Cumulative Fluid Research Articles

Weaning Difficulty in Patient with End Stage Renal Disease Acute with Respiratory Failure due to Pulmonary Edema and Pneumonia

Introduction: End Stage Renal Disease (ESRD) 5D patient have potential to respiratory failure due to excess fluid, thus increasing the incidence of repeated hospital admissions. Deaths were reported in about 15%– 30% cases, where 50%–60% of patients needed respiratory support with mechanical ventilation. About 30%– 40% of patients had complications in the weaning process from mechanical ventilation. Prolonged mechanical ventilation increased mortality and morbidity, the length of stay periods and costs. Case Report: This case report will discuss the difficult weaning from mechanical ventilation in patients with ESRD 5D who have respiratory failure due to edema pulmonary and pneumonia who were hospitalized at the Intensive Care Unit (ICU) of Hasan Sadikin Hospital - Bandung for 20 days Conclusion: Weaning difficulty due to accumulation positive fluid balance during hospitalization lead to longer use of mechanical ventilation and pulmonary infection get heavier. A positive cumulative fluid balance could be one factor of weaning difficulty

EARLY INITIATION OF RENAL REPLACEMENT THERAPY IN INTENSIVE CARE UNIT PATIENTS WITH BOTH ACUTE RESPIRATORY DISTRESS SYNDROME AND SEPSIS WITH OR WITHOUT RENAL FAILURE: A RETROSPECTIVE COHORT STUDY BASED ON PROPENSITY SCORE MATCHING.

Background: It is unknown whether early renal replacement therapy (RRT) initiation strategy in intensive care unit (ICU) patients with both acute respiratory distress syndrome (ARDS) and sepsis with or without renal failure is clinically beneficial. Patients and methods: A total of 818 patients with both ARDS and sepsis admitted to the ICU of Tianjin Medical University General Hospital were included in the analysis. Early RRT was defined as initiating the RRT strategy within 24 h of admission. The relationship between early RRT and clinical outcomes, including primary (30-day mortality) and secondary (90-day mortality, serum creatinine, Pa o2 /Fi o2 , duration of invasive mechanical ventilation, cumulative fluid output, and cumulative fluid balance) outcomes, was compared using propensity score matching (PSM). Results: A total of 277 patients (33.9% of the total population) underwent an early RRT initiation strategy before PSM. After PSM, a cohort of 147 patients with early RRT and 147 patients without early RRT with matched baseline characteristics (including serum creatinine at admission) were constructed. Early RRT was not significantly associated with 30- (hazard ratio [HR], 1.25; 95% confidence interval [CI], 0.85-1.85; P = 0.258) or 90-day mortality (HR, 1.30; 95% CI, 0.91-1.87, P = 0.150). At each time point within 72 h after admission, there was no significant difference in serum creatinine, Pa o2 /Fi o2 and duration of mechanical ventilation between the early and the no early RRT groups. Early RRT significantly increased total output at all time points within 72 h of admission and reached a statistically significant negative fluid balance at 48 h. Conclusions: Early RRT initiation strategies had no statistically significant survival benefit in ICU patients with both ARDS and sepsis, with or without renal failure, nor did they significantly improve serum creatinine and oxygenation or shorten the duration of mechanical ventilation. The use and timing of RRT in such patients should be thoroughly investigated.

Effect of fluid overload on survival in patients with sepsis-induced acute kidney injury receiving continuous renal replacement therapy

The association between fluid overload and survival has not been well elucidated in critically ill patients with sepsis-induced acute kidney injury (SIAKI) receiving continuous renal replacement therapy (CRRT). We investigated the optimal cutoff value of fluid overload for predicting mortality and whether minimizing fluid overload through CRRT is associated with a survival benefit in these patients. We examined 543 patients with SIAKI who received CRRT in our intensive care unit. The degree of cumulative fluid overload in relation to body weight was expressed as the percentage fluid overload (%FO). %FO was further subdivided into %FO from AKI diagnosis to CRRT initiation (%FOpreCRRT) and total fluid overload (%FOtotal). The best cutoff value of fluid overload for predicting the 28-day mortality was %FOpreCRRT > 4.6% and %FOtotal > 9.6%. Multivariable analysis demonstrated that patients with %FOpreCRRT > 4.6% and %FOtotal > 9.6% were 1.9 times and 3.37 times more likely to die than those with %FOpreCRRT ≤ 4.6% and %FOtotal ≤ 9.6%. The 28-day mortality was the highest in patients with %FOpreCRRT > 4.6% and %FOtotal > 9.6% (84.7%), followed by those with %FOpreCRRT ≤ 4.6% and %FOtotal > 9.6% (65.0%), %FOpreCRRT > 4.6% and %FOtotal ≤ 9.6% (43.6%), and %FOpreCRRT ≤ 4.6% and %FOtotal ≤ 9.6% (22%). This study demonstrated that fluid overload was independently associated with the 28-day mortality in critically ill patients with SIAKI. Future prospective studies are needed to determine whether minimizing fluid overload using CRRT improves the survival of these patients.

