Positive Fluid Balance Research Articles

Association between diastolic dysfunction and fluid balance in critically ill patients during weaning from mechanical ventilation

ObjectiveTo assess the role of diastolic dysfunction and fluid balance in weaning failure. DesignProspective, observational, single center. SettingIntensive care unit of a university hospital. PatientsAdult patients on mechanical ventilation for more than 48 h who underwent a spontaneous breathing trial (SBT). InterventionsEchocardiography was performed immediately before and at the end of SBT. Patients were classified into two groups according to weaning outcome. Main variable of interestWeaning failure. ResultsAmong 89 patients included, weaning failure occurred in 33 patients (37%). Isolated diastolic dysfunction at the end of the SBT was more frequent in the failure group (39.3% vs. 17.8%, p = 0.025). Average daily fluid balance from ICU admission until first SBT was less negative in patients who failed than in those who succeed in the weaning (−648 mL [−884 to -138] vs. −893 mL [−1284 to −501], p = 0.007). Average daily fluid balance from the first SBT until the ICU discharge was more negative in the weaning failure than in the success group (−973 mL [−1493 to −201] vs. −425 mL [−1065 to 12], p = 0.034). Cox regression analysis showed that diastolic dysfunction was not an independent factor related to weaning failure but needed the association of positive fluid balance and age. ConclusionsWeaning failure due to diastolic dysfunction is highly related to fluid balance, and the deleterious effect of fluid balance on diastolic function is associated with age The timing of fluid removal could play a key role in this scenario.

Prognostic factors for critically ill surgical patients with unplanned intensive care unit readmission: Developing a novel predictive scoring model for predicting readmission

BackgroundUnplanned readmission to the surgical intensive care unit has been demonstrated to worsen patient outcomes. Our objective was to identify risk factors and outcomes associated with unplanned surgical intensive care unit readmission and to develop a predictive scoring model to identify patients at high risk of readmission. MethodsWe retrospectively analyzed patients admitted to the surgical intensive care unit (2020–2021) and categorized them as either with or without unplanned readmission. ResultsOf 1,112 patients in the derivation cohort, 76 (6.8%) experienced unplanned surgical intensive care unit readmission, with sepsis being the leading cause of readmission (35.5%). Patients who were readmitted had significantly higher in-hospital mortality rates than those who were not. Multivariate analysis identified congestive heart failure, high Sequential Organ Failure Assessment–Hepatic score, use of carbapenem during surgical intensive care unit stay, as well as factors before surgical intensive care unit discharge such as inadequate glycemic control, positive fluid balance, low partial pressure of oxygen in arterial blood/fraction of inspired oxygen ratio, and receipt of total parenteral nutrition as independent predictors for unplanned readmission. The scoring model developed using these predictors exhibited good discrimination between readmitted and non-readmitted patients, with an area under the curve of 0.74. The observed rates of unplanned readmission for scores of <4 points and ≥4 points were 4% and 20.2% (P < .001), respectively. The model also demonstrated good performance in the validation cohort, with an area under the curve of 0.74 and 19% observed unplanned readmission rate for scores ≥4 points. ConclusionBesides congestive heart failure, clinicians should meticulously re-evaluate critical variables such as the Sequential Organ Failure Assessment–Hepatic score, partial pressure of oxygen in arterial blood/fraction of inspired oxygen ratio, glycemic control, and fluid status before releasing the patient from the surgical intensive care unit. It is crucial to determine the reasons for using carbapenems during surgical intensive care unit stay and the causes for the inability to discontinue total parenteral nutrition before discharging the patient from the surgical intensive care unit.

