This study is a prospective trial comparing the incidence of post-operative complications to fluid status in patients undergoing coronary artery bypass grafting (CABG) surgery. One hundred and nine subjects undergoing...This study is a prospective trial comparing the incidence of post-operative complications to fluid status in patients undergoing coronary artery bypass grafting (CABG) surgery. One hundred and nine subjects undergoing CABG surgery at the Jewish general hospital were recruited over a 5 months period in the year 2006. All of the patients underwent CABG surgery “on pump”. Post operative fluid overload was measured by weight gain. Using logistic regression with complications (major vs. minor only/none) as an outcome and fluid overload as a covariate, the risk of major complications significantly increases for fluid overload ≥5 kg compared to 1 - 5 kg (p < 0.001), while the risk for ≤1 kg is not significantly different from 1 - 5 kg. Also, the risk of major complications significantly (p = 0.012) increases for days with fluid overload ≥5 days in comparison to ≤1 day.展开更多
Patients with renal disease are at risk of fluid overload which escalates as the disease progresses. In the present study, we evaluated the efficacy of sequential combination diuretic-therapy (SCDT) in management of m...Patients with renal disease are at risk of fluid overload which escalates as the disease progresses. In the present study, we evaluated the efficacy of sequential combination diuretic-therapy (SCDT) in management of massive fluid overload in Furosemide-refractory renal patients. The added diuretics were Spironolactone 25 mg daily for 3 days, to those without risk of hyperkalemia, followed by Hydrochlorothiazide 25 mg/Metolazone 5 mg daily for 3 more days. Excluded patients were those with 1) acute renal disease, 2) echocardiographic evidence of: a) left ventricular ejection fraction < 40%, b) significant stenotic or incompetent valvular disease, c) ASD or VSD, d) significant pericardial disease, and 3) significant limb venous disease or on drugs likely to cause limb-oedema. To assess the extent of fluid overload;clinical examination was complemented with radiological imaging as well as echocardiographic measurement of systolic pulmonary arterial pressure (sPAP). SCDT led to significant symptomatic, clinical, and radiological improvement of fluid overload without significant side effects. The latter were limited to hyperkalemia and hyponatremia which improved with dietary compliance. Moreover, hyperkalemia improved after subsequent addition of Thiazide/Metolazone. SCDT led to significant (p < 0.001) increase in fractional excretion of sodium and decrease in body weight and sPAP. In conclusion;SCDT is a safe and efficacious measure to control fluid overload in patients with renal diseases.展开更多
The World Journal of Cardiology published an article written by Kuwahara et al that we take the pleasure to comment on.We focused our attention on venous congestion.In intensive care settings,it is now widely accepted...The World Journal of Cardiology published an article written by Kuwahara et al that we take the pleasure to comment on.We focused our attention on venous congestion.In intensive care settings,it is now widely accepted that venous congestion is an important clinical feature worthy of investigation.Evaluating venous Doppler profile abnormalities at multiple sites could suggest adequate treatment and monitor its efficacy.Renal dysfunction could trigger or worsen fluid overload in heart disease,and cardio-renal syndrome is a well-characterized spectrum of disorders describing the complex interactions between heart and kidney diseases.Fluid overload and venous congestion,including renal venous hypertension,are major determinants of acute and chronic renal dysfunction arising in heart disease.Organ congestion from venous hypertension could be involved in the development of organ injury in several clinical situations,such as critical diseases,congestive heart failure,and chronic kidney disease.Ultrasonography and abnormal Doppler flow patterns diagnose clinically significant systemic venous congestion.Cardiologists and nephrologists might use this valuable,noninvasive,bedside diagnostic tool to establish fluid status and guide clinical choices.展开更多