A machine learning-based study of multifactor susceptibility and risk control of induced seismicity in unconventional reservoirs

A comprehensive dataset from 594 fracturing wells throughout the Duvernay Formation near Fox Creek, Alberta, is collected to quantify the influences of geological, geomechanical, and operational features on the distribution and magnitude of hydraulic fracturing-induced seismicity. An integrated machine learning-based investigation is conducted to systematically evaluate multiple factors that contribute to induced seismicity. Feature importance indicates that a distance to fault, a distance to basement, minimum principal stress, cumulative fluid injection, initial formation pressure, and the number of fracturing stages are among significant model predictors. Our seismicity prediction map matches the observed spatial seismicity, and the prediction model successfully guides the fracturing job size of a new well to reduce seismicity risks. This study can apply to mitigating potential seismicity risks in other seismicity-frequent regions.

Clinical characteristics and outcomes of critically ill coronavirus disease 2019 patients in Malaysia during the first wave: A multi-center observational study (COVIDICU-MY).

Coronavirus disease 2019 (COVID-19) emerged with a wide range of clinical presentations; Malaysia was not spared from its impact. This study describes the clinical characteristics of COVID-19 patients admitted to intensive care unit, their clinical course, management, and hospital outcomes. COVIDICU-MY is a retrospective analysis of COVID-19 patients from 19 intensive care units (ICU) across Malaysia from 1 March 2020 to 31 May 2020. We collected epidemiological history, demographics, clinical comorbidities, laboratory investigations, respiratory and hemodynamic values, management, length of stay and survival status. We compared these variables between survival and non-survival groups. A total of 170 critically ill patients were included, with 77% above 50 years of age [median age 60, IQR (51-66)] and 75.3% male. Hypertension, diabetes mellitus, hyperlipidemia, chronic cardiac disease, and chronic kidney disease were most common among patients. A high Simplified Acute Physiology Score (SAPS) II score [median 45, IQR (34-49)] and Sequential Organ Failure Assessment (SOFA) score [median 8, IQR (6-11)] were associated with mortality. Patients were profoundly hypoxic with a median lowest PaO2/FiO2 ratio of 150 (IQR 99-220) at admission. 91 patients (53.5%) required intubation on their first day of admission, out of which 38 died (73.1% of the hospital non-survivors). Our sample had more patients with moderate Acute Respiratory Distress Syndrome (ARDS), 58 patients (43.9%), compared to severe ARDS, 33 patients (25%); with both ARDS classification groups contributing to 25 patients (54.4%) and 11 patients (23.9%) of the non-survival group, respectively. Cumulative fluid balance over 24 h was higher in the non-survival group with significant differences on Day 3 (1,953 vs. 622 ml, p < 0.05) and Day 7 of ICU (3,485 vs. 830 ml, p < 0.05). Patients with high serum creatinine, urea, lactate dehydrogenase, aspartate aminotransferase and d-dimer, and low lymphocyte count throughout the stay also had a higher risk of mortality. The hospital mortality rate was 30.6% in our sample. We report high mortality amongst critically ill patients in intensive care units in Malaysia, at 30.6%, during the March to May 2020 period. High admission SAPS II and SOFA, and severe hypoxemia and high cumulative fluid balance were associated with mortality. Higher creatinine, urea, lactate dehydrogenase, aspartate aminotransferase and d-dimer, and lymphopenia were observed in the non-survival group.

Transfusion trigger in the critically ill with sepsis or septic shock: A prospective study.

