Category Archives: Renal

SPLIT Trial

Effect of 0.9% saline versus buffered crystalloid solution on renal complications in ICU patients. Based on concerns that renal artery blood flow (and hence nephron perfusion) falls to greater

Bellomo n 2012 demonstrated an association between chloride rich fluid and AKI

  • Changed from gelatin, albumin and 0.9% saline to balanced
  • Could be that gelatinS were harmful, rather than saline

Hence SPLIT

Double-blind, cluster randomised, double-crossover trial

4 ICUs in New Zealand April til October 2014

  • 3 general medical and surgical
  • 1 predominantly cardiothoracic and vascular surgery

Conducted in all centres with with each centre using 0.9% saline or Plasmalyte for blocks of 7 weeks x 2

2278 patients included

  • 1152 Plasmlayte treated and analysed
  • 1100 0.9% saline treated and analysed

99% of eligible patients were enrolled, followed up and analysed

Treatment groups had similar baseline characteristics

  • About 60 years
  • 2/3 male
  • 42% cardiac surgery
  • 60% elective surgical
  • APACHE-II around 14
  • Approx 60% had received buffered crystalloid pre-ICU and 30% saline

No difference in incidence of AKI (9.6% in Plasmalyte, 9.2% in 0.9% saline)

No difference in need for RRT

Need for RRT

No difference in any of pre-defined subgroups (APACHE high or low, centre, sepsis, cardiac surgery)

Subgroups

No difference in mortality although not powered for that

Conclusion: Among patients receiving crystalloid fluid therapy in the ICU, use of a buffered crystalloid compared with saline did not reduce the risk of AKI.

Effect of a Buffered Crystalloid Solution vs Saline on Acute Kidney Injury Among Patients in the Intensive Care Unit

Association Between a Chloride-Liberal vs Chloride-Restrictive Intravenous Fluid Administration Strategy and Kidney Injury in Critically Ill Adults

Clinical Trial Session 2

CAESAR Study (Azoulay)

Post-ICU syndrome and the burden of care on relatives. Hence the need to develop a tool to assess this.

A high CAESAR score represents higher family satisfaction with care

Conclusion – CAESAR instrument

  • new instrument based on family experience that will help develop family centred care
  • lower scores associated with higher burden
  • clinically, may be useful to identify vulnerable families

 

FLUID-TRIPS (Hammond)

Albumin studies – SAFE, VISEP, CRYSTMAS, CHEST, 6S, ALBIOS

Inter-country variation in types of fluid prescribed

Conclusion

  • signification variation in fluid use remains
  • significant secular changes in patterns of fluid resuscitation between 2007-2014
  • crytalloids still predominate
  • increased use of balanced salt solutions
  • pattern of colloid use consistent with recent RCT

SAFE TRIP study

Fluid-TRIPS protocol

 

CHECKLIST-ICU (Cavalanti)

Checklist and daily goals read out during round

No difference in mortality!

CHECKLIST ICU Trial protocol

Trial statistical analysis plan

Protocols and Hospital Mortality in Critically Ill Patients: The United States Critical Illness and Injury Trials Group Critical Illness Outcomes Study

 

Very high volume hemofiltration with the Cascade system in septic shock patients

Cascade trial

 

 

Quality Assurance in RRT for AKI in critically ill patients

What quality indicators should we use?

Quality indicators need the following

  • Measurable clinical outcomes
  • Technical adherence to standards
  • Assessment of interpersonal relationships as defined by stakeholders

What constitutes quality CRRT? KDIGO says the following:

  • Initiate RRT emergency when life-threatening metabolic changes (Not graded)
  • Consider broader clinical context and conditions which can be modified with RRT rather than absolute values of lab tests when deciding to start RRT (not graded)
  • Discontinue when no longer required (not graded)
  • Avoid subclavian route
  • Use heparin as first line anticoagulant

Continue reading Quality Assurance in RRT for AKI in critically ill patients

NEXT Day – HOT TOPICS 2015

Multimodal monitoring (Oddo)

Monitoring devices does not replace clinical examination

ICP can be elevated despite absent mass lesion on CT brain

No possible to have continuous neuroimaging as monitor

Sedation interruption among TBI with intracranial hypertension is not recommended

ICP and CPP monitoring are recommended as part of a protocol-guided, individualised care

References

Consensus statement on multimodal monitoring on neurocritical care

NEJM ICP trial 2012

Monitoring the brain and systemic oxygenation in neurocritical care patients

Multimodal neuromonitoring to detect brain hypoxia in TBI

Continue reading NEXT Day – HOT TOPICS 2015