Background:Septic shock has a high incidence and mortality rate in Intensive Care Units(ICUs).Earlier intravenous fluid resuscitation can significantly improve outcomes in septic patients but easily leads to fluid ove...Background:Septic shock has a high incidence and mortality rate in Intensive Care Units(ICUs).Earlier intravenous fluid resuscitation can significantly improve outcomes in septic patients but easily leads to fluid overload(FO),which is associated with poor clinical outcomes.A single point value of fluid cannot provide enough fluid information.The aim of this study was to investigate the impact of fluid balance(FB)latent trajectories on clinical outcomes in septic patients.Methods:Patients were diagnosed with septic shock during the first 48 h,and sequential fluid data for the first 3 days of ICU admission were included.A group-based trajectory model(GBTM)which is designed to identify groups of individuals following similar developmental trajectories was used to identify latent subgroups of individuals following a similar progression of FB.The primary outcomes were hospital mortality,organ dysfunction,major adverse kidney events(MAKE)and severe respiratory adverse events(SRAE).We used multivariable Cox or logistic regression analysis to assess the association between FB trajectories and clinical outcomes.Results:Nine hundred eighty-six patients met the inclusion criteria and were assigned to GBTM analysis,and three latent FB trajectories were detected.64(6.5%),841(85.3%),and 81(8.2%)patients were identified to have decreased,low,and high FB,respectively.Compared with low FB,high FB was associated with increased hospital mortality[hazard ratio(HR)=1.63,95%CI 1.22–2.17],organ dysfunction[odds ratio(OR)=2.18,95%CI 1.22–3.42],MAKE(OR=1.80,95%CI 1.04–2.63)and SRAE(OR=2.33,95%CI 1.46–3.71),and decreasing FB was significantly associated with decreased MAKE(OR=0.46,95%CI 0.29–0.79)after adjustment for potential covariates.Conclusion:Latent subgroups of septic patients followed a similar FB progression.These latent fluid trajectories were associated with clinical outcomes.The decreasing FB trajectory was associated with a decreased risk of hospital mortality and MAKE.展开更多
BACKGROUND The burden of chronic kidney disease(CKD)is rising rapidly globally.Fluid overload(FO),an independent predictor of mortality in CKD,should be accurately assessed to guide estimation of the volume of fluid t...BACKGROUND The burden of chronic kidney disease(CKD)is rising rapidly globally.Fluid overload(FO),an independent predictor of mortality in CKD,should be accurately assessed to guide estimation of the volume of fluid to be removed during haemodialysis(HD).Clinical score(CS)and bio-impedance analysis(BIA)have been utilized in assessment of FO and BIA has demonstrated reproducibility and accuracy in determination of fluid status in patients on HD.There is need to determine the performance of locally-developed CSs in fluid status assessment when evaluated against BIA.AIM To assess the hydration status of patients on maintenance HD using BIA and a CS,as well as to evaluate the performance of that CS against BIA in fluid status assessment.METHODS This was a single-centre,hospital-based cross-sectional study which recruited adult patients with CKD who were on maintenance HD at Kenyatta National Hospital.The patients were aged 18 years and above and had been on maintenance HD for at least 3 mo.Those with pacemakers,metallic implants,or bilateral limbs amputations were excluded.Data on the patients’clinical history,physical examination,and chest radiograph findings were collected.BIA was performed on each of the study participants using the Quantum®II bio-impedance analyser manufactured by RJL Systems together with the BC 4®software.In evaluating the performance of the CS,BIA was considered as the gold standard test.A 2-by-2 table of the participants’fluid status at each of the CS values obtained compared to their paired BIA results was constructed(either++,+-,--or-+for FO using the CS and BIA,respectively).The results from this 2-by-2 table were used to compute the sensitivity and specificity of the CS at the various reference points and subsequently plot a receiver operating characteristic(ROC)curve that was used to determine the best cut-off point.Those above and below the best CS cut-off point as determined by the ROC were classified as being positive and negative for FO,respectively.The proportions of participants diagnosed with FO by the CS and BIA,respectively,were computed and summarized in a 2-by-2 contingency table for comparison.McNemar’s