Current practice around transfusion trigger in critically ill sepsis patients is not clear. Moreover, any association of haemoglobin trigger and other transfusion parameters such as age of red blood cells (RBCs) at transfusion and number of units of RBCs transfused with mortality and other adverse outcomes need further assessment. In this prospective study, patients aged 18-70 yr and admitted to intensive care with a diagnosis of sepsis were included (n=108). Baseline demographic, clinical and laboratory parameters were noted and various transfusion data, i.e., haemoglobin trigger, number of units of RBCs and the age of RBCs were recorded. Following outcome data were collected: 28 and 90 day mortality, duration of mechanical ventilation, vasopressor therapy, intensive care unit (ICU) and hospital stay and requirement of renal replacement therapy. Of the total 108 participants, 78 (72.2%) survived till 28 days and 66 (61.1%) survived till 90 days. Transfusion trigger was 6.9 (6.7-7.1) g/dl [median (interquartile range)]. On multivariable logistic regression analysis, acute physiology and chronic health evaluation (APACHE) II [adjusted odds ratio (aOR) (95% confidence interval {CI}): 0.86 (0.78, 0.96); P=0.005], cumulative fluid balance (CFB) [aOR (95% CI): 0.99 (0.99, 0.99); P=0.005] and admission platelet count [aOR (95% CI): 1.69 (1.01, 2.84); P=0.043] were the predictors of 28 day mortality [model area under the receiver operating characteristics (AUROC) 0.81]. APACHE II [aOR (95% CI): 0.88 (0.81, 0.97); P=0.013], CFB [a OR (95% CI): 0.99977 (0.99962, 0.99993); P=0.044] and transfusion trigger [aOR (95% CI): 3 (1.07, 8.34); P=0.035] were the predictors of 90 day mortality (model AUROC: 0.82). In sepsis, patients admitted to the ICU, current practice suggests transfusion trigger is below 7 g/dl and it does not affect any adverse outcome including 28 day mortality.

Predictive Value of Urinary Neutrophil Gelatinase-Associated Lipocalin in Detection of Severe Acute Kidney Injury in Critically Ill Children

Aims and Objectives: The primary objective was to determine the positive and negative predictive values, sensitivity, and specificity of urinary neutrophil gelatinase-associated lipocalin (uNGAL) for diagnosis of severe acute kidney injury (AKI). The secondary objectives were to find the association between uNGAL with day-3 cumulative fluid balance (CFB), requirement of kidney replacement therapy (KRT), and length of pediatric intensive care unit (PICU) stay. Materials and Methods: In this prospective cohort, uNGAL was done by chromatography on patients admitted at PICU in a tertiary care hospital with Pediatric Risk of Mortality III (PRISM III) score of &gt;10. AKI was defined by KDIGO 2012 criteria. Urinary NGAL was done on all patients (&gt;3 months to ≤12 years) with PRISM III score &gt;10 on day 1 and day 3 of PICU admission who had no AKI on admission. Results: Out of 288 patients admitted with PRISM III score &gt;10 and normal kidney function on admission, 58.3% developed AKI and 29.9% developed severe AKI. Day-3 uNGAL was found to be superior to day-1 uNGAL in detecting AKI with 96.4% sensitivity, 84.4% specificity, 85.04% PPV, and 96.26% NPV. The percentage increase in day-3 CFB and risk of requiring KRT was significantly (P &lt; 0.001) higher in the groups with raised day-1 uNGAL and day-3 uNGAL. The length of PICU stay was significantly correlated to the group with raised day-3 uNGAL (P &lt; 0.001). Conclusion: Urinary NGAL had a good predictive value in detecting severe AKI in critically ill children. It is also associated with requirement of KRT and day-3 CFB. Duration of PICU stay was significantly associated with day-3 uNGAL (P &lt; 0.001).

Frequency of blood lactate elevation following esophagectomy and its association to postoperative complications.

Esophagectomy is a major surgical intervention and a cornerstone in the treatment of esophageal cancer. There is clinical experience that blood lactate concentration often is elevated in the period following esophagectomy, but the incidence and clinical consequences are sparsely studied. We extracted data from all patients undergoing esophagectomy at Karolinska University Hospital 2016-2018, n= 153. Most were performed with minimally invasive technique, n= 130. Blood lactate values directly after surgery, highest value during the first night, and morning level on postoperative day one were recorded. Primary outcome was hospital length of stay and secondary outcome was a composite of postoperative infection, additional surgery, or intensive care during the hospital stay. Development of anastomotic leak was analyzed separately. Postoperative hyperlactatemia was common as 93% of patients had peak lactate concentration >1.6 mmol/L and 27% >3.5 mmol/L in the first night following operation. Median hospital length of stay was 14 days. Blood lactate showed a weak correlation to hospital stay and intensive care the morning following surgery, but not at arrival to postoperative ward. There were no statistical differences between those with and without anastomotic leak at any of the time points. Elevated lactate in the first 12-16 h postoperatively was related to surgical factors (open technique, surgery time, and perioperative bleeding) but not to patient related factors (ASA-class, Charlson comorbidity index, sex, age) or cumulative fluid balance. In conclusion, elevated blood lactate in the immediate time following esophagectomy showed a weak association to intensive care and length of stay but not anastomotic leak.

