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ICN Victoria: Botha on Acute Renal Failure

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ICN Victoria presents Professor John Botha on advances in renal failure in ICU

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ICN Victoria: Botha on Acute Renal Failure

  1. 1. PENINSULA HEALTH c12 classification by the College of Intensive Care Medicine • The Problem with Acute Renal Failure • John Botha • MBChB M Med FCP(SA)FRACP FCICM Dip PG Echo Dip Neph • Director of Intensive Care Peninsula Health • Adjunct Clinical Professor Monash University Peninsula Health, Winner – Metropolitan Health Service of the Year 2007 and 2009 2
  2. 2. Why is Hospital Acquired AKI a problem for the bedside clinician? • Renal Physiology is Complex • Markers of Renal Injury are not clinically used(or useful?) • Fluid management in Sepsis is Difficult and overzealous administration is bad • The role of the endothelial glycocalyx in fluid distribution is important and its integrity is difficult to measure • Fluid Types may impact on Renal Outcome • Therapies for AKI with RIFLE Risk and Injury are limited • High Intensity RRT has not proven benefit • Optimising Filter life is problematic • In patients who have RRT in ICU the outcomes is poor
  3. 3. Problematic physiology 1. The kidney is at risk of hyperoxia 2. The kidney is at risk of hypoxia
  4. 4. • The kidney has a high exposure to O2 • Oxygen tension is tightly regulated in all organs because high PO2 is toxic • In the kidney superoxide production is tightly dependent on O2 availability
  5. 5. • The human kidney has structural antioxidant defences. • Arteries and veins are closely associated • This facilitates counter-current diffusion and enables a high degree of AV shunting
  6. 6. Renal veins have a unique peri-arterial structure It facilitates diffusive O2 shunting
  7. 7. Close coupling of veins and arteries to achieve counter-current O2 diffusion
  8. 8. This shunting is dependent on Renal Blood Flow
  9. 9. The cortex and the medulla Are linked by shunting If the cortex is underperfused More AV shunting occurs in interlobular vessels This can lead to medullary ischemia Even if medullary flow is preserved
  10. 10. Medullary PO2 is very low
  11. 11. The septic kidney: global renal blood flow
  12. 12. Intra-renal blood flow In septic sheep
  13. 13. Intra-renal oxygenation Cortico-medullary dissociation Knowing global Or even intra-renal blood flow says little about medullary oxygenation
  14. 14. Clinical implications • Global renal blood flow may be dissociated from GFR, medullary flow and medullary O2 • Reliable ways to measure renal blood flow are not available • If there were reliable therapies to increase renal blood flow the effect of this on GFR is unpredictable. • The renal medulla is always at risk of hypoxia
  15. 15. Biomarkers for the prediction of acute kidney injury: a narrative review on current status and future challenges Hilde R. H. de Geus, Michiel G. Betjes and Jan Bakker Clin Kidney J (2012) 5 (2): 102-108 Biomarkers for AKI • Functional markers- SCr and plasma/serum CyC • Up-regulated proteins -NGAL, KIM-1, L-FABP and IL-18 • Low-molecular weight proteins -Urine CyC • Enzymes NAG,- a-GST, p-GST, GGT and AP Markers of Renal Injury are not clinically used(or useful?)
  16. 16. The reported AUCs are disappointing ranging from 0.50 to 0.84, with one or two exceptions, which can be explained by statistical or methodological differences in study design. The discriminatory function in heterogeneous populations is poor and influenced by pre-existing renal function and time of sample collection with respect to the renal insult Clinical appraisal of a patient using standard parameters such as SCr and diuresis remains the cornerstone for now Reasonable to use biomarkers together with other parameters such as traditional clinical characteristics to optimize the accuracy of prediction of developing AKI
  17. 17. Acute Renal Failure in the Critically Ill Multinational Multicentre Study JAMA August 17 2005 Vol 294 Septic Shock Major Surg Cardio Shock Hypo Vol Drug HRS Obstr Uro Other 47.5% 34.3% 26.9% 25.6% 19% 5.7% 2.6% 12.%
  18. 18. MORTALITY 0% 10% 20% 30% 40% 50% 60% ICU WARD
  19. 19. Fluid management in Sepsis is Difficult and overzealous administration is bad Fluid resuscitation in septic shock- A positive fluid balance and elevated central venous pressure are associated with increased mortality • Boyd, John H. MD, FRCP(C); Forbes, Jason MD; Nakada, Taka- aki MD, PhD; Walley, Keith R. MD, FRCP(C); Russell, James A. MD, FRCP Critical Care medicine Feb 2011 Vol 32
  20. 20. Design • VASST Study Patients: The Vasopressin in Septic Shock Trial (VASST) study enrolled 778 patients who had septic shock • A retrospective review of the use of intravenous fluids during the first 4 days of care.