chi-squared test was used to assess any statistically significant difference in proportions of patients diagnosed as having FO by CS and BIA.Logistic regression analysis was conducted to assess whether the variables for the duration of dialysis,the number of missed dialysis sessions,advisement by health care professional on fluid or salt intake,actual fluid intake,the number of anti-hypertensives used,or body mass index were associated with a patient’s odds of having FO as diagnosed by BIA.RESULTS From 100 patients on maintenance HD screened for eligibility,80 were recruited into this study.Seventy-one(88.75%)patients were fluid overloaded when evaluated using BIA with mean extracellular volume of 3.02±1.79 L as opposed to the forty-seven(58.25%)patients who had FO when evaluated using the CS.The difference was significant,with a P value of<0.0001(95%confidence interval:0.1758-0.4242).Using CS,values above 4 were indicative of FO while values less than or equal to 4 denoted the best cut-off for no FO.The sensitivity and specificity for the CS were 63%and 78%respectively.None of the factors evaluated for association with FO showed statistical significance on the multivariable logistic regression model.CONCLUSION FO is very prevalent in patients on chronic HD at the Kenyatta National Hospital.CS detects FO less frequently when compared with BIA.The sensitivity and specificity for the CS were 63%and 78%respectively.None of the factors evaluated for association with FO showed statistical significance on the multivariable logistic regression model.展开更多
Background:Fluid overload(FO)after resuscitation is frequent and contributes to adverse outcomes among postinjury open abdomen(OA)patients.Bioelectrical impedance analysis(BIA)is a promising tool for monitoring fluid ...Background:Fluid overload(FO)after resuscitation is frequent and contributes to adverse outcomes among postinjury open abdomen(OA)patients.Bioelectrical impedance analysis(BIA)is a promising tool for monitoring fluid status and FO.Therefore,we sought to investigate the efficacy of BIA-directed fluid resuscitation among OA patients.Methods:A pragmatic,prospective,randomized,observer-blind,single-center trial was performed for all trauma patients requiring OA between January 2013 and December 2017 to a national referral center.A total of 140 postinjury OA patients were randomly assigned in a 1:1 ratio to receive either a BIA-directed fluid resuscitation(defined as BIA)protocol that included fluid administration with monitoring of hemodynamic parameters and different degrees of interventions to achieve a negative fluid balance targeting the hydration level(HL)measured by BIA or a traditional fluid resuscitation(TRD)in which clinicians determined the fluid resuscitation regimen according to traditional parameters during 30 d of intensive care unit(ICU)management.The primary outcome was the 30-day primary fascial closure(PFC)rate.The secondary outcomes included the time to PFC,postoperative 7-day cumulative fluid balance(CFB)and adverse events within 30 d after OA.The Kaplan–Meier method and the log-rank test were utilized for PFC after OA.A generalized linear regression model for the time to PFC and CFB was built.Results:A total of 134 patients completed the trial(BIA,n=66;TRD,n=68).The BIA patients were significantly more likely to achieve PFC than the TRD patients(83.33%vs.55.88%,P<0.001).In the BIA group,the time to PFC occurred earlier than that of the TRD group by an average of 3.66 d(P<0.001).Additionally,the BIA group showed a lower postoperative 7-day CFB by an average of 6632.80 ml(P<0.001)and fewer complications.Conclusions:Among postinjury OA patients in the ICU,the use of BIA-guided fluid resuscitation resulted in a higher PFC rate and fewer severe complications than the traditional fluid resuscitation strategy.展开更多