Changing epidemiology of acute kidney injury in critically ill patients with COVID-19: a prospective cohort

BackgroundAcute kidney injury (AKI) is common in critically ill patients with coronavirus disease-19 (COVID-19). We aimed to explore the changes in AKI epidemiology between the first and the second COVID wave in the United Kingdom (UK).MethodsThis was an observational study of critically ill adult patients with COVID-19 in an expanded tertiary care intensive care unit (ICU) in London, UK. Baseline characteristics, organ support, COVID-19 treatments, and patient and kidney outcomes up to 90 days after discharge from hospital were compared.ResultsA total of 772 patients were included in the final analysis (68% male, mean age 56 ± 13.6). Compared with wave 1, patients in wave 2 were older, had higher body mass index and clinical frailty score, but lower baseline serum creatinine and C-reactive protein (CRP). The proportion of patients receiving invasive mechanical ventilation (MV) on ICU admission was lower in wave 2 (61% vs 80%; p < 0.001). AKI incidence within 14 days of ICU admission was 76% in wave 1 and 51% in wave 2 (p < 0.001); in wave 1, 32% received KRT compared with 13% in wave 2 (p < 0.001). Patients in wave 2 had significantly lower daily cumulative fluid balance (FB) than in wave 1. Fewer patients were dialysis dependent at 90 days in wave 2 (1% vs. 4%; p < 0.001).ConclusionsIn critically ill adult patients admitted to ICU with COVID-19, the risk of AKI and receipt of KRT significantly declined in the second wave. The trend was associated with less MV, lower PEEP and lower cumulative FB.Trial registration: NCT04445259.

Improving awareness of kidney function through electronic urine output monitoring: a comparative study

BackgroundThe current classification for acute kidney injury (AKI) according to the Kidney Disease: Improving Global Outcomes (KDIGO) criteria integrates both serum creatinine (SCr) and urine output (UO). Most reports on AKI claim to use KDIGO guidelines but fail to include the UO criterion. It has been shown that patients who had intensive UO monitoring, with or without AKI, had significantly less cumulative fluid volume and fluid overload, reduced vasopressor use, and improved 30-day mortality. We examined whether real-time monitoring of this simple, sensitive, and easy-to-use biomarker in the ICU led to more appropriate intervention by healthcare providers and better outcomes. MethodsRenalSense Clarity RMS Consoles were installed in the General ICU at the Hadassah Medical Center, Israel, from December 2019 to November 2020. The Clarity RMS system continuously and electronically monitors UO in real-time. 100 patients were randomly selected from this period as the study group (UOelec) and compared to a matched control group (UOmanual) from the same period two years earlier. To test whether there was an association between oliguric hours and fluid treatment in each group, the correlation was calculated and analyzed for each of the different UO monitoring methods.ResultsTherapeutic intervention: The correlation of the sum of all oliguric hours on Day 1 and 2 with the sum of any therapeutic intervention (fluid bolus or furosemide) showed a significant correlation for the study group UOelec (P = 0.017). The matched control group UOmanual showed no such correlation (P = 0.932). Length of Stay (LOS): Median LOS [IQR] in the ICU of UOelec versus UOmanual was 69.46 [44.7, 125.9] hours and 116.5 [62.46, 281.3] hours, respectively (P = 0.0002).ConclusionsThe results of our study strongly suggest that ICU patients had more meaningful and better medical intervention, and improved outcomes, with electronic UO monitoring than with manual monitoring.

Non-interventional follow-up versus fluid bolus in RESPONSE to oliguria in hemodynamically stable critically ill patients: a randomized controlled pilot trial

BackgroundFluid bolus therapy is a common intervention to improve urine output. Data concerning the effect of a fluid bolus on oliguria originate mainly from observational studies and remain controversial regarding the actual benefit of such therapy. We compared the effect of a follow-up approach without fluid bolus to a 500 mL fluid bolus on urine output in hemodynamically stable critically ill patients with oliguria at least for 2 h (urine output < 0.5 mL/kg/h) in randomized setting.MethodsWe randomized 130 patients in 1:1 fashion to receive either (1) non-interventional follow-up (FU) for 2 h or (2) 500 mL crystalloid fluid bolus (FB) administered over 30 min. The primary outcome was the proportion of patients who doubled their urine output, defined as 2-h urine output post-randomization divided by urine output 2 h pre-randomization. The outcomes were adjusted for the stratification variables (presence of sepsis or AKI) using two-tailed regression. Obtained odds ratios were converted to risk ratios (RR) with 95% confidence intervals (CI). The between-group difference in the continuous variables was compared using mean or median regression and expressed with 95% CIs.ResultsAltogether 10 (15.9%) of 63 patients in the FU group and 22 (32.8%) of 67 patients in FB group doubled their urine output during the 2-h period, RR (95% CI) 0.49 (0.23–0.71), P = 0.026. Median [IQR] change in individual urine output 2 h post-randomization compared to 2 h pre-randomization was − 7 [− 19 to 17] mL in the FU group and 19[0–53] mL in the FB group, median difference (95% CI) − 23 (− 36 to − 10) mL, P = 0.001. Median [IQR] duration of oliguria in the FU group was 4 [2–8] h and in the FB group 2 [0–6] h, median difference (95%CI) 2 (0–4) h, P = 0.038. Median [IQR] cumulative fluid balance on study day was lower in the FU group compared to FB group, 678 [518–1029] mL versus 1071 [822–1505] mL, respectively, median difference (95%CI) − 387 (− 635 to − 213) mL, P < 0.001.ConclusionsFollow-up approach to oliguria compared to administering a fluid bolus of 500 mL crystalloid in oliguric patients improved urine output less frequently but lead to lower cumulative fluid balance.Trial registration clinical.trials.gov, NCT02860572. Registered 9 August 2016.Graphical