  21. 21. • Based on net fluid balance, they determined whether fluid balance quartile correlated with 28-day mortality
  22. 22. Table 1 Table 1. Fluid intake, urine output, and net fluid balance at 12 hrs and cumulative day 4 balance Copyright © 2011 Critical Care Medicine. Published by Lippincott Williams & Wilkins. 31 Fluid resuscitation in septic shock: A positive fluid balance and elevated central venous pressure are associated with increased mortality* Boyd, John H.; Forbes, Jason; Nakada, Taka- aki; Walley, Keith R.; Russell, James A. Critical Care Medicine. 39(2):259-265, February 2011. doi: 10.1097/CCM.0b013e3181feeb15
  23. 23. Figure 2 Figure 2.A, Cox survival curves, adjusted for age, Acute Physiology and Chronic Health Evaluation (APACHE) II score, and severity of shock (dose of norepinephrine), are shown for fluid balance quartiles at 12 hrs. Quartiles 3 and 4 have significant increases in mortality compared with both quartiles 1 and 2 . B, Cox survival curves, adjusted for age, APACHE II score, and dose of norepinephrine, are shown for cumulative fluid balance quartiles at day 4. Quartiles 3 and 4 have significant increases in mortality compared with both quartiles 1 and 2. Copyright © 2011 Critical Care Medicine. Published by Lippincott Williams & Wilkins. 32
  24. 24. Table 2 Table 2. Hazard ratio for death according to fluid balance quartiles Copyright © 2011 Critical Care Medicine. Published by Lippincott Williams & Wilkins. 33 Fluid resuscitation in septic shock: A positive fluid balance and elevated central venous pressure are associated with increased mortality* Boyd, John H.; Forbes, Jason; Nakada, Taka- aki; Walley, Keith R.; Russell, James A. Critical Care Medicine. 39(2):259-265, February 2011. doi: 10.1097/CCM.0b013e3181feeb15
  25. 25. • A more positive fluid balance both early in resuscitation and cumulatively over 4 days is associated with an increased risk of mortality in septic shock
  26. 26. Next Question. • Whether fluid balance was predictive of central venous pressure ? • Whether a guideline-recommended central venous pressure of 8–12 mm Hg yielded a mortality advantage?
  27. 27. Figure 3 B, Day 4 fluid balance during the preceding 24 hrs does not correlate with central venous pressure nor with the dose of norepinephrine. Copyright © 2011 Critical Care Medicine. Published by Lippincott Williams & Wilkins. 36 Figure 3.A, Fluid balance on study enrolment (12 hrs) significantly correlates with central venous pressure and dose of norepinephrine, p < .001 in both cases.
  28. 28. Figure 4 . B, Cox survival curves, adjusted for age, APACHE II score, and dose of norepinephrine, are shown for CVP groups on day 4. There were no significant differences in mortality among groups. Cright © 2011 Critical Care Medicine. Published by Lippincott Williams & Wilkins. 37 Figure 4.A, Cox survival curves, adjusted for age, Acute Physiology and Chronic Health Evaluation (APACHE) II score, and severity of shock (dose of norepinephrine), are shown for central venous pressure (CVP) groups at 12 hrs. Patients with a CVP of <8 mm Hg at 12 hrs have the lowest mortality followed by those with CVP of 8–12 mm Hg and patients with a CVP >12 mm Hg had the highest mortality
  29. 29. • Central venous pressure correlated with fluid balance at 12 hrs. • On days 1–4, there was no significant correlation. • At 12 hrs, patients with a central venous pressure <8 mm Hg had the lowest mortality rate followed by those with central venous pressure 8–12 mm Hg. The highest mortality rate was observed in those with central venous pressure >12 mm Hg. • There was no correlation between CVP and mortality at day 4
  30. 30. • However, in patients whose central venous pressure was <8 mm Hg • Found a more positive fluid balance among survivors compared with non survivors • Suggesting that there is a point at which too little fluid is indeed harmful
  31. 31. The Elusive Sweet Spot !!!! ©
  32. 32. Then of course how to administer the fluid?
