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When Should We Diurese or Dialyze the Patient With ...
When Should We Diurese or Dialyze the Patient With Septic Shock?
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OK. Great. So we're going to turn now to some of the controversies in this field. And I'd like to thank the organizers for the opportunity to speak about this topic of when we should dialyze or diurese the patient in septic shock. So I have no relevant disclosures to this presentation. Professor Monet has already shown us a very similar slide to this one, highlighting the many deleterious effects of fluid overload. And in his presentation, he also has very nicely highlighted that fluid overload is often iatrogenic in the ICU. As a nephrologist, I just want to highlight some of the adverse consequences in our patients with AKI. So this has been a field that has been of tremendous interest over the last 15 years or so. And on the right, I'm showing you data from a multi-center US study focused on the impact of fluid overload in patients in the ICU with AKI. And what you can see is that across a long time period, patients who are not fluid overloaded have better outcomes compared to patients who are fluid overloaded. And in this literature, fluid overload is typically defined as more than 10% of your body weight in terms of fluid. There's been a lot of interest, then, in how fluid overload may have adverse consequences in patients with AKI. That's an entirely separate talk. But just I want to highlight a few of these. In this patient population, fluid overload is impacting independent risk factor for sepsis. It may impact our ability to achieve levels of important drugs, including antibiotics. It may mask the ascertainment of AKI itself or AKI severity. So really then, turning to our question of how we should dialyze or diurese the patient with septic shock, this is really an area under construction, an area where there's tremendous controversy. So I'm first going to really show you the literature we have about protocolized diuresis in the ICU and then give you some of my thoughts on how we can apply this to dialyze or diurese the patient with septic shock. So you're all very familiar with this study. This is the FACT trial. This is really our landmark study focused on protocolized diuresis. This was in patients with ARDS. As you know, this study used filling pressures as the driver for diuresis, along with measures of end-organ perfusion. And the specific measures that were used in the study were mean arterial pressure, off of vasopressors, average urinary output, as well as bedside measures of effective circulation. These aren't either cardiac index or physical signs of end-organ perfusion. And this drove the use of diuretics or fluids in kind of these sort of far-bottom boxes. Now, there are some important caveats to the FACT protocol. This study really focused on patients who had been out of shock for 12 hours, so off vasopressors. This study does not apply in patients with AKI. And recall that this study was designed now on the order of 20 years ago. And so in this study, AKI was defined as dialysis-dependent oliguria with a creatinine greater than 3, or oliguria with a lower creatinine with urinary studies indicative of AKI, but not using our sort of now more standard AKI definitions. And there were very specific recommendations in this protocol for how to use diuretics. The other important point to highlight about this study is, as I mentioned, this study focused on filling pressures as drivers of diuresis. Importantly in this study, patients did not achieve the targeted filling pressures. In fact, the filling pressures were on the order of 4 to 5 millimeters of mercury higher in both arms. So it's important, as you think about protocolized diuresis, to think not only about if you're using filling pressure targets, the target as well as the measures of end-organ perfusion. And obviously now in the ICU, we often have patients who do not have ways to measure static pressures. And we'll talk more about the controversies of static pressures. So there have been algorithms that have been proposed that simplify the FACT algorithm, as well as some practical tips that we can use when we don't have filling pressures as a measure of end-organ, as a way to measure volume status. And these may include a positive fluid balance. For example, a patient who is above their admission weight, who's received fluid, or has clinical evidence of volume overload, may be someone where it's appropriate to consider diuretics. And also, I think an important point is to consider, if a patient is diuretic responsive and the urine output tapers off, that that may be a time that we should pause and reconsider whether or not diuresis is warranted. There have been some nice studies that have associated, that have looked at diuresis protocols more practically in the ICU. This is a study from the University of Kentucky, focused on a historical cohort, and then a cohort where a diuresis protocol was implemented. And this study really highlights that, in this analysis, the diuresis protocol was associated with much better fluid balance over a 72-hour period. And this was, in fact, associated with fewer adverse events, excuse me, associated with lower in-hospital mortality. But again, this is a historical cohort study, and not a true randomized trial, but certainly a provocative result. So what do we do if the patient's not diuretic responsive? I think this is sort of the million-dollar question, right, for me as a nephrologist, right? And I really often ask myself why the patient is not diuretic responsive. This can be for a variety of reasons, right? Our patients with sepsis or who have hypoalbuminemia may clearly have decreased oncotic pressure. They typically have a pro-inflammatory milieu. And for these reasons, they may not be able to recruit fluid quickly from the extravascular to the intravascular space. There are, in the condition of cardio-renal syndrome, there