943: THE EFFECT OF FLUID BALANCE ON PRONING AND SUCCESSFUL EXTUBATION IN INTUBATED COVID-19 PATIENTS

Introduction: Coronavirus disease 2019 (Covid-19) represents viral pneumonia from severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. In ARDS patients, positive fluid balance has been associated with prolonged mechanical ventilation, longer length of stay, and higher mortality. As a result, restrictive fluid strategies improved oxygenation and reduced duration of mechanical ventilation. Optimal fluid management strategy for invasively ventilated COVID-19 patients is lacking. The objective of this study is to evaluate the effect of fluid balance on need for proning and successful liberation of invasive mechanical ventilation (MV) in patients with COVID-19 ARDS. Methods: All data were retrospectively collected from EHR of COVID-19 patients admitted to our ICU. COVID ARDS patients in our institution are managed based on ARDS management guidelines that include lung protective ventilation strategy, PEEP protocol, and prone positioning for persistent PaO2/FiO2 (P/F) ratio < 150. Fluid balance in ml was calculated on Day 1 (F1) and Day 7 (F7) of ICU admission. Groups were divided into those successfully liberated (L-group) and those unable to be liberated from MV (U-group). Results: A total of 57 patients intubated with COVID-19 ARDS were included, with 29 in the L-group and 28 in the U-group. Compared to U-group, L-group had similar age (64 +/- 13 vs 64 +/- 13, p = 1.0), number of comorbidities (2.3 +/- 2.2 vs 2.7 +/- 2.5, p = 0.5), P/F ratio on day 1 (D1, 144 +/- 110 vs 130 +/- 95, p = 0.6), D1 SOFA score (6.4 +/- 4.5 vs 5.9 +/- 4.3, p = 0.7), and F1 (434 +/- 1106 vs 413 +/- 1301, p = 0.9). F7 was significantly less for L-group than U-group (290 +/- 2500 vs 2000 +/- 4000, p = 0.05). [F7 – F1] was also significantly less for L-group compared to U-group (- 144 +/- 1400 vs 1600 +/- 2800, p = 0.004). There was less need for proning (38 % vs 72 %, p = 0.01), and lower mortality (24% vs 86 %, p < 0.001) in the L-group compared to the U-group. Conclusions: In a cohort of invasively ventilated patients with COVID-19 ARDS, a lower cumulative fluid balance was associated with less need for proning and more successful liberation of MV, indicating that restricted fluid management in these patients may be beneficial. These findings should be investigated in large multicenter prospective studies.

Feasibility study using longitudinal bioelectrical impedance analysis to evaluate body water status during fluid resuscitation in a swine sepsis model

Fluid resuscitation is crucial in the initial management of sepsis; however, little is known about the serial changes and overall distribution of fluids administered into the body. To identify the feasibility of longitudinal bioelectrical impedance analysis during fluid treatment, a preclinical porcine model of Escherichia coli-induced sepsis was used. After sepsis induction, pigs were treated with fluid and vasopressors and monitored for up to 12 h after bacterial infusion or until death. Bipolar electrodes for bioelectrical impedance analysis were attached to the left extremities and measurements were performed every 10 min. Among the 12 subjects, 7 pigs expired during the experiment, and the median survival was 9.5 h. As sepsis progressed with an increase in cumulative fluid balance, R0 [∝ 1/extracellular water (ECW)] decreased, while Ri [∝ 1/intracellular water (ICW)] and ratio of extracellular water to total body water (ECW/TBW) increased. The phase angle constantly decreased throughout the monitoring period, and all non-survivors died when the phase angle decreased by more than 10%. Among the variables, ΔR0 and Δphase angle showed moderate negative correlations, and ΔECW/TBW showed a moderate positive correlation with the hourly fluid balance. Compared to survivors, a greater increase in ΔECW/TBW and a decrease in phase angle were observed in non-survivors over time, with an increase in cumulative fluid balance. Differences in ΔECW/TBW and phase angle emerged at 240 min when the difference in cumulative fluid balance between the two groups (survivors vs non-survivors) exceeded 1000 mL. In conclusion, continuous measurements of bioelectrical impedance analysis in a porcine sepsis model are feasible and may reflect changes in the body water profile during fluid resuscitation.

