Diuresis - facts, fiction and future
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A presentation by Mareike Körber at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine. All available content from SSAI2017: https://scanfoam.org/ssai2017/ Delivered in collaboration between scanFOAM, SSAI & SFAI.
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Diuresis - facts, fiction and future
- 1. U N I V E R S I T Ä T S M E D I Z I N B E R L I N Diuresis – facts, fiction and future Dr. Mareike Kristina Körber Department of Anesthesiology and Operative Intensive Care Medicine
- 2. Financial disclosure Research funding by Bayer Healthcare Boehringer Ingelheim Bristol Myers Squibb/Pfizer
- 3. diu – re – sis Excretion of urine; commonly denotes production of unusually large volumes Farlex Partner Medical Dictionary © Farlex 2012
- 5. Facts
- 6. Fact I Awareness for changes in diuresis is fundamental for early recognition of AKI
- 7. Facts I AKI occurs in 30% non-cardiac and up to 60% in cardiac surgery Bihorak A, Nephron 2015; Shin S et al., Res Int 2016
- 9. Fact II Forced diuresis by loop diuretics is a near ubiquitous tool in perioperative volume overload
- 10. Pro & Con loop diuretics Prompt effect Activation of RAAS and sympathtic nerve system High level of evidence Electrolyte imbalance potentially causing arrhythmia Decades of experience Progression of ventricular left heart failure suspected
- 11. Wu M et al., J Critical Care Care 2014 Loop diuretics Bolus or continous?
- 13. Fiction
- 14. Fiction I Diuretic drugs prevent AKI or shorten time on RRT
- 15. Single-center double blind placebo controlled trial 13-bed ICU van der Voort et al., Critical Care Medicine 2009
- 16. No significant effect of furosemide van der Voort et al., Critical Care Medicine 2009
- 17. pilot randomized, blinded, placebo-controlled trial at three tertiary university-affiliated hospital intensive care units Bagshaw S et al., Journal of Critical Care 2017
- 18. No significant effect of furosemide Bagshaw S et al., Journal of Critical Care 2017
- 20. Fiction II All fluids are equally good to maintain diuresis
- 21. 0.9% Saline Retrospective cohort study from an US database Patients undergoing major open abdominal surgery 0.9% saline (2778 patients) or a balanced (calcium-free) crystalloid solution (926 patients) on the day of surgery Shaw A et al., Annals of Surgery 2012
- 22. 0.9% Saline Less... In-hospital mortality Postoperative infection AKI requiring dialysis Electrolyte disturbances IN THE BALANCED CRISTALLOID GROUP Shaw A et al., Annals of Surgery 2012
- 23. Patients admitted to ICU without AKI or RRT requiring cristalloid infusion Young P et al. JAMA 2015
- 24. 23 cardiac surgery centers in spain 1058 patients included (350 received 6% HES intra- and postoperatively) Vives M et al., British Journal of Anesthesia 2016
- 25. Vives M et al., British Journal of Anesthesia 2016
- 26. Vives M et al., British Journal of Anesthesia 2016
- 27. Vives M et al., British Journal of Anesthesia 2016
- 29. Future
- 30. Future I Control of infusion and diuresis will be overtaken by automatic systems
- 32. RenalGuard® • Use in prevention of contrast-induced AKI • Infusion rate matched with urine output • Additional adminstration of furosemide if needed
- 34. Future II Will we initiate RRT earlier in the future?
- 35. RRT initiation <12h or standard (median after 31h) AKI without urgent RRT indication in critically ill patients Wald R et al., Kidney International 2015
- 36. RRT initiation <12h or standard (median after 31h); AKI without urgent RRT indication in critically ill patients Wald R et al., Kidney International 2015
- 37. ICU patients with KDIGO stage 3 Early RRT (after randomization) vs. delayed (RRT if severe hyperkalemia, metabolic acidosis, pulmonary edema, blood urea nitrogen level higher than 112 mg per deciliter, or oliguria for more than 72 hours after randomization occured) Gaudry S et al., NEJM 2016
- 38. Gaudry S et al., NEJM 2016
- 39. Future III Will we use biomarkers only in the future to diagnose AKI?
- 40. Results of plasma and urinary NGAL predicting AKI in ICU patients varied NGAL cannot at present be recommended as a routine marker of AKI in the ICU Studies investigating the value of NGAL in predicting the use of RRT showed homogenously reasonable predictive value Hjortrup P et al., Critical Care 2013
- 42. Measurement of insulin-like growth factor–binding protein 7 (IGFBP7) and tissue inhibitor of metalloproteinase-2 (TIMP-2) If the biomarkers were positive patients were randomized to (KDIGO) care bundle or standard care Göcze I et al., Annals of surgery 2017
- 43. Göcze I et al., Annals of surgery 2017
Editor's Notes
- men 1,35l/d and women 1,15l/d in median
- If you give a loop diuretic the question if its better continous or as a bolus
- Inclusion criteria: mechanically ventilated patients with CVVH, written informed consent Exclusion criteria: age below 18 years, chronic renal failure, pregnancy, known furosemide allergy and ARF caused by glomerulonephritis
- Inclusion criteria: evidence of early AKI (RIFLE category – RISK) , ≥2 criteria for SIRS within 24 h of screening, achieved EGDT goals
- 0,4mg/kg Bolus und 0.05mg/kg/h
- Propensity score matching Attempt to avoid potassium containing infusion fluids
- Shown are the Kaplan–Meier curves of the probability of a patient having urine output, for at least 1 day, of more than 1000 ml per 24 hours in the absence of diuretic treatment or more than 2000 ml per 24 hours with diuretic treatment and not requiring initiation or resumption of renal-replacement therapy for at least 7 days, from randomization to day 28
- (urinary cell cycle arrest biomarkers used to predict AKI after major cardiac and noncardiac surgery) (KDIGO) care bundle (early optimization of fluid status, maintenance of perfusion pressure, discontinuation of nephrotoxic agents)
- Diuresis is complex entity in our daily clinical practice. It has a wide range of influencing factors and consequences possibly lasting for a patients hole life. Therefore we should use new parameters, devices, recommendations together with our personal experience and clinical empathy.