Medicine, University of Southern California, 1510 San Pablo Street, Los Angeles, CA 90033, USA
| | - Claire Francoz
- Hepatology and Liver Intensive Care, Hospital Beaujon, 100 Boulevard Du General Leclerc, Clichy 92110, France
| | - Francois Durand
- Hepatology and Liver Intensive Care, Hospital Beaujon, University of Paris, 100 Boulevard Du General Leclerc, Clichy 92110, France
| | - Constantine J Karvellas
- Division of Gastroenterology (Liver Unit), Department of Critical Care Medicine, University of Alberta, 1-40 Zeidler Ledcor Building, Edmonton, Alberta T6G 2X8, Canada
| | - Mitra K Nadim
- Division of Nephrology and Hypertension, Keck School of Medicine, University of Southern California, 1520 San Pablo Street, Suite 4300, Los Angeles, CA 90033, USA.
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28
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Lumlertgul N, Murugan R, Seylanova N, McCready P, Ostermann M. Net ultrafiltration prescription survey in Europe. BMC Nephrol 2020; 21:522. [PMID: 33256635 PMCID: PMC7706211 DOI: 10.1186/s12882-020-02184-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 11/24/2020] [Indexed: 01/05/2023] Open
Abstract
Background Fluid overload is common in patients in the intensive care unit (ICU) and ultrafiltration (UF) is frequently required. There is lack of guidance on optimal UF practice. We aimed to explore patterns of UF practice, barriers to achieving UF targets, and concerns related to UF practice among practitioners working in Europe. Methods This was a sub-study of an international open survey with focus on adult intensivists and nephrologists, advanced practice providers, and ICU and dialysis nurses working in Europe. Results Four hundred eighty-five practitioners (75% intensivists) from 31 countries completed the survey. The most common criteria for UF initiation was persistent oliguria/anuria (45.6%), followed by pulmonary edema (16.7%). Continuous renal replacement therapy was the preferred initial modality (90.0%). The median initial and maximal rate of net ultrafiltration (UFNET) prescription in hemodynamically stable patients were 149 mL/hr. (IQR 100–200) and 300 mL/hr. (IQR 201–352), respectively, compared to a median UFNET rate of 98 mL/hr. (IQR 51–108) in hemodynamically unstable patients and varied significantly between countries. Two-thirds of nurses and 15.5% of physicians reported assessing fluid balance hourly. When hemodynamic instability occurred, 70.1% of practitioners reported decreasing the rate of fluid removal, followed by starting or increasing the dose of a vasopressor (51.3%). Most respondents (90.7%) believed in early fluid removal and expressed willingness to participate in a study comparing protocol-based fluid removal versus usual care. Conclusions There was a significant variation in UF practice and perception among practitioners in Europe. Future research should focus on identifying the best strategies of prescribing and managing ultrafiltration in critically ill patients. Supplementary Information The online version contains supplementary material available at 10.1186/s12882-020-02184-y.
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Affiliation(s)
- Nuttha Lumlertgul
- Department of Critical Care, King's College London, Guy's & St Thomas' Hospital, NHS Foundation Trust, London, SE1 7EH, UK.,Division of Nephrology, Department of Internal medicine, King Chulalongkorn Memorial Hospital, Bangkok, Thailand.,Excellence Center in Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand.,Research Unit in Critical Care Nephrology, Chulalongkorn University, Bangkok, Thailand
| | - Raghavan Murugan
- The Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, 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, PA, USA
| | - Nina Seylanova
- Department of Critical Care, King's College London, Guy's & St Thomas' Hospital, NHS Foundation Trust, London, SE1 7EH, UK.,Sechenov Biomedical Science and Technology Park, Sechenov First Moscow State Medical University, Moscow, Russian Federation
| | - Patricia McCready
- Department of Critical Care, King's College London, Guy's & St Thomas' Hospital, NHS Foundation Trust, London, SE1 7EH, UK
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's & St Thomas' Hospital, NHS Foundation Trust, London, SE1 7EH, UK.
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29
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Wiedermann CJ. Phases of fluid management and the roles of human albumin solution in perioperative and critically ill patients. Curr Med Res Opin 2020; 36:1961-1973. [PMID: 33090028 DOI: 10.1080/03007995.2020.1840970] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Positive fluid balance is common among critically ill patients and leads to worse outcomes, particularly in sepsis, acute respiratory distress syndrome, and acute kidney injury. Restrictive fluid infusion and active removal of accumulated fluid are being studied as approaches to prevent and treat fluid overload. Use of human albumin solutions has been investigated in different phases of restrictive fluid resuscitation, and this narrative literature review was undertaken to evaluate hypoalbuminemia and the roles of human serum albumin with respect to hypovolemia and its management. METHODS PubMed/EMBASE search terms were: "resuscitation," "fluids," "fluid therapy," "fluid balance," "plasma volume," "colloids," "crystalloids," "albumin," "hypoalbuminemia," "starch," "saline," "balanced salt solution," "gelatin," "goal-directed therapy" (English-language, pre-January 2020). Additional papers were identified by manual searching of reference lists. RESULTS Restrictive fluid administration, plus early vasopressor use, may reduce fluid balance, but in some cases fluid overload cannot be entirely avoided. Deresuscitation, with fluid actively removed through diuretics or ultrafiltration, reduces duration of mechanical ventilation and intensive care unit stay. Combining hyperoncotic human albumin solution with diuretics increases hemodynamic stability and diuresis. Hyperoncotic albumin corrects hypoalbuminemia and raises colloid osmotic pressure, limiting edema formation and potentially improving endothelial function. Serum levels of albumin relative to C-reactive protein and lactate may predict which patients will benefit most from albumin therapy. CONCLUSIONS Hyperoncotic human albumin solution facilitates restrictive fluid therapy and the effectiveness of deresuscitative measures. Current evidence is mostly from observational studies, and more randomized trials are needed to better establish a personalized approach to fluid management.