  33. 33. A positive fluid balance is associated with a worse outcome in patients with acute renal failure. Payen D, de Pont AC, Sakr Y, Spies C, Reinhart K, Vincent JL; Sepsis Occurrence in Acutely Ill Patients (SOAP) Investigators. Crit Care. 2008;12(3):Jun 4.
  34. 34. An observational study fluid balance and patient outcomes in the Randomized Evaluation of Normal vs. Augmented Level of Replacement Therapy trial. RENAL Replacement Therapy Study Investigators,
  35. 35. Improved understanding of microvascular physiology allows explanation of the discrepancy between clinical findings during fluid therapy and the original Starling principle The role of the endothelial glycocalyx in fluid distribution is important and its integrity is difficult to measure
  36. 36. MATERIAL AND METHODS: A total of 150 individuals were tested for levels of inflammatory markers (intercellular adhesion molecule-1 [ICAM-1], vascular cell adhesion molecule-1 [VCAM-1], interleukin-6 [IL-6]) and glycocalix markers (syndecan-1, heparan sulfate). Three groups consisted of patients with severe sepsis or septic shock, patients after major abdominal surgery without systemic inflammatory response syndrome, and healthy volunteers. Blood was drawn, at the time of diagnosis or surgery, and 6, 24, and 48h later. RESULTS: Levels of inflammatory markers were markedly higher in patients with sepsis compared with patients after major abdominal surgery and healthy volunteers. After major abdominal surgery, glycocalix markers in human plasma were at levels comparable to patients with sepsis. In patients with sepsis, levels of IL-6 correlated with syndecan-1, ICAM-1, VCAM-1, and lactate, while ICAM-1 furthermore correlated with CRP and lactate levels. CONCLUSION: High levels of glycocalix markers indicated that significant flaking of the endothelial glycocalix occurred in patients with sepsis, and to a lesser extent in patients after major abdominal surgery. This novel finding could explain the nonspecific capillary leaking syndrome of patients with sepsis and after major abdominal surgery, and may identify new targets for treating those patient populations.
  37. 37. Natriuretic Peptide in the Critically Ill with Acute Kidney Injury Massimo de Cal, Mikko Haapio, Dinna N. Cruz, Paolo Lentini, Andrew A. House, Ilona Bobek, Grazia M. Virzì, Valentina Corradi, Flavio Basso, Pasquale Piccinni, Angela D'Angelo, Jamie W. Chang, Mitchell H. Rosner, and Claudio Ronco Int J Nephrol. 2011; . Increase in median of BNP of patients with AKI on admission
  38. 38. • In this pilot study, demonstrated for the first time an association between plasma BNP levels and AKI in critically ill patients. • Patients with AKI have higher levels of BNP compared to no-AKI patients, and in AKI patients BNP levels continue to increase during the subsequent 48 hours. • Results suggest that plasma BNP may distinguish the occurrence of AKI.
  39. 39. Fluid Type may impact Renal Outcome
  40. 40. Resuscitation fluid use in critically ill adults: an international cross-sectional study in 391 intensive care units Simon Finfer, Bette Liu, Colman Taylor, Rinaldo Bellomo, Laurent Billot, Deborah Cook, Bin Du, Colin McArthur, John Myburgh and SAFE TRIPS Investigators
  41. 41. Percentage of fluid resuscitation episodes given as crystalloid, colloid or blood product according to country
  42. 42. Type of colloid used as a percentage of all colloid episodes by country.