Machine learning vs. traditional regression analysis for fluid overload prediction in the ICU

Fluid overload, while common in the ICU and associated with serious sequelae, is hard to predict and may be influenced by ICU medication use. Machine learning (ML) approaches may offer advantages over traditional regression techniques to predict it. We compared the ability of traditional regression techniques and different ML-based modeling approaches to identify clinically meaningful fluid overload predictors. This was a retrospective, observational cohort study of adult patients admitted to an ICU ≥ 72 h between 10/1/2015 and 10/31/2020 with available fluid balance data. Models to predict fluid overload (a positive fluid balance ≥ 10% of the admission body weight) in the 48–72 h after ICU admission were created. Potential patient and medication fluid overload predictor variables (n = 28) were collected at either baseline or 24 h after ICU admission. The optimal traditional logistic regression model was created using backward selection. Supervised, classification-based ML models were trained and optimized, including a meta-modeling approach. Area under the receiver operating characteristic (AUROC), positive predictive value (PPV), and negative predictive value (NPV) were compared between the traditional and ML fluid prediction models. A total of 49 of the 391 (12.5%) patients developed fluid overload. Among the ML models, the XGBoost model had the highest performance (AUROC 0.78, PPV 0.27, NPV 0.94) for fluid overload prediction. The XGBoost model performed similarly to the final traditional logistic regression model (AUROC 0.70; PPV 0.20, NPV 0.94). Feature importance analysis revealed severity of illness scores and medication-related data were the most important predictors of fluid overload. In the context of our study, ML and traditional models appear to perform similarly to predict fluid overload in the ICU. Baseline severity of illness and ICU medication regimen complexity are important predictors of fluid overload.

Fluid assessment, fluid balance, and fluid overload in sick children: a report from the Pediatric Acute Disease Quality Initiative (ADQI) conference

BackgroundThe impact of disorders of fluid balance, including the pathologic state of fluid overload in sick children has become increasingly apparent. With this understanding, there has been a shift from application of absolute thresholds of fluid accumulation to an appreciation of the intricacies of fluid balance, including the impact of timing, trajectory, and disease pathophysiology.MethodsThe 26th Acute Disease Quality Initiative was the first to be exclusively dedicated to pediatric and neonatal acute kidney injury (pADQI). As part of the consensus panel, a multidisciplinary working group dedicated to fluid balance, fluid accumulation, and fluid overload was created. Through a search, review, and appraisal of the literature, summative consensus statements, along with identification of knowledge gaps and recommendations for clinical practice and research were developed.ConclusionsThe 26th pADQI conference proposed harmonized terminology for fluid balance and for describing a pathologic state of fluid overload for clinical practice and research. Recommendations include that the terms daily fluid balance, cumulative fluid balance, and percent cumulative fluid balance be utilized to describe the fluid status of sick children. The term fluid overload is to be preserved for describing a pathologic state of positive fluid balance associated with adverse events. Several recommendations for research were proposed including focused validation of the definition of fluid balance, fluid overload, and proposed methodologic approaches and endpoints for clinical trials.

Effect of controlled hypotensive hemorrhage on plasma sodium levels in anesthetized pigs: An exploratory study.

Perioperative hyponatremia, due to non-osmotic release of the antidiuretic hormone arginine vasopressin, is a serious electrolyte disorder observed in connection with many types of surgery. Since blood loss during surgery contributes to the pathogenesis of hyponatremia, we explored the effect of bleeding on plasma sodium using a controlled hypotensive hemorrhage pig model. After 30-min baseline period, hemorrhage was induced by aspiration of blood during 30 min at mean arterial pressure <50 mmHg. Thereafter, the animals were resuscitated with retransfused blood and a near-isotonic balanced crystalloid solution and monitored for 180 min. Electrolyte and water balances, cardiovascular response, renal hemodynamics, and markers of volume regulation and osmoregulation were investigated. All pigs (n = 10) developed hyponatremia. All animals retained hypotonic fluid, and none could excrete net-free water. Urinary excretion of aquaporin 2, a surrogate marker of collecting duct responsiveness to antidiuretic hormone, was significantly reduced at the end of the study, whereas lysine vasopressin, i.e., the pig antidiuretic hormone remained high. In this animal model, hyponatremia developed due to net positive fluid balance and generation of electrolyte-free water by the kidneys. A decreased urinary aquaporin 2 excretion may indicate an escape from antidiuresis.