are some very specific reasons that patients may not be able to be diuretic responsive, involving both the gastrointestinal tract as well as the kidney itself. And finally, patients with AKI may not be able to respond to diuretics simply because they have tubular injury. So in those patients with AKI, I think we have to be very careful and think about the role of ultrafiltration. Now, this is extrapolating from the heart failure literature a very different field. But this is a field where the impact of ultrafiltration has been directly compared to the effect of diuretics. Recall that the Caress Heart Failure Study was a study of patients with acute decompensated heart failure. These patients were randomized either to receive diuretics to maintain a robust urine output of three to five liters per day, or ultrafiltration using the Aquadex machine to achieve a very similar net ultrafiltration. And what you can see here in the study is that there was no significant difference in body weight compared to in the two arms. The ultrafiltration arm is shown in red. The diuretic arm is shown in blue. But this lack of difference in body weight was associated with a difference in serum creatinine. So in the ultrafiltration arm, creatinine actually went up compared to the diuretic arm. So again, ultrafiltration here without any sort of clear benefit. So we've heard now over the course of a number of talks this morning about the many different ways that we can guide resuscitation. The role of physical exams, static monitors, dynamic monitors. We have a number of these. I've just listed a few of them here, as well as metabolic monitors, including lactate and SVO2. Frankly, I don't know of any monitors that are directly designed to guide de-resuscitation. And I think one area of interest that we can discuss in the last 10 minutes as we have our discussion is, can you use the lack of responsiveness with these dynamic monitors as a way to guide your de-resuscitation? For example, if you have a patient who is clearly not fluid responsive, is that a patient where you can start to try to decongest and de-resuscitate and see what the impact is? And can you use the dynamic monitor and the subsequent response to the dynamic monitor as another way to guide yourself? I don't think we know. I think these are areas where different practitioners practice quite widely. But we clearly need some data to help us guide de-resuscitation because so many of our patients in the ICU become fluid overloaded. I'm going to end with just sort of my brief conceptual model of what I've talked about. The goal of fluid removal in the ICU is really, either with diuretics or renal replacement therapy, is really to mobilize fluid without causing intravascular fluid repletion. So obviously, the intravascular space is connected to the interstitial space. Those make up our extracellular fluid compartment, which is connected by the cell wall to the intracellular fluid compartment. We want to gradually and gently draw fluid from the extracellular fluid space out of the body to de-resuscitate and recruit. And the challenge for our critically ill patients is that many conditions can really contribute to our inability to decongest and de-recruit. And what we don't know in any individual patient is how much each of those factors apply. So what to do with the patient in shock? I think we have to think of several factors that may guide our de-resuscitation strategy. First, how fluid positive is the patient, both over the course of the hospitalization as well as on a daily basis? Is the patient diuretic responsive? Clearly, if you have a patient who is diuretic responsive, that would seem to be somebody where you can try to mobilize some fluid. I think in each individual patient, we have to consider what are the current deleterious consequences of fluid overload on all of the organ functions. And I think finally, we have to consider if you're willing to accept the potential consequence of long-term or longer-term dialysis dependence for the benefit of fluid removal. And this may be highly individualized and based on individual patients. So I'll stop there and conclude that fluid overload, as you've seen, is associated with adverse consequences in critically ill patients. Our established protocols for diuresis focus on patients who've had shock resolution for 12 hours, so really don't apply to our patients in septic shock. Personally, I think patients who are not diuretic responsive who are on renal replacement therapy are the most challenging to manage. And when to diurese these patients is really an individualized decision. And finally, we clearly need more studies to guide our management in this area. And I'll stop there, and thank you for your attention. Thank you.
Video Summary
In this video, the speaker discusses the controversy surrounding when to dialyze or diurese patients in septic shock. The presenter highlights the adverse consequences of fluid overload in patients with acute kidney injury (AKI) and the impact of fluid overload on sepsis and drug administration. The speaker refers to the FACT trial, which focused on protocolized diuresis in patients with acute respiratory distress syndrome (ARDS). The presenter also mentions the use of diuretic protocols and the potential role of ultrafiltration in patients with AKI. Overall, the speaker emphasizes the need for further studies to guide the management of fluid overload in septic shock patients.
Asset Subtitle
Sepsis, Pharmacology, 2023
Asset Caption
Type: one-hour concurrent | Controversies in Fluid Administration in Septic Shock (SessionID 1227739)
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Content Type
Presentation
Knowledge Area
Sepsis
Knowledge Area
Pharmacology
Membership Level
Professional
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Tag
Fluids Resuscitation Management
Year
2023
Keywords
septic shock
fluid overload
acute kidney injury
diuretic protocols
ultrafiltration
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