Hospitalizations for heart failure exceed 1 million per year in both the United States and Europe and more than 90%are due to symptoms and signs of fluid overload.Rates of rehospitalizations or emergency department vi...Hospitalizations for heart failure exceed 1 million per year in both the United States and Europe and more than 90%are due to symptoms and signs of fluid overload.Rates of rehospitalizations or emergency department visit at 60 days are remarkable regardless of whether loop diuretics were administered at low vs high doses or by bolus injection vs continuous infusion.Ultrafiltration(UF)has been considered a promising alternative to stepped diuretic therapy and it consists in the mechanical,adjustable removal of iso-tonic plasma water across a semipermeable membrane with the application of hydrostatic pressure gradient generated by a pump.Fluid removal with ultrafiltration presents several advantages such as elimination of higher amount of sodium with less neurohormonal activation.However,the conflicting results from UF studies highlight that patient selection and fluid removal targets are not completely understood.The best way to assess fluid status and therefore establish the fluid removal target is also still a matter of debate.Herein,we provide an up-to-date systematic review about the role of ultrafiltration among patients with fluid overload and its gaps in daily practice.展开更多
文摘This study is a prospective trial comparing the incidence of post-operative complications to fluid status in patients undergoing coronary artery bypass grafting (CABG) surgery. One hundred and nine subjects undergoing CABG surgery at the Jewish general hospital were recruited over a 5 months period in the year 2006. All of the patients underwent CABG surgery “on pump”. Post operative fluid overload was measured by weight gain. Using logistic regression with complications (major vs. minor only/none) as an outcome and fluid overload as a covariate, the risk of major complications significantly increases for fluid overload ≥5 kg compared to 1 - 5 kg (p < 0.001), while the risk for ≤1 kg is not significantly different from 1 - 5 kg. Also, the risk of major complications significantly (p = 0.012) increases for days with fluid overload ≥5 days in comparison to ≤1 day.
文摘Patients with renal disease are at risk of fluid overload which escalates as the disease progresses. In the present study, we evaluated the efficacy of sequential combination diuretic-therapy (SCDT) in management of massive fluid overload in Furosemide-refractory renal patients. The added diuretics were Spironolactone 25 mg daily for 3 days, to those without risk of hyperkalemia, followed by Hydrochlorothiazide 25 mg/Metolazone 5 mg daily for 3 more days. Excluded patients were those with 1) acute renal disease, 2) echocardiographic evidence of: a) left ventricular ejection fraction < 40%, b) significant stenotic or incompetent valvular disease, c) ASD or VSD, d) significant pericardial disease, and 3) significant limb venous disease or on drugs likely to cause limb-oedema. To assess the extent of fluid overload;clinical examination was complemented with radiological imaging as well as echocardiographic measurement of systolic pulmonary arterial pressure (sPAP). SCDT led to significant symptomatic, clinical, and radiological improvement of fluid overload without significant side effects. The latter were limited to hyperkalemia and hyponatremia which improved with dietary compliance. Moreover, hyperkalemia improved after subsequent addition of Thiazide/Metolazone. SCDT led to significant (p < 0.001) increase in fractional excretion of sodium and decrease in body weight and sPAP. In conclusion;SCDT is a safe and efficacious measure to control fluid overload in patients with renal diseases.
文摘The World Journal of Cardiology published an article written by Kuwahara et al that we take the pleasure to comment on.We focused our attention on venous congestion.In intensive care settings,it is now widely accepted that venous congestion is an important clinical feature worthy of investigation.Evaluating venous Doppler profile abnormalities at multiple sites could suggest adequate treatment and monitor its efficacy.Renal dysfunction could trigger or worsen fluid overload in heart disease,and cardio-renal syndrome is a well-characterized spectrum of disorders describing the complex interactions between heart and kidney diseases.Fluid overload and venous congestion,including renal venous hypertension,are major determinants of acute and chronic renal dysfunction arising in heart disease.Organ congestion from venous hypertension could be involved in the development of organ injury in several clinical situations,such as critical diseases,congestive heart failure,and chronic kidney disease.Ultrasonography and abnormal Doppler flow patterns diagnose clinically significant systemic venous congestion.Cardiologists and nephrologists might use this valuable,noninvasive,bedside diagnostic tool to establish fluid status and guide clinical choices.