Impact of Positive Fluid Balance and Timing of Renal Replacement Therapy in AKI in a Real-Life Scenario

Impact of Positive Fluid Balance and Timing of Renal Replacement Therapy in AKI in a Real-Life Scenario

Impact of a cumulative positive fluid balance during the first three ICU days in patients with sepsis: a propensity score-matched cohort study

BackgroundThe optimal strategy for fluid management during the first few days of ICU in sepsis patients remains controversial. We aimed to investigate the impact of cumulative fluid balance during the first three days of ICU on the mortality of patients with sepsis.MethodsThis study analyzed prospectively collected data from the Korean Sepsis Alliance Database, which registered 11,981 sepsis patients from 20 hospitals. We selected three propensity score-matched cohorts consisting of patients with a negative or positive cumulative fluid balance during the first three ICU days: from ICU admission to the first midnight as the D1 cohort, until the second midnight as the D2 cohort, and until the third midnight as the D3 cohort. The propensity score for fluid balance was calculated using covariates including the amount of fluid output during the first three ICU days. The primary outcome was mortality at day 28 in the ICU.ResultsFrom a total of 11,981 patients, 2516 patients were included for propensity score matching. After matching in a 1:1 ratio, there were 483, 373, and 392 matched pairs of patients assigned to the D1, D2, and D3 cohorts, respectively. In the D1 cohort, there were no significant differences in mortality at day 28 (hazard ratio [HR], 1.17; 95% confidence interval [CI] 0.85–1.60; P = 0.354) between the two groups. The positive fluid groups in both the D2 (HR, 2.13; 95% CI 1.48–3.06; P < 0.001) and D3 (HR, 1.56; 95% CI 1.10–2.22; P = 0.012) cohorts had significantly higher mortality rates than the negative fluid groups.ConclusionsIn patients with sepsis, a positive fluid balance on the first ICU day was not associated with mortality at day 28. In contrast, cumulative positive fluid balances on the second and third ICU days were associated with higher mortality at day 28.

The relationship between commencement of continuous renal replacement therapy and urine output, fluid balance, mean arterial pressure and vasopressor dose

Background and objectives: The effect of initiating continuous renal replacement therapy (CRRT) on urine output, fluid balance and mean arterial pressure (MAP) in adult intensive care unit (ICU) patients is unclear. We aimed to evaluate the impact of CRRT on urine output, MAP, vasopressor requirements and fluid balance, and to identify factors affecting urine output during CRRT. Design: Retrospective cohort study using data from existing databases and CRRT machines. Setting: Medical and surgical ICUs at a single university-associated centre. Participants: Patients undergoing CRRT between 2015 and 2018. Main outcome measures: Hourly urine output, fluid balance, MAP and vasopressor dose 24 hours before and after CRRT commencement. Missing values were estimated via Kaplan smoothing univariate time-series imputation. Mixed linear modelling was performed with noradrenaline equivalent dose and urine output as outcomes. Results: In 215 patients, CRRT initiation was associated with a reduction in urine output. Multivariate analysis confirmed an immediate urine output decrease (-0.092 mL/kg/h; 95% confidence interval [CI], -0.150 to -0.034 mL/kg/h) and subsequent progressive urine output decline (effect estimate, -0.01 mL/kg/h; 95% CI, -0.02 to -0.01 mL/kg/h). Age and greater vasopressor dose were associated with lower post-CRRT urine output. Higher MAP and lower rates of net ultrafiltration were associated with higher post-CRRT urine output. With MAP unchanged, vasopressor dose increased in the 24 hours before CRRT, then plateaued and declined in the 24 hours thereafter (effect estimate, -0.004 μg/kg/ min per hour; 95% CI, -0.005 to -0.004 μg/kg/min per hour). Fluid balance remained positive but declined towards neutrality following CRRT implementation. Conclusions: CRRT was associated with decreased urine output despite a gradual decline in vasopressor and a positive fluid balance. The mechanisms behind the reduction in urine output associated with commencement of CRRT requires further investigation.

Isolate Whey Protein Promotes Fluid Balance and Endurance Capacity Better Than Isolate Casein and Carbohydrate-Electrolyte Solution in a Warm, Humid Environment.