  43. 43. Chloride Restrictive
  44. 44. • Loop diuretics • Mannitol • Dopamine Therapies for AKI with RIFLE Risk and Injury are limited
  45. 45. AIM The primary aim of the study is to assess the effects of a continuous supplementary infusion of standard L-amino acids on renal function, renal failure and recovery from renal injury in critically ill patients who require at least three days of intensive care. The effects of a continuous supplementary infusion of a standard mixture of L-amino acids will be compared to standard care with regards to the onset and severity of clinically significant renal dysfunction, need for RRT, renal recovery rates, need for ongoing dialysis, and health status (quality of life, physical function and overall survival) at follow-up 90 days after randomisation. Nephro-protective effects of L-amino acids in critically ill patients: A multi-centre randomised controlled trial. Gordon S. Doig, Fiona Simpson, Elizabeth Sweetman, Philippa Heighes, Rinaldo Bellomo, Michael Reade, Peter Harrigan, Andrew Davies,Carol Pollock, John Botha, Douglas Chesher, and Prasad Devarajan
  46. 46. Therapeutic agents for the treatment of AKI Anti-inflammatory agents b1 Integrin antagonist, adenosine receptor antagonist, mesenchymal stem cells, C5a receptor antagonist, IL-10, IL-6 antagonist, statins, erythropoietin, a melanocyte stimulating hormone, haeme oxygenase-1 inducers (rapamycin), activated protein C, toll like receptor (TLR) blockers (Eritoran), sphingosine 2A agonist, fibrates, statins, peroxisome proliferator activared receptor (PPAR)-c agonist, minocycline, inducable nitric oxide (iNOS) inhibitor, insulin, ethyl pyruvate, C5-antagonists, alkaline phosphatase Anti-apoptotic agents NGAL, adenosine receptor antagonist, mesenchymal stem cells, erythropoietin, a-melanocyte stimulating hormone, caspase inhibitors, minocycline, guanosine, pifithrin-a, poly ADP ribose polymerase (PARP) inhibitor Iron scavengers NGAL, apotransferrin, deferoxamine Anti-oxidants Edavarone, stobadine, deferoxamine Vasodilators Endothelin receptor antagonist, fenoldopam, anti natriuretic peptide Growth factors Erytropoetin, hepatocyte growth factor ?
  47. 47. 0% 10% 20% 30% 40% 50% 60% Never Seldom Sometimes Often Always Use of Frusemide Lasix Bolus Lasix Infusion What happens in practice?
  48. 48. Mean Arterial Blood Pressure targeted 0 20 40 60 80 100 120 60-70 70-80 >80
  49. 49. Nephrology consult 0 10 20 30 40 50 60 70 Never Seldom Sometime Often Always
  50. 50. Central Venous Pressure Monitoring Monitor CVP 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% Never Seldom Sometimes Often Always
  51. 51. DOSE OF RRT: The VA/NIH STUDY Intensity of Renal Support in Critically ill Patients High Intensity RRT has no proven benefit
  52. 52. Randomisation Intensive Management Intermittent haemodialysis 6 times a week If hemodynamically unstable CVVHDF 35 ml/kg/hr Conventional Management 3 times a week CVVHDF 20ml/kg/hr END POINT Primary Endpoint 60 day all cause mortality
  53. 53. Primary Outcome Death from any cause by day 60: Intensive Strategy (53.5%) Less Intensive Strategy (51.5%) (P Value 0.57)
  54. 54. Intensity of Continuous Renal-Replacement Therapy in Critically Ill Patients The RENAL Replacement Therapy Study Investigators N Engl J Med 2009; 361:1627-1638
  55. 55. Trial Management, Grant Applicants Rinaldo Bellomo Celia Bradford David Gattas Dorrilyn Rajbhandari Statistician Serigne Lo – George Institute 7 TRIAL SITES Auckland City (NZ) Shay McGuinness, Rachael Parke Austin (VIC) Rinaldo Bellomo, Glenn Eastwood Dandenong (VIC) Sanjiv Vij, Katherine Shepherd, Bridget O’Bree Frankston (VIC) John Botha, Sharon Allsop, David Lewis Monash (VIC) Craig Walker, Pauline Galt, Tammy Lamac Royal North Shore (NSW) Celia Bradford, Anne O’Connor Royal Prince Alfred (NSW) David Gattas, Dorrilyn Rajbhandari, Heidi Buhr SLHD (RPAH Zone) HREC Approval: X09-0068 & HREC/09/RPAH/98 The Heparin Citrate (THC) Study Optimising Filter life is problematic
