Intensive Care Unit Management of the Critically Ill Patient with Fluid Overload after Open Heart Surgery

Bellomo, Rinaldo; Raman, Jai; Ronco, Claudio

doi:10.1159/000047400

Cited by 62 publications

(46 citation statements)

References 22 publications

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“…While in the US, some experience has been carried out with the Aquadex (CHF solutions, USA) [9]. In Europe, a significant experience with the DEDYCA machine and its previous prototypes (Bellco, Mirandola, Italy) has been carried out [10][11][12].…”

Section: Ultrafiltration Equipmentmentioning

confidence: 99%

Current and future role of ultrafiltration in CRS

Ronco

Giomarelli

2010

Heart Fail Rev

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Ultrafiltration has been used in patients with decompensated HF and volume overload refractory to diuretics. Criteria for the initiation of renal replacement therapy (RRT) in the ICU are oliguria, anuria, urea, creatinine, Na and K blood concentrations, pulmonary edema unresponsive to diuretics, uncompensated metabolic acidosis, temperature >40°C, uremic complication, and overdose with a dialyzable toxin. Moreover, the treatment of acute renal failure requires a different style and philosophy from renal replacement therapy for chronic renal failure. The degree and the location of renal lesion, the entity, the gravity of the concomitant acute or chronic cardiac damage, the weight of a trauma, surgical stress, or septic complication they determine a variability of clinical picture that can modify the prescription and the timing of RRT and the monitoring technology. In the presence of cardiac alterations due to a condition of chronic heart failure, all the acute events contribute to the progression of the cardiac insufficiency and the patient will always have as a result an ulterior reduction in the cardiac function. It derives the opportunity to put more precociously in action everything of it how much serves for a real cardioprotection. A valid hemodynamic monitoring is essential to reach the lowest possible value of pressure of left ventricular filling, without reduction in the cardiac output, increase in the cardiac frequency or the ulterior activation of the neurohormones. An early ultrafiltration allows a more easy control of the circulating mass but also an effective neurohormonal purification and of all the inflammation mediators.

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Section: Ultrafiltration Equipmentmentioning

confidence: 99%

Current and future role of ultrafiltration in CRS

Ronco

Giomarelli

2010

Heart Fail Rev

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“…Reduction in blood pressure of previously normotensive patients is associated with subsequent AKI [2] . Perioperative hemodynamic instability and fluid overload associated with cardiopulmonary bypass (CPB) are common in cardiac surgery patients and may be both are significant contributors to and consequences of CSA-AKI [3,4] . The fluid volume from the pump prime and cardioplegia are important sources of fluid overload.…”

Section: Introductionmentioning

confidence: 99%

Perioperative Hemodynamic Instability and Fluid Overload are Associated with Increasing Acute Kidney Injury Severity and Worse Outcome after Cardiac Surgery

Haase-Fielitz

Haase²,

Bellomo

et al. 2017

Blood Purif

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Purpose: The study aimed to investigate patients' characteristics, fluid and hemodynamic management, and outcomes according to the severity of cardiac surgery-associated acute kidney injury (CSA-AKI). Methods: In a single-center, prospective cohort study, we enrolled 282 adult cardiac surgical patients. In a secondary analysis, we assessed preoperative patients' characteristics, physiological variables, and medication for intra- and postoperative fluid and hemodynamic management and outcomes according to CSA-AKI stages by the Renal risk, Injury, Failure, Loss, End-stage renal disease (RIFLE) classification. Variables of fluid and hemodynamic management were further assessed with regard to the need for postoperative renal replacement therapy (RRT) and in-hospital mortality by the area under the curve for the receiver operating characteristic (AUC-ROC) and multivariate regression analysis. Results: Patients with worsening RIFLE stage, were significantly older, had lower estimated glomerular filtration rate and higher body mass index, more peripheral vascular and chronic obstructive pulmonary disease, atrial fibrillation, and prolonged duration of cardiopulmonary bypass (all p < 0.01). Patients with more severe AKI stage stayed longer in the intensive care and hospital, had higher in-hospital mortality, and requirement for RRT (all p < 0.001). Also, with worsening RIFLE stage, patients had lower intraoperative mean arterial pressure (MAP); p = 0.047, despite higher doses of norepinephrine (p < 0.001). The intraoperative MAP showed the best discriminatory ability (AUC-ROC: >0.8) for and was independently associated with RRT and in-hospital mortality. Moreover, with increasing AKI severity, patients received significantly more fluid infusion, and required higher dose of furosemide; nonetheless, they had increased postoperative fluid balance. Conclusions: In this cohort, reduced MAP and increased fluid balance were independently associated with increased mortality and need for RRT after cardiac surgery.

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“…76 Whilst the problem of salt and water overload is not new, the magnitude of the problem is recent. Although avoidance of perioperative hypovolaemia remains an essential requirement and preoperative intravascular optimization improves outcome, 24,28,29,[77][78][79] excessive fluid infusion leading to sodium, chloride and water overload is now becoming recognized as a major cause of postoperative morbidity and a contributory factor to length of hospital stay, organ failure and mortality. 80 In a review of US practice, Arieff reviewed 13 patients who died of postoperative pulmonary oedema; their mean postoperative fluid retention was 7 litres with a positive fluid balance greater than 67 ml/kg/day within the first 36 postoperative hours.…”

Section: Recommendation 14mentioning

confidence: 99%