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Affiliation(s)
- Christian J Wiedermann
- Institute of Public Health, Medical Decision Making and HTA, University of Health Sciences, Medical Informatics and Technology, Hall (Tyrol), Austria
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30
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Jenks C, Raman L, Dhar A. Review of acute kidney injury and continuous renal replacement therapy in pediatric extracorporeal membrane oxygenation. Indian J Thorac Cardiovasc Surg 2020; 37:254-260. [PMID: 33967449 DOI: 10.1007/s12055-020-01071-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 09/25/2020] [Accepted: 09/29/2020] [Indexed: 10/22/2022] Open
Abstract
Purpose To review the relevant literature of acute kidney injury (AKI) and continuous renal replacement therapy (CRRT) as it relates to pediatric extracorporeal membrane oxygenation (ECMO). Methods Available online relevant literature. Results ECMO is a therapeutic modality utilized to support patients with refractory respiratory and/or cardiac failure. AKI and fluid overload (FO) are frequently observed in this patient population. There are multiple modalities that can be utilized for AKI and FO which include the following: diuretics, in-line hemofiltration, and CRRT. There are multiple considerations when using CRRT with ECMO including access, CRRT flows, hemolysis, anticoagulation, and CRRT termination. Conclusion While each ECMO center has its own set of equipment, experiences, and practices, it is imperative that the international ECMO community continues to work together to provide an evidence-based approach to address the morbidity and mortality associated with AKI and FO.
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Affiliation(s)
- Christopher Jenks
- Blair E Batson Children's Hospital, Department of Pediatrics, Section of Critical Care, University of Mississippi Medical Center, Jackson, MS USA
| | - Lakshmi Raman
- Children's of Dallas, Department of Pediatrics, Section of Critical Care, University of Texas Southwestern Medical Center, Dallas, TX USA.,Children's Health, Dallas, TX USA
| | - Archana Dhar
- Children's of Dallas, Department of Pediatrics, Section of Critical Care, University of Texas Southwestern Medical Center, Dallas, TX USA.,Children's Health, Dallas, TX USA
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31
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Neethling E, Moreno Garijo J, Mangalam TK, Badiwala MV, Billia P, Wasowicz M, Van Rensburg A, Slinger P. Intraoperative and Early Postoperative Management of Heart Transplantation: Anesthetic Implications. J Cardiothorac Vasc Anesth 2020; 34:2189-2206. [DOI: 10.1053/j.jvca.2019.09.037] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Revised: 09/07/2019] [Accepted: 09/24/2019] [Indexed: 12/16/2022]
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Hall A, Crichton S, Dixon A, Skorniakov I, Kellum JA, Ostermann M. Fluid removal associates with better outcomes in critically ill patients receiving continuous renal replacement therapy: a cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:279. [PMID: 32487189 PMCID: PMC7268712 DOI: 10.1186/s13054-020-02986-4] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/04/2019] [Accepted: 05/12/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Fluid overload is associated with morbidity and mortality in patients receiving renal replacement therapy (RRT). We aimed to explore whether fluid overload at initiation of RRT was independently associated with mortality and whether changes in cumulative fluid balance during RRT were associated with outcome. METHODS We retrospectively analysed the data of patients who were admitted to the multidisciplinary adult intensive care unit (ICU) in a tertiary care centre in the UK between 2012 and 2015 and received continuous RRT (CRRT) for acute kidney injury for at least 24 h. We collected baseline demographics, body mass index (BMI), comorbidities, severity of illness, laboratory parameters at CRRT initiation, daily cumulative fluid balance (FB), daily prescribed FB target, fluid bolus and diuretic administration and outcomes. The day of the lowest cumulative FB during CRRT was identified as nadir FB. RESULTS Eight hundred twenty patients were analysed (median age 65 years; 49% female). At CRRT initiation, the median cumulative FB was + 1772 ml; 89 patients (10.9%) had a cumulative FB > 10% body weight (BW). Hospital survivors had a significantly lower cumulative FB at CRRT initiation compared to patients who died (1495 versus 2184 ml; p < 0.001). In the 7 days after CRRT initiation, hospital survivors had a significant decline in cumulative FB (mean decrease 473 ml per day, p < 0.001) whilst there was no significant change in cumulative FB in non-survivors (mean decrease 112 ml per day, p = 0.188). Higher severity of illness at CRRT initiation, shorter duration of CRRT, the number of days without a prescribed FB target and need for higher doses of noradrenaline were independent risk factors for not reaching a FB nadir during CRRT. Multivariable analysis showed that older age, lower BMI, higher severity of illness, need for higher doses of noradrenaline and smaller reductions in cumulative FB during CRRT were independent risk factors for ICU and hospital mortality. Cumulative FB at CRRT initiation was not independently associated with mortality. CONCLUSION In adult patients receiving CRRT, a decrease in cumulative FB was independently associated with lower mortality. Fluid overload and need for vasopressor support at CRRT initiation were not independently associated with mortality after correction for severity of illness.
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Affiliation(s)
- Anna Hall
- Department of Critical Care, Guy's & St Thomas' Hospital, London, UK
| | - Siobhan Crichton
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Alison Dixon
- Department of Critical Care, Guy's & St Thomas' Hospital, London, UK
| | - Ilia Skorniakov
- Department of Nephrology and Dialysis, Sverdlovsk Regional Clinical Hospital 1, Yekaterinburg, Russia
| | - John A Kellum
- Department of Critical Care Medicine, Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Marlies Ostermann
- Department of Critical Care, King's College London, Guy's & St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, UK.
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Fluid Removal With Ultrasound Guided Protocol Improves the Efficacy and Safety of Dehydration in Post-Resuscitated Critically Ill Patients: A Quasi-Experimental, Before and After Study. Shock 2019; 50:401-407. [PMID: 29351128 DOI: 10.1097/shk.0000000000001107] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Fluid overload is associated with increased morbidity and mortality in critically ill patients. However, researches rarely study the precise start or end point of fluid removal and no protocol was developed to control the fluid removal process. We hypothesized that individualized fluid removal with ultrasound-guided protocol could improve the efficacy and safety of fluid removal in post-resuscitated critically ill patients. A quasi-experimental, before and after trial was conducted to identify the benefits of ultrasound-guided fluid removal. Fluid removal was performed either following the doctor's experience in Control group, or abiding the ultrasound guided protocol in Ultrasound group. The study end points were the start time, end time, length of fluid removal, and the complications related to fluid removal. A total of 85 subjects were finally analyzed in this study. The fluid removal was started earlier, completed quicker and ended earlier (21.0 ± 14.6 h vs. 35.1 ± 26.5 h, 49.8 ± 32.6 vs. 93.0 ± 42.8 h, 69.0 ± 32.2 h vs. 126.4 ± 52.5 h, P < 0.05) in Ultrasound group than in Control. The subjects had more daily negative fluid balance and urine output (-990.4 ± 636.1 mL vs. -723.6 ± 549.5 mL, 2425.8 ± 886.7 mL vs. 1560.7 ± 1125.3 mL, P < 0.05) in Ultrasound group. The time of lung B-lines to reduce to zero was shorter and B-line at the end point was less (49.5 ± 36.6 h vs. 75.6 ± 58.8 h, 0[1] vs. 0[0], P < 0.05) in Ultrasound group. The length of intensive care unit stay in shock subgroup had a tendency to shorten (96.1 ± 61.5 h vs. 174.6 ± 132.0 h, P > 0.05) in Ultrasound group. We concluded that fluid removal with individualized ultrasound-guided protocol improves the efficacy and safety of dehydration in critically ill patients.