DURATION OF HYPOTENSION IS A PREDICTOR OF ACUTE KIDNEY INJURY IN THE POST-CARDIAC SURGERY PATIENT.

<h3>Objectives</h3> Post-operative hypotension is a common problem for any patient undergoing major surgery. It has been thoroughly evaluated in the non-cardiac surgical cohort and is associated with increased risk of myocardial infarction, acute kidney injury (AKI) and mortality (1,2,3). However, the nature of the post-operative hypotension and its implications in the cardiac surgery cohort have not been well described. Our objective is to better describe this cohort of patients, to describe the frequency and duration of hypotension in the first 12 hours after cardiac surgery in the intensive care unit and its relationship to patient-centred outcomes. <h3>Design and Method</h3> A retrospective study of consecutive adult cardiac surgical patients requiring intra-operative cardiopulmonary bypass over a 10-week period at a tertiary teaching hospital in London, UK. Demographic and baseline data were collected for each patient in addition to post-operative adverse events and then compared with continuous arterial blood pressure monitoring data for the first 12 hours after arrival in the ICU after surgery. Any relationship between hypotension and subsequent outcome was explored. Hypotension was defined as a mean arterial pressure (MAP) <65 and severe hypotension as MAP <50 lasting for at least a minute. Multivariate regression analysis was carried out to identify correlation between hypotension and subsequent complications. <h3>Results</h3> A total of 51 cases were included with a broad case mix (69% coronary artery bypass graft (CABG), 11.5% aortic valve surgery, 5.8% mitral valve surgery, 7.7% CABG plus valve surgery and 5.8% other). Average age was 64.5 years and 73.6% of patients were male. Average Euroscore II was 1.60. On average, patients experienced 10 hypotensive events with a total duration of hypotension of 79.7 minutes. The average duration of each hypotensive event was 6.7 minutes. 47.1% of patients experienced severe hypotension with an average duration of 2.3 minutes. To address this hypotension, patients received on average 2188ml of intravenous (IV) crystalloid solution in the first 6 hours and a further 578ml in the subsequent 6 hours resulting in an average cumulative fluid balance at 12 hours of 1591ml, in addition to vasopressors. The duration of the hypotensive event predicted subsequent AKI with OR 1.02 (95% CI 1.00 – 1.04, p=0.053). Hypotension was not correlated with respiratory, hepatic or neurological complications post-operatively. It was also not correlated with ICU or hospital length of stay. <h3>Conclusions</h3> Whilst it has been previously proven that post-operative hypotension increases the complication rate generally, this study suggests that the duration of hypotensive events in the post-cardiac surgical patient appears to be a predictor for developing an acute kidney injury which, to our knowledge, has not been described before in this patient cohort. Not only is this hypothesis-generating for future studies, but it also suggests that the use of hypotension-predicting technologies could perhaps improve speed of treatment thereby decreasing the duration of hypotension and subsequently decreasing the rate of AKI after major cardiac surgery.

Nordic survey on assessment and treatment of fluid overload in intensive care.

Fluid overload in patients in the intensive care unit (ICU) is associated with higher mortality. There are few randomized controlled trials to guide physicians in treating patients with fluid overload in the ICU, and no guidelines exist. We aimed to elucidate how ICU physicians from Nordic countries define, assess, and treat fluid overload in the ICU. We developed an online questionnaire with 18 questions. The questions were pre-tested and revised by specialists in intensive care medicine. Through a network of national coordinators. The survey was distributed to a wide range of Nordic ICU physicians. The distribution started on January 5th, 2022 and ended on May 6th, 2022. We received a total of 1,066 responses from Denmark, Norway, Finland, Sweden, and Iceland. When assessing fluid status, respondents applied clinical parameters such as clinical examination findings, cumulative fluid balance, body weight, and urine output more frequently than cardiac/lung ultrasound, radiological appearances, and cardiac output monitoring. A large proportion of the respondents agreed that a 5% increase or more in body weight from baseline supported the diagnosis of fluid overload. The preferred de-resuscitation strategy was diuretics (91%), followed by minimization of maintenance (76%) and resuscitation fluids (71%). The majority declared that despite mild hypotension, mild hypernatremia, and ongoing vasopressor, they would not withhold treatment of fluid overload and would continue diuretics. The respondents were divided when it came to treating fluid overload with loop diuretics in patients receiving noradrenaline. Around 1% would not administer noradrenaline and diuretics simultaneously and 35% did not have a fixed upper limit for the dosage. The remaining respondents 63% reported different upper limits of noradrenaline infusion (0.05-0.50 mcg/kg/min) when administering loop diuretics. Self-reported practices among Nordic ICU physicians when assessing, diagnosing, and treating fluid overload reveals variability in the practice. A 5% increase in body weight was considered a minimum to support the diagnosis of fluid overload. Clinical examination findings were preferred for assessing, diagnosing and treating fluid overload, and diuretics were the preferred treatment modality.

