Background
Methods
Study design
Patients
IHD sessions
Hemodynamic management
Data collection
End points
Statistical analysis
Results
Population
Characteristics | Overall population |
---|---|
Mechanical ventilation | 39 (36 %) |
SOFA score | 8 [7–11] |
Vasopressor administration | 53 (50 %) |
Vasopressor dose (μg.kg-1.min-1) | 0.00 [0.00–0.15] |
Inotropes administration | 9 (8 %) |
Arterial lactate (mmol.L-1) | 1.4 [1.1–1.8] |
Elevated lactates above upper laboratory limit (2.2 mmol.L-1) | 14 (13 %) |
Heart rate (min-1) | 90 [80–98] |
Mean arterial pressure (mm Hg) | 75 [68–80] |
Mean arterial pressure below 65 mm Hg | 8 (7 %) |
Central venous pressure (mm Hg) | 8 [6–12] |
Cardiac index (L.min-1.m-2) | 3.5 [2.9–4.0] |
Indexed systemic vascular resistance (dyne.s.cm-5) | 1525 [1324–1864] |
Extravascular lung water (mL.kg-1 PBW) | 7.9 [6.0–9.9] |
Extravascular lung water > 7 mL.kg-1 PBW | 64 (60 %) |
Pulmonary vascular permeability index | 1.6 [1.3–2.0] |
IHD sessions
Characteristics | Overall population |
---|---|
Number of IHD sessions | 107 |
Number of IHD sessions per patient | 3 [2–5] |
Time between ICU admission and first IHD session (days) | 18 [10–30] |
Duration of IHD sessions (min) | 240 [240–245] |
Total fluid removal per session (mL) | 2620 [1990–3240] |
Fluid removal per hour (mL.H-1) | 655 [453–824] |
Dialyzer blood flow rate at IHD session onset (mL.min-1) | 250 [250–272] |
Dialysate flow rate at IHD session onset (mL.min-1) | 500 [500–625] |
Dialysate temperature at IHD session onset (°C) | 36 [36–36] |
Dialysate sodium concentration at IHD session onset (mmol.L-1) | 145 [144–150] |
Hypotension
Characteristics | No hypotension during session | Hypotension during session |
---|---|---|
(n = 46) | (n = 61) | |
Age | 70 [64–79] | 67 [58–78] |
Male gender | 38 (83 %) | 47 (77 %) |
SAPS II | 53 [40–62] | 53 [37–60] |
Reasons for PiCCO® monitoring | ||
• Septic shock | 30 (65 %) | 34 (56 %) |
• Cardiogenic shock | 7 (15 %) | 10 (16 %) |
• Other | 9 (20 %) | 17 (28 %) |
Time between ICU admission and IHD session (day) | 20 [12–34] | 16 [9–29] |
SOFA score at the day of IHD session | 7 [6–9] | 10 [8–11]†
|
Mechanical ventilation at IHD session onset | 18 (39 %) | 21 (34 %) |
Inotrope at IHD session onset | 7 (15 %) | 2 (3 %) |
Vasopressor at IHD session onset | 20 (43 %) | 33 (54 %) |
Vasopressor dose at IHD session onset (μg.kg-1.min-1) | 0 [0–0.10] | 0.04 [0–0.19] |
Heart rate at IHD session onset (min-1) | 89 [80–98] | 90 [81–98] |
MAP at IHD session onset (mm Hg) | 78 [71–83] | 72 [67–79]†
|
CVP at IHD session onset (mm Hg) | 9 [7–13] | 8 [5–11] |
CI at IHD session onset (L.min-1.m-2) | 3.7 [3.0–3.9] | 3.4 [2.8–4.0] |
ISVR at IHD session onset (dyne.s.cm-5) | 1561 [1366–1907] | 1501 [1262–1764] |
EVLWI at IHD session onset (mL.kg-1 PBW) | 8.2 [6.1–10.9] | 7.7 [6.0–9.7] |
PVPI at IHD session onset | 1.5 [1.2–2.0] | 1.6 [1.4–2.0] |
Preload dependence at IHD session onset | 1 (2 %) | 4 (7 %) |
Arterial lactates (mmol.L-1) | 1.4 [1.1–1.8] | 1.4 [1.1–1.8] |
Elevated lactates above upper laboratory limit (2.2 mmol.L-1) | 4 (9 %) | 10 (16 %) |
Duration of IHD sessions (min) | 240 [240–240] | 240 [240–250] |
Total fluid removal during IHD session (mL) | 3000 [2162–3370] | 2400 [1670–3200] |