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34
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Renal Replacement Therapy in Critical Care: When to Start? CURRENT ANESTHESIOLOGY REPORTS 2019. [DOI: 10.1007/s40140-019-00325-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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35
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Ostermann M, Liu K, Kashani K. Fluid Management in Acute Kidney Injury. Chest 2019; 156:594-603. [PMID: 31002784 DOI: 10.1016/j.chest.2019.04.004] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Revised: 03/24/2019] [Accepted: 04/04/2019] [Indexed: 01/02/2023] Open
Abstract
Correction of intravascular hypovolemia is a key component of the prevention and management of acute kidney injury (AKI), but excessive fluid administration is associated with poor outcomes, including the development and progression of AKI. There is growing evidence that fluid administration should be individualized and take into account patient characteristics, nature of the acute illness and trajectories, and risks and benefits of fluids. Existing data support the preferential use of buffered solutions for fluid resuscitation of patients at risk of AKI who do not have hypochloremia. There is a limited role for albumin, and starches should be avoided. Fluids should only be administered until intravascular hypovolemia has been corrected and euvolemia has been achieved using the minimum amount of fluid required to achieve and maintain euvolemia. Oliguria alone should not be viewed as a trigger for fluid administration. If fluid overload occurs, fluid therapy needs to be discontinued, and fluid removal using diuretic agents or extracorporeal therapies should be considered.
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Affiliation(s)
- Marlies Ostermann
- King's College London, Guy's & St Thomas' Hospital, Department of Critical Care, London, England.
| | - Kathleen Liu
- Divisions of Nephrology and Critical Care Medicine, Departments of Medicine and Anesthesia, University of California San Francisco, San Francisco, CA
| | - Kianoush Kashani
- Division of Nephrology and Hypertension, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, NY
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36
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Teixeira JP, Ambruso S, Griffin BR, Faubel S. Pulmonary Consequences of Acute Kidney Injury. Semin Nephrol 2019; 39:3-16. [DOI: 10.1016/j.semnephrol.2018.10.001] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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37
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Continuous renal replacement therapy during extracorporeal membrane oxygenation. Curr Opin Crit Care 2018; 24:493-503. [DOI: 10.1097/mcc.0000000000000559] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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38
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Murugan R, Balakumar V, Kerti SJ, Priyanka P, Chang CCH, Clermont G, Bellomo R, Palevsky PM, Kellum JA. Net ultrafiltration intensity and mortality in critically ill patients with fluid overload. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:223. [PMID: 30244678 PMCID: PMC6151928 DOI: 10.1186/s13054-018-2163-1] [Citation(s) in RCA: 77] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Accepted: 08/16/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Although net ultrafiltration (UFNET) is frequently used for treatment of fluid overload in critically ill patients with acute kidney injury, the optimal intensity of UFNET is unclear. Among critically ill patients with fluid overload receiving renal replacement therapy (RRT), we examined the association between UFNET intensity and risk-adjusted 1-year mortality. METHODS We selected patients with fluid overload ≥ 5% of body weight prior to initiation of RRT from a large academic medical center ICU dataset. UFNET intensity was calculated as the net volume of fluid ultrafiltered per day from initiation of either continuous or intermittent RRT until the end of ICU stay adjusted for patient hospital admission body weight. We stratified UFNET as low (≤ 20 ml/kg/day), moderate (> 20 to ≤ 25 ml/kg/day) or high (> 25 ml/kg/day) intensity. We adjusted for age, sex, body mass index, race, surgery, baseline estimated glomerular filtration rate, oliguria, first RRT modality, pre-RRT fluid balance, duration of RRT, time to RRT initiation from ICU admission, APACHE III score, mechanical ventilation use, suspected sepsis, mean arterial pressure on day 1 of RRT, cumulative fluid balance during RRT and cumulative vasopressor dose during RRT. We fitted logistic regression for 1-year mortality, Gray's survival model and propensity matching to account for indication bias. RESULTS Of 1075 patients, the distribution of high, moderate and low-intensity UFNET groups was 40.4%, 15.2% and 44.2% and 1-year mortality was 59.4% vs 60.2% vs 69.7%, respectively (p = 0.003). Using logistic regression, high-intensity compared with low-intensity UFNET was associated with lower mortality (adjusted odds ratio 0.61, 95% CI 0.41-0.93, p = 0.02). Using Gray's model, high UFNET was associated with decreased mortality up to 39 days after ICU admission (adjusted hazard ratio range 0.50-0.73). After combining low and moderate-intensity UFNET groups (n = 258) and propensity matching with the high-intensity group (n = 258), UFNET intensity > 25 ml/kg/day compared with ≤ 25 ml/kg/day was associated with lower mortality (57% vs 67.8%, p = 0.01). Findings were robust to several sensitivity analyses. CONCLUSIONS Among critically ill patients with ≥ 5% fluid overload and receiving RRT, UFNET intensity > 25 ml/kg/day compared with ≤ 20 ml/kg/day was associated with lower 1-year risk-adjusted mortality. Whether tolerating intensive UFNET is just a marker for recovery or a mediator requires further research.
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Affiliation(s)
- Raghavan Murugan
- Department of Critical Care Medicine, The Center for Critical Care Nephrology, CRISMA, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA. .,Department of Critical Care Medicine, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA. .,Critical Care Medicine, and Clinical & Translational Science, University of Pittsburgh, Suite 220, Room 206, 3347 Forbes Avenue, Pittsburgh, PA, 15261, USA.
