Bedside prediction of intradialytic hemodynamic instability in critically ill patients: the SOCRATE study

Abstract

Background: Despite improvements in intermittent hemodialysis management, intradialytic hemodynamic instability (IHI) remains a common issue that could account for increased mortality and delayed renal recovery. However, predictive factors of IHI remain poorly explored. The objective of this study was to evaluate the relationship between baseline macrohemodynamic, tissue hypoperfusion parameters and IHI occurrence. Methods: Prospective observational study conducted in a 18-bed medical ICU of a tertiary teaching hospital. Cardiovascular SOFA score, index capillary refill time (CRT) and lactate level were measured just before (T0) consecutive intermittent hemodialysis sessions performed for AKI. The occurrence of IHI requiring a therapeutic intervention was recorded. Results: Two hundred eleven sessions, corresponding to 72 (34%) first sessions and 139 (66%) later sessions, were included. As IHI mostly occurred during first sessions (43% vs 12%, P < 0.0001), following analyses were performed on the 72 first sessions. At T0, cardiovascular SOFA score ≥1 (87% vs 51%, P = 0.0021) was more frequent before IHI sessions, as well as index CRT ≥ 3 s (55% vs 15%, P = 0.0004), and hyperlactatemia > 2 mmol/L (68% vs 29%, P = 0.0018). Moreover, the occurrence of IHI increased with the number of macrohemodynamic and tissue perfusion impaired parameters, named SOCRATE score (cardiovascular SOFA, index CRT and lactATE): 10% (95% CI [3%, 30%]), 33% (95% CI [15%, 58%]), 55% (95% CI [35%, 73%]) and 80% (95% CI [55%, 93%]) for 0, 1, 2 and 3 parameters, respectively (AUC = 0.79 [0.69-0.89], P < 0.0001). These results were confirmed by analyzing the 139 later sessions included in the study. Conclusions: The SOCRATE score based on 3 easy-to-use bedside parameters correlates with the risk of IHI. By improving risk stratification of IHI, this score could help clinicians to manage intermittent hemodialysis initiation in critically ill AKI patients.

Intra-dialytic hypotension following the transition from continuous to intermittent renal replacement therapy

“…Beyond routinely available clinical information, predicting tolerance to fluid removal may require adjunct information including dynamic assessment of preload responsiveness at the bedside [ 41 ] and other sources of information. In a recent study, a combination of cardiovascular SOFA score, capillary refill time and serum lactate achieved moderate performance in predicting hemodynamic instability [ 42 ].…”

Monitoring skin blood flow to rapidly identify alterations in tissue perfusion during fluid removal using continuous veno-venous hemofiltration in patients with circulatory shock

“…This might again be explained by the different fluid removal rates: in the present study, the fluid removal rate was fixed during the study period, whereas in the study by Klijn et al [55] it was doubled every 15 min. Bigé et al [56] observed that an index CRT > 3 s had a reasonably good predictive value for intradialytic hypotension, but this measure was less reliable in our patients (AUC 0.62 vs 0.71), perhaps because we included fewer patients with a CRT > 3 s at baseline (27% vs 55%, respectively).…”

Deresuscitation during continuous renal replacement therapy: A before-after pilot study (The EARLY DRY COHORT)

“…Hypoperfusion as de ned in our study was not a known prognostic factor considering patients with CRRT, but it is physiologically plausible that it may impede organ failure recovery. Besides, capillary re ll time has been described as a predictor of poor hemodynamic tolerance during RRT (32) and small variations in volemia can be detected by capillary re ll time variations (33). In our opinion, it promotes strict hemodynamic monitoring during deresuscitation to avoid the side effects related to inadequate forced uid removal.…”