Fluid Administration in Critically Ill Patients with Acute Kidney Injury

Abstract

Physiologic end points for fluid resuscitation in septic shock patients with acute kidney injury (AKI) have been undertaken in randomized studies using the Early Goal-Directed Therapy (EGDT) approach. These studies have demonstrated a beneficial effect on in-hospital mortality with EGDT. The Saline versus Albumin Fluid Evaluation (SAFE) randomized study in critically ill patients demonstrated no difference in survival when saline versus albumin solutions were used for resuscitation. However, a benefit of albumin has been demonstrated in a randomized study on renal function and survival in cirrhotic patients with spontaneous bacterial periotonitis. On the other hand, recent observational studies have shown a correlation between fluid overload and mortality in AKI patients whether or not they necessitated dialysis. Moreover, the Adult Respiratory Distress Syndrome ( F luid administration is frequently necessary to stabilize the patient with severe sepsis or septic shock. Moreover, sepsis has been reported to account for approximately 50% of patients with acute kidney injury (AKI) in intensive care units (ICUs) (1). Thus the timing and type of fluid administered as well as renal outcomes are very important. Recently, the timing of the fluid administration and the physiologic end points to be monitored have emerged as Early Goal-Directed Therapy (EGDT) (2). In the patient with septic shock, early intervention with fluid resuscitation within the first 6 hours in the emergency department (ED) has been described as EGDT. Previous studies had generally reported results relating to later interventions in ICUs after admission from the ED.The predefined physiologic goals of EGDT within 6 hours of diagnosis are mean arterial pressure Ն 65 mmHg, central venous pressure (CVP) between 8 and 12 mmHg, improvement of blood lactate levels, central venous oxygen saturation Ͼ 70%, and urine output Ն 0.5 ml/kg/h. The first randomized study to test this protocol-driven approach was undertaken in patients with systemic inflammatory response syndrome criteria: systolic blood pressure Յ 90 mmHg or lactate Ն 4 mmol/L, central venous oxygen saturation Ͻ 50%, and mean serum creatinine 2.6 mg/dl.Compared with the control group receiving standard emergency care, the EGDT group received more fluid, blood transfusions, and inotropic use with dobutamine. The physiologic parameters were improved in the EGDT group during the first 6 hours (Table 1). Moreover, the primary end point of inhospital mortality was less in the EGDT group (30.5 versus 46.5%, P Ͻ 0.009). Other physiologic parameters were also improved during hours 7 to 72 (Table 2). Of note, although more fluid was administered from 0 to 6 hours in the ED, the EGDT group received less fluid during hours 7 to 72 and fewer of these patients were on mechanical ventilation (2.6% versus 16.8%, P Ͻ 0.001). This initial study did not specifically examine AKI but examined multiple organ functioning scores (Acute Physiology and Chronic Health Evaluation II and Simplified Acute Physiology Score), wh...

Characteristics of Acute Kidney Injury in Patients Infected with the 2009 Influenza A (H1N1) Virus

“…The need for dialysis was also associated with mortality in the study conducted in Argentina, although not in the study conducted in Canada (9,10). It is known that fluid overload increases mortality among critically ill patients (15). In the study presented here, dialysis was initiated early (seven of the nine dialyzed patients received dialysis within 24 hours after the initial nephrology consultation) to avoid fluid overload.…”

Diagnostic Value of Urinary Sodium, Chloride, Urea, and Flow

“…Epidemiologic studies indicate that fluid overload and mechanical ventilation are associated with increased mortality in patients with ATN. 18 Fluid overload in a patient with ATN can also impair cardiac function secondary to increased ventricular wall stress, functional mitral insufficiency, and endomyocardial ischemia. Such cardiac dysfunctions can delay recovery from ATN.…”

Acute kidney injury

“…10,11 Early review by a nephrology team may help ameliorate AKI, 12 but the numbers of patients developing AKI and the centralisation of services make this impossible for all. As a result, local and regional care protocols exist for monitoring, investigation and supportive care (see Fig 1 for an example of such a pathway).…”