基金supported by the National Science and Technology Supporting Plan of the Ministry of Science and Technology of China(2012BAI11B05)。
文摘Background:Septic shock has a high incidence and mortality rate in Intensive Care Units(ICUs).Earlier intravenous fluid resuscitation can significantly improve outcomes in septic patients but easily leads to fluid overload(FO),which is associated with poor clinical outcomes.A single point value of fluid cannot provide enough fluid information.The aim of this study was to investigate the impact of fluid balance(FB)latent trajectories on clinical outcomes in septic patients.Methods:Patients were diagnosed with septic shock during the first 48 h,and sequential fluid data for the first 3 days of ICU admission were included.A group-based trajectory model(GBTM)which is designed to identify groups of individuals following similar developmental trajectories was used to identify latent subgroups of individuals following a similar progression of FB.The primary outcomes were hospital mortality,organ dysfunction,major adverse kidney events(MAKE)and severe respiratory adverse events(SRAE).We used multivariable Cox or logistic regression analysis to assess the association between FB trajectories and clinical outcomes.Results:Nine hundred eighty-six patients met the inclusion criteria and were assigned to GBTM analysis,and three latent FB trajectories were detected.64(6.5%),841(85.3%),and 81(8.2%)patients were identified to have decreased,low,and high FB,respectively.Compared with low FB,high FB was associated with increased hospital mortality[hazard ratio(HR)=1.63,95%CI 1.22–2.17],organ dysfunction[odds ratio(OR)=2.18,95%CI 1.22–3.42],MAKE(OR=1.80,95%CI 1.04–2.63)and SRAE(OR=2.33,95%CI 1.46–3.71),and decreasing FB was significantly associated with decreased MAKE(OR=0.46,95%CI 0.29–0.79)after adjustment for potential covariates.Conclusion:Latent subgroups of septic patients followed a similar FB progression.These latent fluid trajectories were associated with clinical outcomes.The decreasing FB trajectory was associated with a decreased risk of hospital mortality and MAKE.
文摘BACKGROUND The burden of chronic kidney disease(CKD)is rising rapidly globally.Fluid overload(FO),an independent predictor of mortality in CKD,should be accurately assessed to guide estimation of the volume of fluid to be removed during haemodialysis(HD).Clinical score(CS)and bio-impedance analysis(BIA)have been utilized in assessment of FO and BIA has demonstrated reproducibility and accuracy in determination of fluid status in patients on HD.There is need to determine the performance of locally-developed CSs in fluid status assessment when evaluated against BIA.AIM To assess the hydration status of patients on maintenance HD using BIA and a CS,as well as to evaluate the performance of that CS against BIA in fluid status assessment.METHODS This was a single-centre,hospital-based cross-sectional study which recruited adult patients with CKD who were on maintenance HD at Kenyatta National Hospital.The patients were aged 18 years and above and had been on maintenance HD for at least 3 mo.Those with pacemakers,metallic implants,or bilateral limbs amputations were excluded.Data on the patients’clinical history,physical examination,and chest radiograph findings were collected.BIA was performed on each of the study participants using the Quantum®II bio-impedance analyser manufactured by RJL Systems together with the BC 4®software.In evaluating the performance of the CS,BIA was considered as the gold standard test.A 2-by-2 table of the participants’fluid status at each of the CS values obtained compared to their paired BIA results was constructed(either++,+-,--or-+for FO using the CS and BIA,respectively).The results from this 2-by-2 table were used to compute the sensitivity and specificity of the CS at the various reference points and subsequently plot a receiver operating characteristic(ROC)curve that was used to determine the best cut-off point.Those above and below the best CS cut-off point as determined by the ROC were classified as being positive and negative for FO,respectively.The proportions of participants diagnosed with FO by the CS and BIA,respectively,were computed and summarized in a 2-by-2 contingency table for comparison.McNemar’s chi-squared test was used to assess any statistically significant difference in proportions of patients diagnosed as having FO by CS and BIA.Logistic regression analysis was conducted to assess whether the variables for the duration of dialysis,the number of missed dialysis sessions,advisement by health care professional on fluid or salt intake,actual fluid intake,the number of anti-hypertensives used,or body mass index were associated with a patient’s odds of having FO as diagnosed by BIA.RESULTS From 100 patients on maintenance HD screened for eligibility,80 were recruited into this study.Seventy-one(88.75%)patients were fluid overloaded when evaluated using BIA with mean extracellular volume of 3.02±1.79 L as opposed to the forty-seven(58.25%)patients who had FO when evaluated using the CS.The difference was significant,with a P value of<0.0001(95%confidence interval:0.1758-0.4242).Using CS,values above 4 were indicative of FO while values less than or equal to 4 denoted the best cut-off for no FO.The sensitivity and specificity for the CS were 63%and 78%respectively.None of the factors evaluated for association with FO showed statistical significance on the multivariable logistic regression model.CONCLUSION FO is very prevalent in patients on chronic HD at the Kenyatta National Hospital.CS detects FO less frequently when compared with BIA.The sensitivity and specificity for the CS were 63%and 78%respectively.None of the factors evaluated for association with FO showed statistical significance on the multivariable logistic regression model.