Fluid balance and renal replacement therapy initiation strategy: a secondary analysis of the STARRT-AKI trial

BackgroundAmong critically ill patients with acute kidney injury (AKI), earlier initiation of renal replacement therapy (RRT) may mitigate fluid accumulation and confer better outcomes among individuals with greater fluid overload at randomization.MethodsWe conducted a pre-planned post hoc analysis of the STandard versus Accelerated initiation of Renal Replacement Therapy in Acute Kidney Injury (STARRT-AKI) trial. We evaluated the effect of accelerated RRT initiation on cumulative fluid balance over the course of 14 days following randomization using mixed models after censoring for death and ICU discharge. We assessed the modifying effect of baseline fluid balance on the impact of RRT initiation strategy on key clinical outcomes. Patients were categorized in quartiles of baseline fluid balance, and the effect of accelerated versus standard RRT initiation on clinical outcomes was assessed in each quartile using risk ratios (95% CI) for categorical variables and mean differences (95% CI) for continuous variables.ResultsAmong 2927 patients in the modified intention-to-treat analysis, 2738 had available data on baseline fluid balance and 2716 (92.8%) had at least one day of fluid balance data following randomization. Over the subsequent 14 days, participants allocated to the accelerated strategy had a lower cumulative fluid balance compared to those in the standard strategy (4509 (− 728 to 11,698) versus 5646 (0 to 13,151) mL, p = 0.03). Accelerated RRT initiation did not confer greater 90-day survival in any of the baseline fluid balance quartiles (quartile 1: RR 1.11 (95% CI 0.92 to 1.34), quartile 2: RR 1.03 (0.87 to 1.21); quartile 3: RR 1.08 (95% CI 0.91 to 1.27) and quartile 4: RR 0.87 (95% CI 0.73 to 1.03), p value for trend 0.08).ConclusionsEarlier RRT initiation in critically ill patients with AKI conferred a modest attenuation of cumulative fluid balance. Nonetheless, among patients with greater fluid accumulation at randomization, accelerated RRT initiation did not have an impact on all-cause mortality.Trial registration: ClinicalTrials.gov number, https://clinicaltrials.gov/ct2/show/NCT02568722, registered October 6, 2015.

The Association of Cumulative Fluid Balance and Sepsis Patient Mortality During Treatment in the Intensive Care Unit

Introduction: Fluid management in sepsis patients is crucial, especially in the first three hours after sepsis diagnosis is established. However, excessive fluid administration will increase patient mortality. This study’s purpose is to determine the correlation among cumulative fluid balance and mortality in patients with sepsis and/or septic shock admitted to the Intensive Care Unit (ICU) of Dr. Wahidin Sudirohusodo Central Hospital, Makassar. Methods: This comes about as an analytical observational study with a retrospective method. The population involved in this study was patients diagnosed with sepsis and septic shock who were treated in the ICU of Dr. Wahidin Sudirohusodo Central Hospital, Makassar from January to December 2021 with a total sample of 56 people. Data were analyzed using Mann-Whitney and Chi-Square statistical tests with a significance level of α=0.05. Data were studied using SPSS 25.0 (SPSS, Inc. Chicago, IL). Results: The mean cumulative fluid balance in septic patients was -1299.51±5228.34 ml. Based on the fluid balance category, 24 people (42.9%) had a positive balance and 32 people (57.1%) had a negative balance. There was a correlation among cumulative fluid balance and mortality in sepsis patients hospitalized in the ICU of Dr. Wahidin Sudirohusodo Central Hospital (p &lt; 0.001), out of 24 patients with a positive balance, the non-survivors percentage was 66.7% and 33.3% of patients survived, while out of 32 patients with a negative balance, the percentage of non-survivors was 18.7% and 81.3% of patients survived. Conclusions: There is a correlation among cumulative fluid balance and mortality of septic patients in the ICU. A positive cumulative fluid balance will cause a higher mortality rate or risk of death compared to a negative cumulative fluid balance.

Influence of early fluid overload on bronchopulmonary dysplasia in very low-birth-weight infants.