Protein ingestion is known to enhance post-exercise hydration. Whether the type of protein (i.e., whey, casein) can alter this response is unknown. Accordingly, this study aimed to compare the effects of the addition of milk-derived whey isolate or casein protein to carbohydrate-electrolyte (CE) drinks on post-exercise rehydration and endurance capacity. Thirty male soldiers (age: 24 ± 2.1 y; VO2max: 49.3 ± 4.7 mL/kg/min) were recruited. Upon losing ~2.2% of body mass by running in warm and humid conditions (32.3 °C, 76% relative humidity [RH]), participants ingested either a CE solution (66 g/L carbohydrate [CHO]), or CE plus isolate whey protein (CEW, 44 g/L CHO, 22 g/L isolate whey), or CE plus isolate casein protein (CEC, 44 g/L CHO, 22 g/L isolate casein) beverage in a volume equal to 150% of body mass loss. At the end of the 3 h rehydration period, a positive fluid balance was higher with CEW (0.22 L) compared to CEC (0.19 L) and CE (0.12 L). Overall mean fluid retention was higher in CEW (80.35%) compared with the CE (76.67%) and CEC trials (78.65%). The time of the endurance capacity test [Cooper 2.4 km (1.5 miles) run test] was significantly higher in CEC (14.25 ± 1.58 min) and CE [(12.90 ± 1.01 min; (p = 0.035)] than in CEW [(11.40 ± 1.41 min); (p = 0.001)]. The findings of this study indicate that the inclusion of isolate whey protein in a CE solution yields superior outcomes in terms of rehydration and enhanced endurance capacity, as compared to consuming the CE solution alone or in conjunction with isolate casein protein.

The Impact of Positive Fluid Balance on Sepsis Subtypes: A Causal Inference Study.

Sepsis, the leading cause of death in hospitalized patients globally, was investigated in this study, examining the varying effects of positive fluid balance on sepsis subtypes through causal inference. In this study, data from the eICU database were utilized, extracting 35 features from sepsis patients. Fluid balance during ICU stay was the treatment, and ICU mortality was the primary outcome. Data preprocessing ensured linear assumptions for logistic regression. Binarized positive fluid balance with mortality was examined using DoWhy's logistic regression, while continuous data were analyzed with random forest T-learner. ATE served as the primary metric. Results revealed that septic patients with higher fluid balance had worse mortality outcomes, with an ATE of 0.042 (95% CI: (0.034, 0.047)) using logistic regression and an ATE of 0.0340 (95% CI: (0.028-0.040)) using T-learner. In the pulmonary sepsis subtype, higher mortality was associated with increased fluid balance, showing an ATE of 0.047 (95% CI: (0.037, 0.055)) using logistic regression and an ATE of 0.28 (95% CI: (0.22, 0.34)) with T-learner. Conversely, urinary sepsis patients had improved mortality with higher fluid balance, presenting an ATE of -0.135 (95% CI: (-0.024, -0.0035)) using logistic regression and an ATE of -0.28 (95% CI: (-0.34, -0.22)) with T-learner. Our research implies that fluid balance impact on ICU mortality differs among sepsis subtypes. Positive fluid balance raises mortality in sepsis and pulmonary sepsis but may protect against urinary sepsis. Further trials are needed to confirm these findings.

Cumulative fluid balance in the postoperative period of abdominal surgery

Materials and methods. To analyze the volumes of administered and removed fluid, fluid balance, cumulative fluid balance during 5 days and its relationship with mortality in 143 patients after abdominal surgical interventions who were treated in the department of anesthesiology and intensive care. Two groups of patients were identified: 1st (n = 86) - without sepsis, 2nd (n = 57) - with the presence of sepsis. There were no deaths in group 1, 11 patients (19.3%) died in group 2.Results. The patients of the 2nd group had a positive fluid balance in the volume of 1.55 (1.2; 2.4) liters on the first day, which was significantly greater than in the patients of the 1st group - 1.1 (0.4; 1.8) liters (p = 0.0016). At the subsequent stages, the fluid balance in patients in the studied groups did not differ. The optimal limits for maintaining the cumulative fluid balance during 5 days in patients of the 2nd group in the postoperative period of surgical interventions were established: less than 5.6 liters or less than 8 % of the patient’s body weight. Exceeding the 5-day cumulative fluid balance above 5.6 liters or more than 8 % of body weight resulted in a significant increase in the risk of mortality among patients in group 2: odds ratio (OR) - 1.39 (p &lt; 0.01) and 1.24 (p &lt; 0.01), respectively.Conclusion. The features of fluid balance in patients with sepsis in the postoperative period of abdominal surgical interventions are highlighted.