| | - Vikram Balakumar
- Department of Critical Care Medicine, The Center for Critical Care Nephrology, CRISMA, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Department of Critical Care Medicine, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Samantha J Kerti
- Department of Critical Care Medicine, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Priyanka Priyanka
- Department of Critical Care Medicine, The Center for Critical Care Nephrology, CRISMA, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Department of Critical Care Medicine, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Chung-Chou H Chang
- Department of Critical Care Medicine, The Center for Critical Care Nephrology, CRISMA, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Department of Critical Care Medicine, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Department of Biostatistics, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA, USA
| | - Gilles Clermont
- Department of Critical Care Medicine, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Rinaldo Bellomo
- Department of Intensive Care Medicine, The University of Melbourne, Austin Hospital, Heidelberg, VIC, Australia
| | - Paul M Palevsky
- Department of Critical Care Medicine, The Center for Critical Care Nephrology, CRISMA, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Renal Section, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - John A Kellum
- Department of Critical Care Medicine, The Center for Critical Care Nephrology, CRISMA, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Department of Critical Care Medicine, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Jaber S, Quintard H, Cinotti R, Asehnoune K, Arnal JM, Guitton C, Paugam-Burtz C, Abback P, Mekontso Dessap A, Lakhal K, Lasocki S, Plantefeve G, Claud B, Pottecher J, Corne P, Ichai C, Hajjej Z, Molinari N, Chanques G, Papazian L, Azoulay E, De Jong A. Risk factors and outcomes for airway failure versus non-airway failure in the intensive care unit: a multicenter observational study of 1514 extubation procedures. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:236. [PMID: 30243304 PMCID: PMC6151191 DOI: 10.1186/s13054-018-2150-6] [Citation(s) in RCA: 92] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 08/07/2018] [Indexed: 12/18/2022]
Abstract
BACKGROUND Patients liberated from invasive mechanical ventilation are at risk of extubation failure, including inability to breathe without a tracheal tube (airway failure) or without mechanical ventilation (non-airway failure). We sought to identify respective risk factors for airway failure and non-airway failure following extubation. METHODS The primary endpoint of this prospective, observational, multicenter study in 26 intensive care units was extubation failure, defined as need for reintubation within 48 h following extubation. A multinomial logistic regression model was used to identify risk factors for airway failure and non-airway failure. RESULTS Between 1 December 2013 and 1 May 2015, 1514 patients undergoing extubation were enrolled. The extubation-failure rate was 10.4% (157/1514), including 70/157 (45%) airway failures, 78/157 (50%) non-airway failures, and 9/157 (5%) mixed airway and non-airway failures. By multivariable analysis, risk factors for extubation failure were either common to airway failure and non-airway failure: intubation for coma (OR 4.979 (2.797-8.864), P < 0.0001 and OR 2.067 (1.217-3.510), P = 0.003, respectively, intubation for acute respiratory failure (OR 3.395 (1.877-6.138), P < 0.0001 and OR 2.067 (1.217-3.510), P = 0.007, respectively, absence of strong cough (OR 1.876 (1.047-3.362), P = 0.03 and OR 3.240 (1.786-5.879), P = 0.0001, respectively, or specific to each specific mechanism: female gender (OR 2.024 (1.187-3.450), P = 0.01), length of ventilation > 8 days (OR 1.956 (1.087-3.518), P = 0.025), copious secretions (OR 4.066 (2.268-7.292), P < 0.0001) were specific to airway failure, whereas non-obese status (OR 2.153 (1.052-4.408), P = 0.036) and sequential organ failure assessment (SOFA) score ≥ 8 (OR 1.848 (1.100-3.105), P = 0.02) were specific to non-airway failure. Both airway failure and non-airway failure were associated with ICU mortality (20% and 22%, respectively, as compared to 6% in patients with extubation success, P < 0.0001). CONCLUSIONS Specific risk factors have been identified, allowing us to distinguish between risk of airway failure and non-airway failure. The two conditions will be managed differently, both for prevention and curative strategies. TRIAL REGISTRATION ClinicalTrials.gov, NCT 02450669 . Registered on 21 May 2015.
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Affiliation(s)
- Samir Jaber
- PhyMedExp, University of Montpellier, Anesthesiology and Intensive Care; Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, Centre Hospitalier Universitaire Montpellier, 34295, Montpellier, cedex 5, France.
| | - Hervé Quintard
- Université Cote d'Azur, CNRS U7275, CHU de Nice, Service réanimation polyvalente et U 7275, IPMC, Nice, France
| | - Raphael Cinotti
- Intensive Care & Anesthesiology Department, University of Nantes, Hotel-Dieu Hospital, Nantes, France
| | - Karim Asehnoune
- Intensive Care & Anesthesiology Department, University of Nantes, Hotel-Dieu Hospital, Nantes, France
| | | | - Christophe Guitton
- Medical Intensive Care Unit, Hôtel-Dieu Teaching Hospital, Nantes, France
| | - Catherine Paugam-Burtz
- Intensive Care & Anesthesiology Department, Univ Paris Diderot, Sorbonne Paris Cité, AP-HP, Hôpital Beaujon, F-75018, Paris, France
| | - Paer Abback
- Intensive Care & Anesthesiology Department, Univ Paris Diderot, Sorbonne Paris Cité, AP-HP, Hôpital Beaujon, F-75018, Paris, France
| | - Armand Mekontso Dessap
- Service de Réanimation Médicale, DHU A-TVB, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, Groupe de Recherche Clinique CARMAS, Faculté de Médecine de Créteil, Université Paris Est Créteil, 94010, Créteil Cedex, France
| | - Karim Lakhal
- Intensive Care & Anesthesiology Department, University of Nantes, Laennec Nord Hospital, Nantes, France
| | - Sigismond Lasocki
- Département Anesthésie Réanimation, CHU Angers, 49933, Angers, Cedex 9, France
| | - Gaetan Plantefeve
- Medical-Surgical Intensive Care Unit, General Hospital Centre, Argenteuil, France
| | - Bernard Claud
- Medical-Surgical Intensive Care Unit, General Hospital Centre, Le Puy-en-Velay, France
| | - Julien Pottecher
- Hôpitaux Universitaires de Strasbourg, Pôle Anesthésie Réanimation Chirurgicale SAMU, Hôpital de Hautepierre, Service d'Anesthésie-Réanimation Chirurgicale, Université de Strasbourg, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Faculté de Médecine, Institut de Physiologie, Equipe d'Accueil EA3072 "Mitochondrie, stress oxydant et protection musculaire", Strasbourg, France
| | - Philippe Corne
- Medical Intensive Care Unit, Montpellier University Hospital, Montpellier, France
| | - Carole Ichai
- Université Cote d'Azur, CNRS U7275, CHU de Nice, Service réanimation polyvalente et U 7275, IPMC, Nice, France
| | - Zied Hajjej
- Anesthesiology and Intensive Care; Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, Centre Hospitalier Universitaire Montpellier, 34295, Montpellier, cedex 5, France
| | - Nicolas Molinari
- IMAG, CNRS, Univ Montpellier, CHU Montpellier, Montpellier, France
| | - Gerald Chanques
- PhyMedExp, University of Montpellier, Anesthesiology and Intensive Care; Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, Centre Hospitalier Universitaire Montpellier, 34295, Montpellier, cedex 5, France