ObjectiveThis study aimed to determine the influence of fluid overload on bronchopulmonary dysplasia (BPD) in very low-birth-weight infants (VLBWI) within 1 week after birth.MethodsThis was a retrospective case control study conducted in the Jingzhou Central Hospital. The clinical data of VLBWI (with a birth weight [BW] < 1,500 g and 26 weeks ≤ gestational age [GA] < 32 weeks) who were admitted to the neonatal intensive care unit of this hospital from January 2016 to December 2021 were analyzed retrospectively. A total of 157 cases were enrolled and divided into a BPD group (n = 60) and a non-BPD group (n = 97) according to whether BPD was present. The general condition, fluid intake, and fluid overload of the two groups of neonates within 1 week after birth were compared. The logistic regression was used to assess the association between infant characteristics and BPD. The ROC curve was used to assess how well the 7 day cumulative fluid overload predicted BPD, and to identify an optimal cut off for prediction.ResultsThe comparison of the patients' general condition revealed that the neonates in the BPD group had a younger GA, lower BW, lower 5-min Apgar score, longer duration of invasive mechanical ventilation, and higher incidence of intrauterine infections and administration of surfactants (P < 0.05). The differences in the other indicators were not statistically significant between the two groups. The logistic regression analysis revealed that a younger GA, the presence of intrauterine infection, and a 7-day cumulative fluid overload were the risk factors for the development of BPD. A ROC curve was plotted with the 7-day cumulative fluid overload as the test variable and BPD as the status variable. The area under the curve was 0.75 (95% confidence interval: 0.664–0.826, P = 0.042), with a sensitivity of 76.7% and a specificity of 70.1%, corresponding to a 7-day cumulative fluid overload of 36.2%.ConclusionA younger GA, the presence of intrauterine infection, and a 7-day cumulative fluid overload were risk factors for the development of BPD. A 7 day cumulative fluid overload threshold of 36.2% best predicted the development of BPD.

Bioelectrical impedance analysis during deresuscitation: correlation and agreement with cumulative fluid balance in ICU patients.

Bioelectrical impedance analysis (BIA) is a promising tool to evaluate the body composition of critically-ill patients. The present study aimed to assess its value as a fluid management monitoring tool during standardized deresuscitation strategy. A historical cohort of critically-ill adult patients with fluid overload and continuous renal replacement therapy was used to explore both relationship and agreement between changes in cumulative fluid balance and BIA-derived hydration variables within the 5days following initiation of deresuscitation strategy using net ultrafiltration. Correlations were described using Spearman's rank correlation coefficient, and agreement using Bland-Altman analysis for repeated measurements. Sixty-one couples of fluid shift measurements from 30 patients were analyzed. The deresuscitation strategy induced a negative mean (± SD) cumulative fluid balance (-4.2 ± 3.8 L) and a significant decrease in extra- and intracellular water (P < 0.001). Decreases in extra- and intracellular water were independent of weight variations inputted in the BIA device. Total body water (rho = 0.63), extracellular water (rho = 0.68), and intracellular water (rho = 0.67) were significantly correlated with cumulative fluid balance (all P values < 0.001). The limits of agreement did not allow interchangeability for a delta of 2L between cumulative fluid balance and BIA-derived hydration variables (P > 0.05). BIA hydration-derived variables are significantly correlated with cumulative fluid balance but the large limits of agreements exclude interchangeability of the measures.

Perfusion-based deresuscitation during continuous renal replacement therapy: A before-after pilot study (The early dry Cohort)

BackgroundActive fluid removal has been suggested to improve prognosis following the resolution of acute circulatory failure. We have implemented a routine care protocol to guide fluid removal during continuous renal replacement therapy (CRRT). We designed a before-after pilot study to evaluate the impact of this deresuscitation strategy on the fluid balance. MethodsConsecutive ICU patients suffering from fluid overload and undergoing CRRT for acute kidney injury underwent a perfusion-based deresuscitation protocol combining a restrictive intake, net ultrafiltration (UFnet) of 2 mL/kg/h, and monitoring of perfusion (early dry group, N = 42) and were compared to a historical group managed according to usual practices (control group, N = 45). The primary outcome was the cumulative fluid balance at day 5 or at discharge. ResultsAdjusted cumulative fluid balance was significantly lower in the early dry group (median [IQR]: −7784 [−11,833 to −2933] mL) compared to the control group (−3492 [−9935 to −1736] mL; p = 0.04). The difference was mainly driven by a greater daily UFnet (31 [22–46] mL/kg/day vs. 24 [15–32] mL/kg/day; p = 0.01). There was no significant difference between both groups regarding hemodynamic tolerance. ConclusionOur perfusion-based deresuscitation protocol achieved a greater negative cumulative fluid balance compared to standard practices and was hemodynamically well tolerated.