Cardiopulmonary interactions during ventilator weaning.

Weaning a critically-ill patient from the ventilator is a crucial step in global management. This manuscript details physiological changes induced by altered heart-lung interactions during the weaning process, illustrates the main mechanisms which could lead to weaning failure of cardiac origin, and discuss a tailored management based on the monitoring of changes in central hemodynamics during weaning. The transition from positive-pressure ventilation to spontaneous breathing results in abrupt hemodynamic and metabolic changes secondary to rapidly modified heart-lung interactions, sudden changes in cardiac loading conditions, and increased oxygen demand. These modifications may elicit an excessive burden on both the respiratory and cardiovascular systems, result in a rapid and marked increase of left ventricular filling pressure, and ultimately result in a weaning-induced pulmonary oedema (WIPO). The T-piece trial induces the greatest burden on respiratory and cardiocirculatory function when compared to spontaneous breathing trial using pressure support ventilation with positive or zero end-expiratory pressure. Since LV overload is the mainstay of WIPO, positive fluid balance and SBT-induced acute hypertension are the most frequently reported mechanisms of weaning failure of cardiac origin. Although the diagnosis of WIPO historically relied on an abrupt elevation of pulmonary artery occlusion pressure measured during right heart catheterization, it is nowadays commonly documented by echocardiography Doppler. This non-invasive approach is best suited for identifying high-risk patients, depicting the origin of WIPO, and tailoring individual management. Whether this strategy increases the success rate of weaning needs to be evaluated in a population at high risk of weaning failure of cardiac origin.

Predictive Value of Doppler Renal Resistive Index for Prediction of Acute Kidney Injury in Septic Patients in Intensive Care Unit

Abstract Background Acute kidney injury (AKI) occurs as a serious complication in septic patients. In its severe form, AKI requires renal replacement therapy, which is applied in 5–13% of intensive care units (ICU) patients. AKI is common in patients confined in ICU and remains to be associated with poor outcomes. According to the current diagnostic criteria, serum creatinine (SCr) and urine volume are used as diagnostic and staging criteria for AKI. Aim of the Work To evaluate predictive value of renal resistive index in detection of acute kidney injury. Measuring flow resistance in the renal circulation, Renal Resistive Index (RRI) could become part of vital organ function assessment using Doppler ultrasound. Patients and Methods This was a prospective descriptive study conducted on 150 ICU patients with sepsis; to evaluate prediction value of renal resistive index in detection of acute kidney injury. Measuring flow resistance in the renal circulation, RRI could become part of vital organ function assessment using Doppler ultrasound. Results We found that; the mean age of all patients was (38.4 ± 13.5) years. Regarding gender of the patients, the majority (62.7%) of patients were males; while (37.3%) were females. Regarding basic clinical data; the average MAP was (57.6 ± 14.8) mmHg, the average APACHE score was (14.6 ± 3.7), and the average SOFA score was (4.2 ± 0.92). Regarding comorbidities; (24.7%) of patients had septic shock, (20%) had DM, (34%) had HTN, and (14.7%) had IHD. Conclusion High RRI on ICU admission was a significant predictor for development of AKI stage 2 ± 3 during the first week. High RRI can be used as an early warning signal RRI, because of its high specificity. A combined score including RRI, APACHE III and fluid balance improved AKI prediction, suggesting that vasoconstriction or poor vascular compliance, severity of disease and positive fluid balance independently contribute to AKI development.

Use of furosemide in preterm neonates with acute kidney injury is associated with increased mortality: results from the TINKER registry.

