Net ultrafiltration prescription survey in Europe

Abstract

Background Fluid overload is common in patients in the intensive care unit (ICU) and ultrafiltration (UF) is frequently required. There is lack of guidance on optimal UF practice. We aimed to explore patterns of UF practice, barriers to achieving UF targets, and concerns related to UF practice among practitioners working in Europe. Methods This was a sub-study of an international open survey with focus on adult intensivists and nephrologists, advanced practice providers, and ICU and dialysis nurses working in Europe. Results Four hundred eighty-five practitioners (75% intensivists) from 31 countries completed the survey. The most common criteria for UF initiation was persistent oliguria/anuria (45.6%), followed by pulmonary edema (16.7%). Continuous renal replacement therapy was the preferred initial modality (90.0%). The median initial and maximal rate of net ultrafiltration (UFNET) prescription in hemodynamically stable patients were 149 mL/hr. (IQR 100–200) and 300 mL/hr. (IQR 201–352), respectively, compared to a median UFNET rate of 98 mL/hr. (IQR 51–108) in hemodynamically unstable patients and varied significantly between countries. Two-thirds of nurses and 15.5% of physicians reported assessing fluid balance hourly. When hemodynamic instability occurred, 70.1% of practitioners reported decreasing the rate of fluid removal, followed by starting or increasing the dose of a vasopressor (51.3%). Most respondents (90.7%) believed in early fluid removal and expressed willingness to participate in a study comparing protocol-based fluid removal versus usual care. Conclusions There was a significant variation in UF practice and perception among practitioners in Europe. Future research should focus on identifying the best strategies of prescribing and managing ultrafiltration in critically ill patients.

Survey of U.S. Critical Care Practitioners on Net Ultrafiltration Prescription and Practice Among Critically Ill Patients Receiving Kidney Replacement Therapy

“…There was also variation in interventions performed for hemodynamic instability such as decreasing or stopping UF NET and increasing or starting a new vasopressor, administration of albumin and mannitol bolus, as well as barriers to UF NET such as unavailability of machines, belief that early and protocol-based fluid removal is beneficial, and willingness to enrol patients in a clinical trial. The survey findings of U.S. practitioners were similar to findings in a global survey and Europe in that there is important practice variation in several care processes for UF NET [16,17]. This is partly due to the lack of evidence-based guidelines for UF NET prescription and practice in critically ill patients.…”

“…For example, a previous study by Murugan et al (2020) using a multinational survey of critical care practitioners revealed wide regional variations in dosing of diuretics, criteria used for initiation and prescription of UF NET , modality of kidney replacement therapy used for UF NET , the assessment of prescription dose of UF NET , the monitoring of fluid balance, management of complications and perceived barriers to UF NET [16]. Among critical care practitioners in Europe, there was also variation noted in attitudes toward UF NET prescription and processes of care between physicians and nurses [17].…”

Early restrictive fluid balance is associated with lower hospital mortality independent of acute disease severity in critically ill patients on CRRT

“…Most recent studies on fluid balance in patients with RRT dependent AKI have focused on the association between fluid removal rate (namely nUF rate) during RRT and mortality 5 , 7 , 8 , 10 – 12 . The RENAL trial data indicated that nUF rates of > 1.75 ml/kg/h increased mortality compared to a nUF rate of < 1.01 ml/kg/h 7 and this finding was later reproduced in another cohort study 8 .…”

“…Therefore, severity of illness and need for organ support may be more important determinants of mortality, whereas, fluid balance may serve as a mere surrogate marker. In line with this assumption, a recent survey of net ultrafiltration (nUF) prescription in Europe showed that in the occurrence of hemodynamic instability, defined as onset or worsening of tachycardia, hypotension or need to start or increase the dose of vasopressors, 70% of practitioners decreased the rate of fluid removal or even administered fluid boluses 5 . Moreover, in a previous large retrospective study by Shawwa et al hypotension within one hour of CRRT initiation was associated with increased in-hospital mortality 6 .…”

Ultrafiltration in Japanese critically ill patients with acute kidney injury on renal replacement therapy

“…This sub-analysis unveiled that most of the Japanese doctors prescribed furosemide at maximum doses lower than 250 mg/day whereas the multinational survey [ 1 ] as well as the sub-analysis from Europe [ 2 ] showed the prescription of a maximum 250 mg/day or higher by 41.1–56.1% of physicians. Notably, in a study of acute heart failure management in Japan, the maximum dose of furosemide (≤ 200 mg/day) was less than half the dose used in the USA [ 3 ], which was expected to cause lower mortality [ 4 ].…”