Current fluid management practice in critically ill adults on continuous renal replacement therapy: A binational, observational study.

Kyle C White, Kevin B. Laupland, M. Ostermann, Ary Serpa Neto, Michelle Gatton, R. Hurford, Pierre Clement, Barnaby Sanderson, R. Bellomo
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Abstract

Introduction In critically ill patients undergoing continuous renal replacement therapy (CRRT), a positive fluid balance (FB) is associated with adverse outcomes. However, current FB management practices in CRRT patients are poorly understood. We aimed to study FB and its components in British and Australian CRRT patients to inform future trials. Methods We obtained detailed electronic health record data on all fluid-related variables during CRRT and hourly FB for the first seven days of treatment. Results We studied 1,616 patients from three tertiary ICUs in two countries. After the start of CRRT, the mean cumulative FB became negative at 31 hours and remained negative over seven days to a mean nadir of -4.1 L (95% confidence intervals (CI) of -4.6 to -3.5). The net ultrafiltration (NUF) rate was the dominant fluid variable (-67.7 mL/h; SD 75.7); however, residual urine output (-34.7 mL/h; SD 54.5), crystalloid administration (48.1 mL/h; SD 44.6), and nutritional input (36.4 mL/h; SD 29.7) significantly contributed to FB. Patients with a positive FB after 72 hours of CRRT, were more severely ill, required high-dose vasopressors and had high lactate concentrations (5.0 mmol/L; IQR 2.3 - 10.5). A positive FB was independently associated with increased hospital mortality (OR 1.70; 95% CI; p=0.004). Conclusion In the study ICUs, most CRRT patients achieved a predominantly NUF-dependent negative FB. Patients with a positive FB at 72 hours had greater illness severity and haemodynamic instability. Achieving equipoise for conducting trials that target a negative early FB in such patients may be difficult.
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接受持续肾脏替代疗法的成人重症患者目前的液体管理实践:一项两国观察性研究。
导言 在接受持续肾脏替代治疗(CRRT)的重症患者中,正体液平衡(FB)与不良预后有关。然而,目前对 CRRT 患者的体液平衡管理方法知之甚少。我们的目的是研究英国和澳大利亚 CRRT 患者的体液平衡及其组成部分,为未来的试验提供参考。方法 我们获取了 CRRT 期间所有液体相关变量的详细电子健康记录数据,以及治疗头七天每小时的 FB 数据。结果 我们对两个国家三个三级重症监护病房的 1616 名患者进行了研究。CRRT 开始后,平均累积 FB 在 31 小时后出现负值,并在七天内保持负值,平均最低值为-4.1 升(95% 置信区间 (CI) 为-4.6 至-3.5)。净超滤(NUF)率是最主要的液体变量(-67.7 mL/h;SD 75.7);然而,残余尿量(-34.7 mL/h;SD 54.5)、晶体类药物给药(48.1 mL/h;SD 44.6)和营养输入(36.4 mL/h;SD 29.7)对 FB 有显著影响。CRRT 72 小时后 FB 呈阳性的患者病情更为严重,需要使用大剂量血管加压药,乳酸浓度较高(5.0 mmol/L;IQR 2.3 - 10.5)。FB 阳性与住院死亡率增加密切相关(OR 1.70;95% CI;P=0.004)。结论 在研究的重症监护病房中,大多数 CRRT 患者的 FB 主要为依赖 NUF 的阴性。72 小时内 FB 呈阳性的患者病情更严重,血流动力学更不稳定。在针对此类患者进行早期 FB 为阴性的试验时,可能很难实现平衡。
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