Diuretics are commonly used in neonatal AKI with the rationale to decrease positive fluid balance in critically sick neonates. The patterns of furosemide use vary among hospitals, which necessitates the need for a well-designed study. The TINKER (The Indian Iconic Neonatal Kidney Educational Registry) study provides a database, spanning 14 centres across India since August 2018. Admitted neonates (≤ 28days) receiving intravenous fluids for at least 48h were included. Neonatal KDIGO criteria were used for the AKI diagnosis. Detailed clinical and laboratory parameters were collected, including the indications of furosemide use, detailed dosing, and the duration of furosemide use (in days). A total of 600 neonates with AKI were included. Furosemide was used in 8.8% of the neonates (53/600). Common indications of furosemide use were significant cardiac disease, fluid overload, oliguria, BPD, RDS, hypertension, and hyperkalemia. The odds of mortality was higher in neonates < 37 weeks gestational agewith AKIwho received furosemide compared to those who did not receive furosemide 3.78 [(1.60-8.94); p = 0.003; univariate analysis] and [3.30 (1.11-9.82); p = 0.03]; multivariate logistic regression]. In preterm neonates with AKI, mortality was independently associated with furosemide treatment. The furosemide usage rates were higher in neonates with associated co-morbidities, i.e. significant cardiac diseases or surgical interventions. Sicker babies needed more resuscitation at birth, and died early, and hence needed shorter furosemide courses. Thus, survival probability was higher in neonates treated with long furosemide courses vs. short courses.

Acute Kidney Injury Defined by Fluid-Corrected Creatinine in Premature Neonates

Acute kidney injury (AKI) and disordered fluid balance are common in premature neonates; a positive fluid balance dilutes serum creatinine, and a negative fluid balance concentrates serum creatinine, both of which complicate AKI diagnosis. Correcting serum creatinine for fluid balance may improve diagnosis and increase diagnostic accuracy for AKI. To determine whether correcting serum creatinine for fluid balance would identify additional neonates with AKI and alter the association of AKI with short-term and long-term outcomes. This study was a post hoc cohort analysis of the Preterm Erythropoietin Neuroprotection Trial (PENUT), a phase 3, randomized clinical trial of erythropoietin, conducted at 19 academic centers and 30 neonatal intensive care units in the US from December 2013 to September 2016. Participants included extremely premature neonates born at less than 28 weeks of gestation. Data analysis was conducted in December 2022. Diagnosis of fluid-corrected AKI during the first 14 postnatal days, calculated using fluid-corrected serum creatinine (defined as serum creatinine multiplied by fluid balance [calculated as percentage change from birth weight] divided by total body water [estimated 80% of birth weight]). The primary outcome was invasive mechanical ventilation on postnatal day 14. Secondary outcomes included death, hospital length of stay, and severe bronchopulmonary dysplasia (BPD). Categorical variables were analyzed by proportional differences with the χ2 test or Fisher exact test. The t test and Wilcoxon rank sums test were used to compare continuous and ordinal variables, respectively. Odds ratios (ORs) and 95% CIs for the association of exposure with outcomes of interest were estimated using unconditional logistic regression models. A total of 923 premature neonates (479 boys [51.9%]; median [IQR] birth weight, 801 [668-940] g) were included, of whom 215 (23.3%) received a diagnosis of AKI using uncorrected serum creatinine. After fluid balance correction, 13 neonates with AKI were reclassified as not having fluid-corrected AKI, and 111 neonates previously without AKI were reclassified as having fluid-corrected AKI (ie, unveiled AKI). Therefore, fluid-corrected AKI was diagnosed in 313 neonates (33.9%). Neonates with unveiled AKI were similar in clinical characteristics to those with AKI whose diagnoses were made with uncorrected serum creatinine. Compared with those without AKI, neonates with unveiled AKI were more likely to require ventilation (81 neonates [75.0%] vs 254 neonates [44.3%] and have longer hospital stays (median [IQR], 102 [84-124] days vs 90 [71-110] days). In multivariable analysis, a diagnosis of fluid-corrected AKI was associated with increased odds of adverse clinical outcomes, including ventilation (adjusted OR, 2.23; 95% CI, 1.56-3.18) and severe BPD (adjusted OR, 2.05; 95% CI, 1.15-3.64). In this post hoc cohort study of premature neonates, fluid correction increased the number of premature neonates with a diagnosis of AKI and was associated with increased odds of adverse clinical outcomes, including ventilation and BPD. Failing to correct serum creatinine for fluid balance underestimates the prevalence and impact of AKI in premature neonates. Future studies should consider correcting AKI for fluid balance. ClinicalTrials.gov Identifier: NCT01378273.