| | - Laurent Papazian
- APHM, URMITE UMR CNRS 7278, Hôpital Nord, Réanimation des Détresses Respiratoires et Infections Sévères, Aix-Marseille Univ, Marseille, France
| | - Elie Azoulay
- Medical Intensive Care Unit, University of Paris-Diderot, Saint Louis Hospital, Paris, France
| | - Audrey De Jong
- PhyMedExp, University of Montpellier, Anesthesiology and Intensive Care; Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, Centre Hospitalier Universitaire Montpellier, 34295, Montpellier, cedex 5, France
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Nadim MK, Forni LG, Bihorac A, Hobson C, Koyner JL, Shaw A, Arnaoutakis GJ, Ding X, Engelman DT, Gasparovic H, Gasparovic V, Herzog CA, Kashani K, Katz N, Liu KD, Mehta RL, Ostermann M, Pannu N, Pickkers P, Price S, Ricci Z, Rich JB, Sajja LR, Weaver FA, Zarbock A, Ronco C, Kellum JA. Cardiac and Vascular Surgery-Associated Acute Kidney Injury: The 20th International Consensus Conference of the ADQI (Acute Disease Quality Initiative) Group. J Am Heart Assoc 2018; 7:JAHA.118.008834. [PMID: 29858368 PMCID: PMC6015369 DOI: 10.1161/jaha.118.008834] [Citation(s) in RCA: 185] [Impact Index Per Article: 26.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Mitra K Nadim
- Division of Nephrology & Hypertension, Department of Medicine, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Lui G Forni
- Department of Clinical & Experimental Medicine, University of Surrey, Guildford, United Kingdom.,Royal Surrey County Hospital NHS Foundation Trust, Guildford, United Kingdom
| | - Azra Bihorac
- Division of Nephrology, Hypertension & Renal Transplantation, Department of Medicine, University of Florida, Gainesville, FL
| | - Charles Hobson
- Division of Surgical Critical Care, Department of Surgery, Malcom Randall VA Medical Center, Gainesville, FL
| | - Jay L Koyner
- Section of Nephrology, Department of Medicine, University of Chicago, IL
| | - Andrew Shaw
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | - George J Arnaoutakis
- Division of Thoracic & Cardiovascular Surgery, Department of Surgery, University of Florida College of Medicine, Gainesville, FL
| | - Xiaoqiang Ding
- Department of Nephrology, Shanghai Institute for Kidney Disease and Dialysis, Shanghai Medical Center for Kidney Disease, Zhongshan Hospital Fudan University, Shanghai, China
| | - Daniel T Engelman
- Division of Cardiac Surgery, Department of Surgery, Baystate Medical Center, University of Massachusetts Medical School, Springfield, MA
| | - Hrvoje Gasparovic
- Department of Cardiac Surgery, University Hospital Rebro, Zagreb, Croatia
| | | | - Charles A Herzog
- Division of Cardiology, Department of Medicine, Hennepin County Medical Center, University of Minnesota, Minneapolis, MN
| | - Kianoush Kashani
- Division of Nephrology & Hypertension, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Nevin Katz
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University, Baltimore, MD
| | - Kathleen D Liu
- Divisions of Nephrology and Critical Care, Departments of Medicine and Anesthesia, University of California, San Francisco, CA
| | - Ravindra L Mehta
- Department of Medicine, UCSD Medical Center, University of California, San Diego, CA
| | - Marlies Ostermann
- King's College London, Guy's & St Thomas' Hospital, London, United Kingdom
| | - Neesh Pannu
- Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
| | - Peter Pickkers
- Department Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Susanna Price
- Adult Intensive Care Unit, Imperial College, Royal Brompton Hospital, London, United Kingdom
| | - Zaccaria Ricci
- Department of Pediatric Cardiac Surgery, Bambino Gesù Children's Hospital, Roma, Italy
| | - Jeffrey B Rich
- Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH
| | - Lokeswara R Sajja
- Division of Cardiothoracic Surgery, STAR Hospitals, Hyderabad, India
| | - Fred A Weaver
- Division of Vascular Surgery, Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Alexander Zarbock
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Claudio Ronco
- Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital International Renal Research Institute of Vicenza, Italy
| | - John A Kellum
- Department of Critical Care Medicine, School of Medicine, University of Pittsburgh, PA
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Wang XT, Wang C, Zhang HM, Liu DW. Clarifications on Continuous Renal Replacement Therapy and Hemodynamics. Chin Med J (Engl) 2018; 130:1244-1248. [PMID: 28485326 PMCID: PMC5443032 DOI: 10.4103/0366-6999.205863] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective: Continuous renal replacement therapy (CRRT) is a continuous process of bedside blood purification which is widely used in the treatment of acute kidney injury (AKI) and for fluid management. However, since AKI and fluid overload are often found to be associated with hemodynamic abnormalities, determining the relationship between CRRT and hemodynamics remains a challenge in the treatment of critically ill patients. The aim of this review was to summarize key points in the relationship between CRRT and hemodynamics and to understand and monitor renal hemodynamics in critically ill patients, especially those with AKI. Data Sources: This review was based on data in articles published in the PubMed databases up to January 30, 2017, with the following keywords: “continuous renal replacement therapy,” “Hemodynamics,” and “Acute kidney injury.” Study Selection: Original articles and critical reviews on CRRT were selected for this review. Results: CRRT might treat AKI by hemodynamic therapy, and it was an important form of hemodynamic therapy. The targets of hemodynamic therapy should be established when using CRRT. Therefore, hemodynamic management and stability were very important during CRRT. Most studies suggested that renal hemodynamics should be clearly identified. Conclusions: CRRT is not only a replacement for organ function, but an important form of hemodynamic therapy. Improved hemodynamic management of critically ill patients can be achieved by establishing specific therapeutic hemodynamic targets and maintaining circulatory stability during CRRT. Over the long term, observation of renal hemodynamics will provide greater opportunities for the progression of CRRT hemodynamic therapy.
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Affiliation(s)
- Xiao-Ting Wang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Cui Wang
- Department of Critical Care Medicine, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou 550001, China
| | - Hong-Min Zhang
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
| | - Da-Wei Liu
- Department of Critical Care Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China
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Abstract
Fluid resuscitation plays a fundamental role in the treatment of septic shock. Administration of inappropriately large quantities of fluid may lead to volume overload, which is increasingly recognized as an independent risk factor for morbidity and mortality in critical illness. In the early treatment of sepsis, timely fluid challenges should be given to optimize organ perfusion, but continuous positive fluid balance is discouraged. In fact, achievement of a negative fluid balance during treatment of sepsis is associated with better outcomes. This review will discuss the relationship between fluid overload and unfavorable outcomes in sepsis, and how fluid overload can be prevented and managed.