  56. 56. AIM To test the hypothesis that regional citrate anticoagulation is more effective than regional heparin/protamine anticoagulation at maintaining functional filter life in patients receiving CRRT The Heparin Citrate Study ACTRN 12609001079235
  57. 57. INCLUSION Commencing CRRT for acute renal failure Suitable for intervention or control Equipoise Consent (prior or delayed) At least 1 of: K>6.5, pH<7.2, urea>25, creatinine >300, oedema Age <18y Expected <24h in ICU Contraindication to intervention or control (eg liver, H.I.T) Expected difficulty adhering to allocated group EXCLUSION The Heparin Citrate Study ACTRN 12609001079235
  58. 58. INTERVENTION Regional citrate anticoagulation Regional heparin/protamine anticoagulation CONTROL The Heparin Citrate Study ACTRN 12609001079235 CRRT CIRCUIT ANTICOAGULATION Between Sites: Different hardware, modalities, protocols Within Sites: Same hardware, modality. Same/v similar starting blood flow and fluid flow rates Unblinded (statistician was blinded)
  59. 59. PRIMARY OUTCOME Functional filter life transmembrane pressure >300mmHg visible clot obstructing flow / blood pump other reason (free text) Measured in time to clotting event (hours) All free text reasons for stopping were adjudicated by 2 independent, blinded intenvisists, and any disagreements resolved by consensus Deemed by consensus: clotted, didn’t clot, or unsure The Heparin Citrate Study ACTRN 12609001079235
  60. 60. RESULTS Baseline Characteristics – diagnosis and severity The Heparin Citrate Study ACTRN 12609001079235 Table. Baseline characteristics of the intervention and control group Citrate (N=105) Heparin/protamine (N=107) ~ 12% cardiac surgery, ~8 %septic shock, well matched groups including severity of illness APACHE III Diagnostic Group - no./total (%) Coronary artery bypass grafts 14/105 (13.3) 13/107 (12.1) Renal disorders 10/105 (9.5) 7/107 (6.5) Sepsis with shock, non-urinary 8/105 (7.6) 7/107 (6.5) Other respiratory diseases 6/105 (5.7) 7/107 (6.5) Valvular heart surgery 5/105 (4.8) 6/107 (5.6) Other 62/105 (59.0) 67/107 (62.6) APACHE II score - mean(SD) 25.6 (7.6) 25.0 (6.9) Meeting criteria for severe sepsis - no./total (%) 45/105 (42.9) 32/107 (29.9) SOFA: patients scoring 3+ at time of randomisation, no./total (%) Renal 45/101 (44.5) 51/106 (48.1) Cardiovascular 69/101 (68.3) 68/106 (64.2) Respiratory 46/101 (45.5) 51/106 (48.1) Coagulation 5/101 (5.0) 3/106 (2.8) Liver 3/101 (3.0) 7/106 (6.6)
  61. 61. RESULTS Baseline Characteristics – vent, inotrope, labs The Heparin Citrate Study ACTRN 12609001079235 Table. Baseline characteristics of the intervention and control group Citrate (N=105) Heparin/protamine (N=107) ~73% patients ventilated, ~67% inotropes Well matched at baseline for renal and haematological parameters Mechanically ventilated - no./total (%) 77/105 (73.3) 75/107 (73.3) Receiving inotropes - no./total (%) 74/105 (68.4) 71/107 (66.4) Renal parameters - mean (SD) Urea (mmol/L) 21.9 (13.3) 23.4 (13.8) Creatinine (µmol/L) 309 (157) 322 (177) Phosphate (mmol/L) 2.02 (0.83) 1.94 (0.94) Urine output in 6h prior to randomisation (mL) 170 (262) 190 (222) Haematological parameters - mean (SD) Haemoglobin (g/L) 98.0 (16.6) 98.3 (26.2) Platelet count (x10^9/L) 209 (146) 215 (143) INR 1.5 (1.2) 1.4 (0.52) APTT (s) 40 (18) 40 (14)
  62. 62. RESULTS Primary Outcome The Heparin Citrate Study ACTRN 12609001079235 • Includes the first filter in each patient ONLY Citrate median 39h (100 filters*) vs Hep/prot median 22.8h (104 filters*) Log rank p= 0.0037
  63. 63. RESULTS Number of Filters, Duration of CRRT The Heparin Citrate Study ACTRN 12609001079235 * filter outcome adjudicated by 2 independent intensivists Regional citrate anticoagulation was associated with use of fewer filters, less clotted filters and longer cumulative duration of CRRT Number of filters included in the study* Citrate Heparin/ protamine Total Clotted 226 310 536 Didn't Clot 127 112 239 Unclear 37 45 82 TOTAL 390 467 857 Duration of CRRT (hours) 8281 8015 16296