基金supported by grants from the National Natural Science Foundation of China(81770532,WDD)the Jiangsu Province Medical Foundation for Youth Talents(QNRC2016901,WDD)。
文摘Background:Fluid overload(FO)after resuscitation is frequent and contributes to adverse outcomes among postinjury open abdomen(OA)patients.Bioelectrical impedance analysis(BIA)is a promising tool for monitoring fluid status and FO.Therefore,we sought to investigate the efficacy of BIA-directed fluid resuscitation among OA patients.Methods:A pragmatic,prospective,randomized,observer-blind,single-center trial was performed for all trauma patients requiring OA between January 2013 and December 2017 to a national referral center.A total of 140 postinjury OA patients were randomly assigned in a 1:1 ratio to receive either a BIA-directed fluid resuscitation(defined as BIA)protocol that included fluid administration with monitoring of hemodynamic parameters and different degrees of interventions to achieve a negative fluid balance targeting the hydration level(HL)measured by BIA or a traditional fluid resuscitation(TRD)in which clinicians determined the fluid resuscitation regimen according to traditional parameters during 30 d of intensive care unit(ICU)management.The primary outcome was the 30-day primary fascial closure(PFC)rate.The secondary outcomes included the time to PFC,postoperative 7-day cumulative fluid balance(CFB)and adverse events within 30 d after OA.The Kaplan–Meier method and the log-rank test were utilized for PFC after OA.A generalized linear regression model for the time to PFC and CFB was built.Results:A total of 134 patients completed the trial(BIA,n=66;TRD,n=68).The BIA patients were significantly more likely to achieve PFC than the TRD patients(83.33%vs.55.88%,P<0.001).In the BIA group,the time to PFC occurred earlier than that of the TRD group by an average of 3.66 d(P<0.001).Additionally,the BIA group showed a lower postoperative 7-day CFB by an average of 6632.80 ml(P<0.001)and fewer complications.Conclusions:Among postinjury OA patients in the ICU,the use of BIA-guided fluid resuscitation resulted in a higher PFC rate and fewer severe complications than the traditional fluid resuscitation strategy.
文摘Hospitalizations for heart failure exceed 1 million per year in both the United States and Europe and more than 90%are due to symptoms and signs of fluid overload.Rates of rehospitalizations or emergency department visit at 60 days are remarkable regardless of whether loop diuretics were administered at low vs high doses or by bolus injection vs continuous infusion.Ultrafiltration(UF)has been considered a promising alternative to stepped diuretic therapy and it consists in the mechanical,adjustable removal of iso-tonic plasma water across a semipermeable membrane with the application of hydrostatic pressure gradient generated by a pump.Fluid removal with ultrafiltration presents several advantages such as elimination of higher amount of sodium with less neurohormonal activation.However,the conflicting results from UF studies highlight that patient selection and fluid removal targets are not completely understood.The best way to assess fluid status and therefore establish the fluid removal target is also still a matter of debate.Herein,we provide an up-to-date systematic review about the role of ultrafiltration among patients with fluid overload and its gaps in daily practice.