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Affiliation(s)
- J R Prowle
- Adult Critical Care Unit and Department of Renal Medicine and Transplantation, The Royal London Hospital, Barts Health National Health Service Trust, London, United Kingdom; and
- Critical Care and Perioperative Medicine Research Group, William Harvey Research Institute, Queen Mary University of London, London, United Kingdom
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Roumelioti ME, Glew RH, Khitan ZJ, Rondon-Berrios H, Argyropoulos CP, Malhotra D, Raj DS, Agaba EI, Rohrscheib M, Murata GH, Shapiro JI, Tzamaloukas AH. Fluid balance concepts in medicine: Principles and practice. World J Nephrol 2018; 7:1-28. [PMID: 29359117 PMCID: PMC5760509 DOI: 10.5527/wjn.v7.i1.1] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Revised: 11/16/2017] [Accepted: 11/27/2017] [Indexed: 02/06/2023] Open
Abstract
The regulation of body fluid balance is a key concern in health and disease and comprises three concepts. The first concept pertains to the relationship between total body water (TBW) and total effective solute and is expressed in terms of the tonicity of the body fluids. Disturbances in tonicity are the main factor responsible for changes in cell volume, which can critically affect brain cell function and survival. Solutes distributed almost exclusively in the extracellular compartment (mainly sodium salts) and in the intracellular compartment (mainly potassium salts) contribute to tonicity, while solutes distributed in TBW have no effect on tonicity. The second body fluid balance concept relates to the regulation and measurement of abnormalities of sodium salt balance and extracellular volume. Estimation of extracellular volume is more complex and error prone than measurement of TBW. A key function of extracellular volume, which is defined as the effective arterial blood volume (EABV), is to ensure adequate perfusion of cells and organs. Other factors, including cardiac output, total and regional capacity of both arteries and veins, Starling forces in the capillaries, and gravity also affect the EABV. Collectively, these factors interact closely with extracellular volume and some of them undergo substantial changes in certain acute and chronic severe illnesses. Their changes result not only in extracellular volume expansion, but in the need for a larger extracellular volume compared with that of healthy individuals. Assessing extracellular volume in severe illness is challenging because the estimates of this volume by commonly used methods are prone to large errors in many illnesses. In addition, the optimal extracellular volume may vary from illness to illness, is only partially based on volume measurements by traditional methods, and has not been determined for each illness. Further research is needed to determine optimal extracellular volume levels in several illnesses. For these reasons, extracellular volume in severe illness merits a separate third concept of body fluid balance.
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Affiliation(s)
- Maria-Eleni Roumelioti
- Division of Nephrology, Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM 87131, United States
| | - Robert H Glew
- Department of Surgery, University of New Mexico School of Medicine, Albuquerque, NM 87131, United States
| | - Zeid J Khitan
- Division of Nephrology, Department of Medicine, Joan Edwards School of Medicine, Marshall University, Huntington, WV 25701, United States
| | - Helbert Rondon-Berrios
- Division of Renal and Electrolyte, Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA 15260, United States
| | - Christos P Argyropoulos
- Division of Nephrology, Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM 87131, United States
| | - Deepak Malhotra
- Division of Nephrology, Department of Medicine, University of Toledo School of Medicine, Toledo, OH 43614-5809, United States
| | - Dominic S Raj
- Division of Renal Disease and Hypertension, Department of Medicine, George Washington University, Washington, DC 20037, United States
| | - Emmanuel I Agaba
- Division of Nephology, Department of Medicine, Jos University Medical Center, Jos, Plateau State 930001, Nigeria
| | - Mark Rohrscheib
- Division of Nephrology, Department of Medicine, University of New Mexico School of Medicine, Albuquerque, NM 87131, United States
| | - Glen H Murata
- Research Service, Raymond G Murphy VA Medical Center and University of New Mexico School of Medicine, Albuquerque, NM 87108, United States
| | | | - Antonios H Tzamaloukas
- Research Service, Raymond G Murphy VA Medical Center and University of New Mexico School of Medicine, Albuquerque, NM 87108, United States
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Ricci Z, Romagnoli S, Ronco C. The 10 false beliefs in adult critical care nephrology. Intensive Care Med 2017; 44:1302-1305. [PMID: 29196792 DOI: 10.1007/s00134-017-5011-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2017] [Accepted: 11/28/2017] [Indexed: 12/25/2022]
Affiliation(s)
- Zaccaria Ricci
- Department of Cardiology and Cardiac Surgery, Pediatric Cardiac Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Piazza Sant'Onofrio, 4, 00165, Rome, Italy.
| | - Stefano Romagnoli
- Department of Anesthesiology and Intensive Care, Azienda Ospedaliero-Universitaria Careggi, Largo Brambilla, 3, 50139, Florence, Italy
| | - Claudio Ronco
- Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Via Rodolfi, 37, 36100, Vicenza, Italy.,International Renal Research Institute of Vicenza (IRRIV), Via Rodolfi, 37, 36100, Vicenza, Italy
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Mezidi M, Ould-Chikh M, Deras P, Maury C, Martinez O, Capdevila X, Charbit J. Influence of late fluid management on the outcomes of severe trauma patients: A retrospective analysis of 294 severely-injured patients. Injury 2017; 48:1964-1971. [PMID: 28729005 DOI: 10.1016/j.injury.2017.06.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 05/27/2017] [Accepted: 06/09/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND Liberal late fluid management (LFM) is associated with higher morbi-mortality in critically ill populations. The aim of the study was to assess the association between LFM and duration of mechanical ventilation in a severe trauma population. METHODS A retrospective analysis of consecutive patients with an ISS≥16 and a length of stay in the intensive care unit (ICU)≥7 days was performed. The conservative LFM group included patients with at least 2 consecutive days with a negative fluid balance between day 3 and day 7; other patients were allocated to the liberal LFM group. RESULTS 294 severely injured patients were included, 157 (53%) as conservative LFM and 137 (47%) as liberal LFM. The groups did not differ significantly in terms of baseline characteristics, severe injuries, severity criteria or transfusion needs. Liberal LFM was significantly associated with more ventilation days (11 vs 8.5days; P=0.02), less ventilator-free days at day 30 (19 vs 21days; P=0.03), longer ICU stay (19 vs 16days; P=0.03) and longer hospital stay (30 vs 25days; P=0.04). Mortality rates were comparable between groups (6%). Liberal LFM was significantly associated in multivariable analysis with a reduced number of ventilator-free days at day 30 (β=-2.14 [95% CI, -4.2 to -0.08], P=0.042). CONCLUSIONS Liberal LFM was associated with higher morbidity in severe trauma patients, longer duration of ventilation, and longer ICU and hospital stays. These results were observed despite similar severity on admission and early fluid management.