  64. 64. RESULTS Primary Outcome The Heparin Citrate Study ACTRN 12609001079235 Frailty Model Analysis: Hazard Ratios for FilterGroup Description Point Estimate95% Wald Confidence Limits FilterGroup Hep/Prot vs Citr 2.029 1.359 3.028 Analysis of Maximum Likelihood Estimates Parameter DF Parameter Estimate Standard ErrorChi-SquarePr > ChiSq Hazard RatioLabel FilterGroup Hep/Prot 1 0.70736 0.20429 11.9888 0.0005 2.029FilterGroup 0 The hazard ratio for a filter experiencing clotting in the heparin/protamine group (compared to citrate) was 2.03 (95% CI 1.34-3.02, p<0.005) Filters in the citrate group are half as likely to clot Cox model with random effect by subject
  65. 65. CONCLUSION During CRRT in ICU, regional citrate anticoagulation, compared to regional heparin/protamine anticoagulation is associated with - Half the risk of filter clotting [HR for clotting in hep/prot group 2.03 (95% CI 1.34-3.02, p<0.005)] - Median filter life 39h v 22.8h (p=0.0037) - Fewer adverse events The Heparin Citrate Study ACTRN 12609001079235
  66. 66. In patients who have RRT in ICU What about their outcome?
  67. 67. Long-Term Survival and Dialysis Dependency Following Acute Kidney Injury in Intensive Care: Extended Follow-up of a Randomized Controlled Trial Martin Gallagher Alan Cass, Rinaldo Bellomo, Simon Finfer, David Gattas, Joanne Lee, Serigne Lo, Shay McGuinness, John Myburgh, Rachael Parke, Dorrilyn Rajbhandari, for the POST-RENAL Study Investigators and the ANZICS Clinical Trials Group Membership of the POST-RENAL. February 11, 2014 PLOS medicine
  68. 68. Figure 2. Kaplan-Meier survival curve for all study participants from randomization to end of extended follow-up, shown by treatment group. Gallagher M, Cass A, Bellomo R, Finfer S, et al. (2014) Long-Term Survival and Dialysis Dependency Following Acute Kidney Injury in Intensive Care: Extended Follow-up of a Randomized Controlled Trial. PLoS Med 11(2): e1001601. doi:10.1371/journal.pmed.1001601
  69. 69. > 76 < 56
  70. 70. Table 5. Cox multivariate model for long-term mortality from randomization. Gallagher M, Cass A, Bellomo R, Finfer S, et al. (2014) Long-Term Survival and Dialysis Dependency Following Acute Kidney Injury in Intensive Care: Extended Follow-up of a Randomized Controlled Trial. PLoS Med 11(2): e1001601. doi:10.1371/journal.pmed.1001601
  71. 71. Table 4. Prevalence of CKD by eGFR and albumin to creatinine ratio in follow-up participants. Gallagher M, Cass A, Bellomo R, Finfer S, et al. (2014) Long-Term Survival and Dialysis Dependency Following Acute Kidney Injury in Intensive Care: Extended Follow-up of a Randomized Controlled Trial. PLoS Med 11(2): e1001601. doi:10.1371/journal.pmed.1001601 http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.1001601
  72. 72. Found that patients with AKI treated with RRT in the ICU were at high risk of dying during the 3.5-year follow-up period; overall 31.9% of those surviving to 90 days died during the extended follow-up period. The risk of dying was much greater than the risk of entering a maintenance dialysis program, with neither outcome being influenced by the use of a higher intensity of RRT. The rate of albuminuria in survivors was substantial, despite relative preservation of renal function
  73. 73. • Consider causes other than ATN. • Be mindful of Nephrotoxic drugs. • Restore MAP and ignore CVP after a few days in ICU • Fluid overload is bad and fluid therapy in ICU is a dynamic process. • After initial resuscitation aim for a neutral or negative fluid balance • Synthetic colloids should be avoided • Consider Citrate • Follow up of survivors should be considered with attention to strategies to decrease albuminuria
  74. 74. PENINSULA HEALTH • Thank You Peninsula Health, Winner – Metropolitan Health Service of the Year 2007 and 2009 2

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