Forced fluid removal in critically ill patients with acute kidney injury
ABSTRACT The aim was to test the feasibility of protocol-driven fluid removal with continuous renal replacement therapy (CRRT) in patients in whom standard fluid balance prescription did not result in substantial negative fluid balances.
In 10 mechanically ventilated patients with sepsis or signs of inflammation and acute kidney injury [age 65 (48-78 years; median, range), simplified acute physiology score II 66 (39-116)], fluid removal was guided by mean arterial pressure (MAP), cardiac index (CI), mixed venous oxygen saturation (SvO (2) ), lactate/base excess, peripheral circulation, and filling pressures, and adjusted hourly with the goal to maximize volume removal for up to 3 days.
Fluid removal rates during the 3 days before and during the study period [66 (36-72) h] were 11 (-30 to +36) ml/kg/day and -59 (-85 to -31) ml/kg/day, respectively (P = 0.002). In 12% of a total of 594 fluid removal rate evaluations, fluid removal had to be decreased or stopped. Most frequent reasons leading to decreasing fluid removal were (n, % of all instances, median lowest value from all patients): SvO (2) (44, 28%, 59%), MAP (36, 23%, 57 mmHg), CI (26, 17%, 2.4 l/min/m(2) ), low peripheral temperature (22, 14%, 'cold'). Overall, systemic hemodynamics remained stable throughout the study period.
In these patients, protocolized fluid removal with CRRT was associated with large negative fluid balances.
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ABSTRACT: The measurement of total body water (TBW) in critically ill intensive care patients with greatly expanded TBW allows body composition studies to be undertaken in such patients with potentially important clinical consequences. Previous workers in this field have stressed the importance of the distortion of compartmental specific activity resulting from continued intravenous (IV) fluid administration during the period of equilibration and have made attempts to predict the equilibrium value of specific activity from the early arterial kinetics. In this paper a method for the measurement of TBW in critically ill intensive care patients is presented together with results of 16 studies on 11 such patients (mean TBW 54.61). It is shown that the effect of continued IV fluid administration in association with prolonged equilibration is small and that the prediction of TBW from analysis of the early (first hour) arterial kinetics is inappropriate. It is concluded that in such patients the volume of distribution of the isotope is constant after four hours from IV injection and that TBW can be measured with a mean precision of 0.7% (SD) from the fourth, fifth, and sixth hour measurements.Metabolism 08/1985; 34(7):688-94. DOI:10.1016/0026-0495(85)90099-X · 3.61 Impact Factor
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ABSTRACT: We hypothesized that patients with septic shock who achieve negative fluid balance (< or =-500 mL) on any day in the first 3 days of management are more likely to survive than those who do not. Retrospective chart review. Thirty-six patients admitted with the diagnosis of septic shock. Twelve-bed medical ICU of a 300-bed community teaching hospital. Medical records of 36 patients admitted to our medical ICU over a 21-month period were examined. Patients with septic shock who required dialysis prior to hospitalization were not included. A number of demographic and physiologic variables were extracted from the medical records. Admission APACHE (acute physiology and chronic health evaluation) II and daily sequential organ failure assessment (SOFA) scores were computed from the extracted data. Variables were compared between survivors and nonsurvivors and in patients who did vs those who did not achieve negative (< or = 500 mL) fluid balance in > or = 1 day of the first 3 days of management. Survival risk ratios (RRs) were used as the measure of association between negative fluid balance and survival. RRs were adjusted for age, APACHE II scores, SOFA scores on the first and third days, and the need for mechanical ventilation, by stratified analyses. Patients ranged in age from 16 to 85 years with a mean (+/- SE) age of 67.4 +/- 3.3 years. The mean admission APACHE II score was 25.4 +/- 1.4, and the day 1 SOFA score was 9.0 +/- 0.8. Twenty patients did not survive; nonsurvivors had higher mean APACHE II scores than survivors (29.8 vs 20.4, respectively) and higher first day SOFA scores than survivors (10.8 vs 6.9, respectively), and they were more likely to require vasopressors and mechanical ventilation compared to patients who survived. Whereas all 11 patients who achieved a negative balance of > 500 mL on > or = 1 of the first 3 days of treatment survived, only 5 of 25 patient who failed to achieve a negative fluid balance of > 500 mL by the third day of treatment survived (RR, 5.0; 95% CI, 2.3 to 10.9; p = 0.00001). At least 1 day of net negative fluid balance in the first 3 days of treatment strongly predicted survival across the strata of age, APACHE II scores, first- and third-day SOFA scores, the need for mechanical ventilation, and creatinine levels measured at admission. These results suggest that at least 1 day of negative fluid balance (< or = -500 mL) achieved by the third day of treatment may be a good independent predictor of survival in patients with septic shock. These findings suggest the hypothesis "that negative fluid balance achieved in any of the first 3 days of septic shock portends a good prognosis," for a larger prospective cohort study.Chest 06/2000; 117(6):1749-54. DOI:10.1378/chest.117.6.1749 · 7.13 Impact Factor
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ABSTRACT: Recent data have suggested that ventilatory strategy could influence outcomes from acute lung injury (ALI) and ARDS. We tested the hypothesis that infection/sepsis and use of higher tidal volumes than those applied in the ARDS Network (ARDSnet) study (> 7.4 mL/kg of predicted body weight) would worsen outcome in patients with ALI/ARDS. International cohort, observational study. One hundred ninety-eight European ICUs participating in the Sepsis Occurrence in Acutely Ill Patients study. All 3,147 adult patients admitted to one of the participating ICUs between May 1, 2002, and May 15, 2002. None. Patients were followed up until death, hospital discharge, or for 60 days. Of the 3,147 patients, 393 patients (12.5%) had ALI/ARDS. ICU and hospital mortality was higher in patients with ALI/ARDS than those without ALI/ARDS (38.9% vs 15.6% and 45.5% vs 21.0%, respectively; p < 0.001). A multivariable logistic regression analysis with ICU outcome as the dependent factor showed that the independent risks for mortality were as follows: presence of cancer, use of tidal volumes higher than those used by the ARDSnet study, degree of multiorgan dysfunction, and higher mean fluid balance. Sepsis, septic shock, and oxygenation at the onset of ALI/ARDS were not independently associated with higher mortality rates. In addition to comorbidities and organ dysfunction, high tidal volumes and positive fluid balance are associated with a worse outcome from ALI/ARDS.Chest 11/2005; 128(5):3098-108. DOI:10.1378/chest.128.5.3098 · 7.13 Impact Factor