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Affiliation(s)
- Mehdi Mezidi
- Trauma Intensive and Critical Care Unit, Department of Anesthesiology and Critical Care, Lapeyronie Hospital, Montpellier I University, Montpellier, France
| | - Mehdi Ould-Chikh
- Trauma Intensive and Critical Care Unit, Department of Anesthesiology and Critical Care, Lapeyronie Hospital, Montpellier I University, Montpellier, France
| | - Pauline Deras
- Trauma Intensive and Critical Care Unit, Department of Anesthesiology and Critical Care, Lapeyronie Hospital, Montpellier I University, Montpellier, France
| | - Camille Maury
- Trauma Intensive and Critical Care Unit, Department of Anesthesiology and Critical Care, Lapeyronie Hospital, Montpellier I University, Montpellier, France
| | - Orianne Martinez
- Trauma Intensive and Critical Care Unit, Department of Anesthesiology and Critical Care, Lapeyronie Hospital, Montpellier I University, Montpellier, France
| | - Xavier Capdevila
- Trauma Intensive and Critical Care Unit, Department of Anesthesiology and Critical Care, Lapeyronie Hospital, Montpellier I University, Montpellier, France; Institut National de la Santé et de la Recherche Médicale, Equipe Inserm U1046, 34295 Montpellier, France
| | - Jonathan Charbit
- Trauma Intensive and Critical Care Unit, Department of Anesthesiology and Critical Care, Lapeyronie Hospital, Montpellier I University, Montpellier, France.
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O'Connor ME, Jones SL, Glassford NJ, Bellomo R, Prowle JR. Defining fluid removal in the intensive care unit: A national and international survey of critical care practice. J Intensive Care Soc 2017; 18:282-288. [PMID: 29123557 DOI: 10.1177/1751143717699423] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Design and objectives To identify and compare how intensive care unit specialists in the United Kingdom and Australia and New Zealand self-reportedly define, assess and manage fluid overload in critically ill patients using a structured online questionnaire. Results We assessed 219 responses. Australia and New Zealand and United Kingdom intensive care unit specialists reported using clinical examination findings, bedside tools and radiological features to assess fluid status, diagnose fluid overload and initiate fluid removal in the critically ill. An elevated central venous pressure is not regarded as helpful in diagnosing fluid overload and targeting a clinician-set fluid balance is the most popular management strategy. Renal replacement therapy is used ahead of more diuretic therapy in patients who are oligo/anuric, or when diuretic therapy has not generated an adequate response. Conclusions This self-reported account of practice by United Kingdom and Australia and New Zealand intensivists demonstrates that fluid overload remains poorly defined with variability in both management and practice.
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Affiliation(s)
- Michael E O'Connor
- Adult Critical Care Unit, Royal London Hospital, Barts Health NHS Trust, London, UK.,Critical Care and Perioperative Medicine Research Group, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Sarah L Jones
- Intensive Care Unit, Royal Darwin Hospital, Tiwi, Australia
| | - Neil J Glassford
- Department of Intensive Care, Austin Hospital, Melbourne, Australia.,Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Melbourne, Australia.,Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia.,School of Medicine, The University of Melbourne, Melbourne, Australia
| | - John R Prowle
- Adult Critical Care Unit, Royal London Hospital, Barts Health NHS Trust, London, UK.,Critical Care and Perioperative Medicine Research Group, William Harvey Research Institute, Queen Mary University of London, London, UK
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48
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Bellomo R, Ronco C, Mehta RL, Asfar P, Boisramé-Helms J, Darmon M, Diehl JL, Duranteau J, Hoste EAJ, Olivier JB, Legrand M, Lerolle N, Malbrain MLNG, Mårtensson J, Oudemans-van Straaten HM, Parienti JJ, Payen D, Perinel S, Peters E, Pickkers P, Rondeau E, Schetz M, Vinsonneau C, Wendon J, Zhang L, Laterre PF. Acute kidney injury in the ICU: from injury to recovery: reports from the 5th Paris International Conference. Ann Intensive Care 2017. [PMID: 28474317 DOI: 10.1186/s13613-017-0260-y.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
The French Intensive Care Society organized its yearly Paris International Conference in intensive care on June 18-19, 2015. The main purpose of this meeting is to gather the best experts in the field in order to provide the highest quality update on a chosen topic. In 2015, the selected theme was: "Acute Renal Failure in the ICU: from injury to recovery." The conference program covered multiple aspects of renal failure, including epidemiology, diagnosis, treatment and kidney support system, prognosis and recovery together with acute renal failure in specific settings. The present report provides a summary of every presentation including the key message and references and is structured in eight sections: (a) diagnosis and evaluation, (b) old and new diagnosis tools,
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Affiliation(s)
- Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia.,Department of ICU, Austin Health, Heidelberg, Australia
| | - Claudio Ronco
- Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza (IRRIV), Vicenza, Italy
| | - Ravindra L Mehta
- Vice Chair Clinical Research, Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Pierre Asfar
- Département de Réanimation Médicale et de Médecine Hyperbare, Centre Hospitalier Universitaire, Angers, France.,Laboratoire de Biologie Neurovasculaire et Mitochondriale Intégrée, CNRS UMR 6214 - INSERM U1083, Université Angers, PRES L'UNAM, Angers, France
| | - Julie Boisramé-Helms
- Service de Réanimation Médicale, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.,EA 7293, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Faculté de médecine, Université de Strasbourg, Strasbourg, France
| | - Michael Darmon
- Medical-Surgical ICU, Saint-Etienne University Hospital and Jean Monnet University, Saint-Étienne, France
| | - Jean-Luc Diehl
- Medical ICU, AP-HP, Georges Pompidou European Hospital, Paris, France.,INSERM UMR_S1140, Paris Descartes University and Sorbonne Paris Cité, Paris, France
| | - Jacques Duranteau
- AP-HP, Service d'Anesthésie-Réanimation, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Hôpital de Bicêtre, Le Kremlin-Bicêtre, France
| | - Eric A J Hoste
- ICU, Ghent University Hospital, Ghent University, Ghent, Belgium.,Research Foundation-Flanders (FWO), Brussels, Belgium