Clinical Features and Outcomes of Acute Kidney Injury in Critically Ill COVID-19 Patients: A Retrospective Observational Study.

An alarming number of COVID-19 patients, especially in severe cases, have developed acute kidney injury (AKI). The study aimed to assess the frequency, risk factors, and impact of AKI on mortality in critically ill COVID-19 patients. The study was a retrospective observational study conducted in the MICU. Univariate and multivariate analyses were performed to identify risk factors for AKI and clinical outcomes. During the study period, 465 consecutive COVID-19 patients were admitted to the MICU. The patients' characteristics were median age, 64 [54-71] years; median SAPSII, 31 [24-38]; and invasive mechanical ventilation (IMV), 244 (52.5%). The overall ICU mortality rate was 49%. Two hundred twenty-nine (49.2%) patients developed AKI. The factors independently associated with AKI were positive fluid balance (OR, 2.78; 95%CI [1.88-4.11]; p < 0.001), right heart failure (OR, 2.15; 95%CI [1.25-3.67]; p = 0.005), and IMV use (OR, 1.55; 95%CI [1.01-2.40]; p = 0.044). Among the AKI patients, multivariate analysis identified the following factors as independently associated with ICU mortality: age (OR, 1.05; 95%CI [1.02-1.09]; p = 0.012), IMV use (OR, 48.23; 95%CI [18.05-128.89]; p < 0.001), and septic shock (OR, 3.65; 95%CI [1.32-10.10]; p = 0.012). The present study revealed a high proportion of AKI among critically ill COVID-19 patients. This complication seems to be linked to a severe cardiopulmonary interaction and fluid balance management, thus accounting for a poor outcome.

Perioperative continuous body weight measurements with load cells under the bed legs in patients undergoing abdominal surgery

BACKGROUND Both excessive positive fluid balance and body weight increase after surgery are risk factors for poor postoperative outcomes. The use in clinical practice and the value of perioperative body weight measurements are unclear at present, possibly due to difficulty in measuring body weight in patients lying on the bed and insufficient clinical research. OBJECTIVES To investigate the relationship between intraoperative fluid balance and body weight change and perioperative nightly body weight change pattern throughout the hospital stay with contact-free unconstraint load cells placed under the bed legs. DESIGN Observational and exploratory study. SETTING A single university hospital. PATIENTS Twenty adult patients were undergoing elective abdominal surgery under general anaesthesia. MAIN OUTCOME MEASURES Body weight. RESULTS Immediately after surgery, body weight increased significantly by 2.7 ± 1.3 kg, equivalent to a 5% increase from the preoperative body weight. This increase was not correlated with (P = 0.178) the intraoperative fluid balance and was significantly greater than the intraoperative fluid balance 1.5 ± 0.4 kg (P &lt; 0.001). The body weight returned to the preoperative level on postoperative day (POD)3 and further significantly decreased to 97% of the preoperative body weight at POD6 (P &lt; 0.001). This physiological nocturnal weight loss pattern was maintained throughout hospitalisation except when fluid was infused. Compared with their preoperative status, patients stayed in bed longer with smaller body movements and left the bed less frequently during the daytime until POD3. Conversely, the patients had greater body movements in bed during the night leading to smaller diurnal variation in the body movements in bed after POD4. CONCLUSION Both perioperative fluid balance calculation and body weight measurement may have different but mutually complementary roles in perioperative managements. Postoperative fluid and nutrition management strategies are potentially new directions for treatment through continuous weight monitoring during the perioperative period. Trial registration : UMIN Clinical Trials Registry (UMIN000040164).

The association between increasing fluid balance, acute kidney injury and mortality in patients with sepsis and septic shock: A retrospective single center audit

PurposeTo determine whether a positive fluid balance is associated with AKI and mortality in sepsis and septic shock patients. MethodsA retrospective chart review of 482 patients treated for sepsis or septic shock. Patients were stratified according to quartiles of cumulative fluid balance on days 1 and 3. Logistic models were built to explore the association between fluid balance, AKI, and ICU mortality. ResultsDuring the first days of ICU admission, fluid input did not differ between survivors and non-survivors, yet a significant difference in output resulted in a more positive fluid balance in non-survivors on day 1 (37.24 ± 31.98 ml/kg vs. 24.97 ± 23.76 ml/kg, p < 0.001) and day 3 (83.33 ± 70.86 ml/kg vs. 62.20 ± 45.90 ml/kg, P = 0.005). Using a logistic regression model, a positive fluid balance on day three was independently associated with higher ICU mortality (odds ratio 1.007 for every one ml/kg, P = 0038) and AKIN stage III (odds ratio 1.006 for every one ml/kg, p = 0.031). ConclusionIn patients with sepsis and septic shock, a more positive fluid balance is associated with an increased incidence of acute kidney injury and death after correction for possible confounders.