| | | | - Matthieu Legrand
- Department of Anesthesiology and Critical Care and Burn Unit, Hôpitaux Universitaire St-Louis-Lariboisière, Assistance Publique-Hôpitaux de Paris (AP-HP), University of Paris, Paris, France
| | - Nicolas Lerolle
- Département de Réanimation Médicale et de Médecine Hyperbare, CHU, Angers, France
| | | | - Johan Mårtensson
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia.,Section of Anaesthesia and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | | | - Jean-Jacques Parienti
- Department of Infectious Diseases, University Hospital, Caen, France.,Department of Biostatistic and Clinical Research, University Hospital, Caen, France
| | - Didier Payen
- Department of Anesthesia and Critical Care, SAMU, Lariboisière University Hospital, Paris, France
| | - Sophie Perinel
- Medical-Surgical ICU, Saint-Etienne University Hospital, Jean Monnet University Saint-Etienne, Saint-Étienne, France
| | - Esther Peters
- Department of Pharmacology and Toxicology, Radboud university Medical Center, Nijmegen, The Netherlands
| | - Peter Pickkers
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Eric Rondeau
- Urgences néphrologiques et Transplantation rénale, Hôpital Tenon, Université Paris 6, Paris, France
| | - Miet Schetz
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Louvain, Belgium
| | - Christophe Vinsonneau
- Service de Réanimation et Surveillance continue, Centre Hospitalier de BETHUNE, Bethune, France
| | - Julia Wendon
- Kings College Hospital Foundation Trust, London, UK
| | - Ling Zhang
- Department of Nephrology, West China Hospital of Sichuan University, Sichuan, Chengdu, China
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49
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Bellomo R, Ronco C, Mehta RL, Asfar P, Boisramé-Helms J, Darmon M, Diehl JL, Duranteau J, Hoste EAJ, Olivier JB, Legrand M, Lerolle N, Malbrain MLNG, Mårtensson J, Oudemans-van Straaten HM, Parienti JJ, Payen D, Perinel S, Peters E, Pickkers P, Rondeau E, Schetz M, Vinsonneau C, Wendon J, Zhang L, Laterre PF. Acute kidney injury in the ICU: from injury to recovery: reports from the 5th Paris International Conference. Ann Intensive Care 2017; 7:49. [PMID: 28474317 PMCID: PMC5418176 DOI: 10.1186/s13613-017-0260-y] [Citation(s) in RCA: 90] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Accepted: 03/15/2017] [Indexed: 02/06/2023] Open
Abstract
The French Intensive Care Society organized its yearly Paris International Conference in intensive care on June 18-19, 2015. The main purpose of this meeting is to gather the best experts in the field in order to provide the highest quality update on a chosen topic. In 2015, the selected theme was: "Acute Renal Failure in the ICU: from injury to recovery." The conference program covered multiple aspects of renal failure, including epidemiology, diagnosis, treatment and kidney support system, prognosis and recovery together with acute renal failure in specific settings. The present report provides a summary of every presentation including the key message and references and is structured in eight sections: (a) diagnosis and evaluation, (b) old and new diagnosis tools,
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Affiliation(s)
- Rinaldo Bellomo
- Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia.,Department of ICU, Austin Health, Heidelberg, Australia
| | - Claudio Ronco
- Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza (IRRIV), Vicenza, Italy
| | - Ravindra L Mehta
- Vice Chair Clinical Research, Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Pierre Asfar
- Département de Réanimation Médicale et de Médecine Hyperbare, Centre Hospitalier Universitaire, Angers, France.,Laboratoire de Biologie Neurovasculaire et Mitochondriale Intégrée, CNRS UMR 6214 - INSERM U1083, Université Angers, PRES L'UNAM, Angers, France
| | - Julie Boisramé-Helms
- Service de Réanimation Médicale, Nouvel Hôpital Civil, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.,EA 7293, Fédération de Médecine Translationnelle de Strasbourg (FMTS), Faculté de médecine, Université de Strasbourg, Strasbourg, France
| | - Michael Darmon
- Medical-Surgical ICU, Saint-Etienne University Hospital and Jean Monnet University, Saint-Étienne, France
| | - Jean-Luc Diehl
- Medical ICU, AP-HP, Georges Pompidou European Hospital, Paris, France.,INSERM UMR_S1140, Paris Descartes University and Sorbonne Paris Cité, Paris, France
| | - Jacques Duranteau
- AP-HP, Service d'Anesthésie-Réanimation, Hôpitaux Universitaires Paris-Sud, Université Paris-Sud, Hôpital de Bicêtre, Le Kremlin-Bicêtre, France
| | - Eric A J Hoste
- ICU, Ghent University Hospital, Ghent University, Ghent, Belgium.,Research Foundation-Flanders (FWO), Brussels, Belgium
| | | | - Matthieu Legrand
- Department of Anesthesiology and Critical Care and Burn Unit, Hôpitaux Universitaire St-Louis-Lariboisière, Assistance Publique-Hôpitaux de Paris (AP-HP), University of Paris, Paris, France
| | - Nicolas Lerolle
- Département de Réanimation Médicale et de Médecine Hyperbare, CHU, Angers, France
| | | | - Johan Mårtensson
- Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia.,Section of Anaesthesia and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | | | - Jean-Jacques Parienti
- Department of Infectious Diseases, University Hospital, Caen, France.,Department of Biostatistic and Clinical Research, University Hospital, Caen, France
| | - Didier Payen
- Department of Anesthesia and Critical Care, SAMU, Lariboisière University Hospital, Paris, France
| | - Sophie Perinel
- Medical-Surgical ICU, Saint-Etienne University Hospital, Jean Monnet University Saint-Etienne, Saint-Étienne, France
| | - Esther Peters
- Department of Pharmacology and Toxicology, Radboud university Medical Center, Nijmegen, The Netherlands
| | - Peter Pickkers
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Eric Rondeau
- Urgences néphrologiques et Transplantation rénale, Hôpital Tenon, Université Paris 6, Paris, France
| | - Miet Schetz
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Louvain, Belgium
| | - Christophe Vinsonneau
- Service de Réanimation et Surveillance continue, Centre Hospitalier de BETHUNE, Bethune, France
| | - Julia Wendon
- Kings College Hospital Foundation Trust, London, UK
| | - Ling Zhang
- Department of Nephrology, West China Hospital of Sichuan University, Sichuan, Chengdu, China
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50
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Fluid management in acute kidney injury. Intensive Care Med 2017; 43:807-815. [DOI: 10.1007/s00134-017-4817-x] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Accepted: 04/22/2017] [Indexed: 12/17/2022]
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