C-reactive protein to albumin ratio in critical care settings

PurposeCompare the performance of the C-reactive protein to albumin ratio (CAR) in predicting in-hospital death between patients with and without COVID-19. Materials and methodsThis prospective cohort study included critically ill patients with and without COVID-19. CAR was obtained at admission and on Day 3, along with fluid balance and other predictive scores. The primary outcome was all-cause in-hospital death, and the Youden index was used to determine CAR cut-off points. ResultsWe included the data of 176 patients; 85 had COVID-19. All-cause in-hospital death was 31.3%. The CAR cut-off points for patients without COVID-19 were 28.5mg/g and 31.6mg/g at admission and on Day 3, respectively, and 13.5mg/g and 7.4mg/g for COVID-19 patients. Day 3 CAR was a better predictor of all-cause in-hospital death than CAR at admission in both groups. Non-survivors in the COVID and non-COVID groups had higher positive fluid balance rates than survivors. ConclusionsThe CAR predicted in-hospital death in both groups, with different cut-off points. CAR on Day 3 had better diagnostic performance than that at admission. Cumulative fluid balance may influence CAR kinetics. An optimal CAR cut-off point for critically ill patients, optimal measuring time, and impact of fluids therapy still need to be established.

Postoperative acute respiratory distress syndrome in randomized controlled trials

BackgroundAcute respiratory distress syndrome is a potentially fatal postoperative complication. We aimed to estimate temporal trends of the representation of patients with postoperative acute respiratory distress syndrome in clinical trials, determine their distinct clinical features, and identify predictors of mortality. MethodsThis is a secondary analysis of 7 randomized controlled clinical trials conducted by the Acute Respiratory Distress Syndrome Network and the Clinical Trials Network for the Prevention and Early Treatment of Acute Lung Injury. Patients with acute respiratory distress syndrome were classified into a postoperative acute respiratory distress syndrome group (ie, patients who had undergone elective surgery in the immediate period before trial enrollment) and a non-postoperative acute respiratory distress syndrome group. ResultsOut of 5,316 patients with acute respiratory distress syndrome, 256 (4.8%) had postoperative acute respiratory distress syndrome. Representation of postoperative acute respiratory distress syndrome in trials gradually declined from 2000 to 2011, but it remained stable afterward at 2.7%. Postoperative acute respiratory distress syndrome was associated with lower 90-day mortality (24.6% vs 30.9%, P = .032) than non-postoperative acute respiratory distress syndrome, even after adjusting for age, acute respiratory distress syndrome severity, usage of vasopressors at baseline, and the study publication year (hazard ratio 0.63, 95% confidence interval 0.49–0.82). Age (odds ratio 1.07, 95% confidence interval 1.04–1.09), immunosuppression (odds ratio 4.12, 95% confidence interval 1.43–11.86), and positive fluid balance (odds ratio 1.09, 95% confidence interval 1.04–1.14) were associated with 90-day mortality among patients with postoperative acute respiratory distress syndrome. ConclusionRepresentation of postoperative acute respiratory distress syndrome in trials of the Acute Respiratory Distress Syndrome Network and the Clinical Trials Network for the Prevention and Early Treatment of Acute Lung Injury gradually declined from 2000 to 2011 but remained stable afterward. Postoperative acute respiratory distress syndrome was associated with lower mortality than non-postoperative acute respiratory distress syndrome. These findings may put both temporal trends and the prognosis of postoperative acute respiratory distress syndrome in perspective. Also, positive fluid balance was associated with the mortality of patients with postoperative acute respiratory distress syndrome.