Fluid removal per hour during IHD session (mL.H-1) | 756 [541–820] | 575 [400–829] |
Dialyzer blood flow rate at IHD session onset (L.min-1) | 250 [250–270] | 250 [250–275] |
Dialysate flow at IHD session onset (mL.min-1) | 500 [500–600] | 500 [500–700] |
Dialysate temperature at IHD session onset (°C) | 36 [36–36] | 36 [36–36] |
Dialysate sodium concentration at IHD session onset (mmol.L-1) | 145 [141–148] | 145 [145–150] |
Risk factor | Odds ratio | CI95% of odds ratio |
p value |
---|---|---|---|
SOFA score, per one point increment | 1.34 | 1.13–1.76 | <0.01 |
MAP at IHD session onset, per one mm Hg increment | 0.93 | 0.84–0.98 | 0.03 |
Inotrope at IHD session onset | 0.04 | ||
• No†
| 1 | ||
• Yes | 0.13 | 0.00–0.76 | |
Time between ICU admission and IHD session (day), per one point increment | 0.96 | 0.91–0.99 | 0.04 |
Hypotension with preload dependence
Characteristics | Hypotension without preload dependence | Hypotension with preload dependence |
---|---|---|
(n = 48) | (n = 11) | |
Age | 70 [58–78] | 64 [59–69] |
Male gender | 38 (79 %) | 7 (64 %) |
SAPS II | 54 [37–60] | 49 [41–55]†
|
Reasons for PiCCO® monitoring | ||
• Septic shock | 25 (52 %) | 8 (73 %) |
• Cardiogenic shock | 8 (17 %) | 2 (18 %) |
• Other | 15 (31 %) | 1 (9 %) |
Time between ICU admission and IHD session (day) | 18 [10–30] | 9 [6–15] |
SOFA score at the day of IHD session | 9 [7–11] | 10 [9–10] |
Mechanical ventilation at IHD session onset | 13 (27 %) | 8 (73 %)†
|
Inotrope at IHD session onset | 1 (2 %) | 1 (9 %) |
Vasopressor at IHD session onset | 25 (52 %) | 7 (64 %) |
Vasopressor dose at IHD session onset (μg.kg-1.min-1) | 0.04 [0–0.19] | 0.01 [0–0.13] |
Heart rate at IHD session onset (min-1) | 88 [79–96] | 92 [83–108]†
|
MAP at IHD session onset (mm Hg) | 70 [66–77] | 72 [72–80] |
CVP at IHD session onset (mm Hg) | 8 [5–11] | 8 [6–10] |
CI at IHD session onset (L.min-1.m-2) | 3.4 [2.8–3.9] | 3.6 [3.2–4.1] |
ISVR at IHD session onset (dyne.s.cm-5) | 1497 [1294–1711] | 1440 [1160–1636] |
EVLWI at IHD session onset (mL.kg-1 PBW) | 8.8 [6.5–12.7] | 10.9 [9.0–12.4] |
PVPI at IHD session onset | 1.5 [1.3–1.9] | 2.0 [1.6–2.0]†
|
Preload dependence at IHD session onset | 3 (6 %) | 1 (9 %) |
Arterial lactates (mmol.L-1) | 1.3 [1.1–1.6] | 1.5 [1.4–1.9] |
Elevated lactates above upper laboratory limit (2.2 mmol.L-1) | 8 (17 %) | 1 (9 %) |
Duration of IHD sessions (min) | 240 [240–250] | 228 [228–240] |
Total fluid removal during IHD session (mL) | 2580 [1738–3400] | 2250[390–2990] |
Fluid removal during IHD session (mL.H-1) | 576 [411–748] | 562 [95–748] |
Dialyzer blood flow rate at IHD session onset (L.min-1) | 250 [250–271] | 250 [250–295] |
Dialysate flow at IHD session onset (mL.min-1) | 500 [500–700] | 700 [500–700] |
Dialysate temperature at IHD session onset (°C) | 36 [36–36] | 36 [36–36] |
Dialysate sodium concentration at IHD session onset (mmol.L-1) | 145 [144–149] | 150 [145–150]†
|
Time between IHD session onset and hypotension (min) | 30 [14–94] | 60 [25–135] |
Cumulative fluid removal at time of hypotension (mL) | 265 [10–825] | 300 [70–1195] |
Parameter | AUC [CI95%] | Optimal cutoff | Se [CI95%]
| Sp [CI95%] | FP | FN | PPV | NPV | PLR | NLR | Youden index |
---|---|---|---|---|---|---|---|---|---|---|---|
PVPI at IHD onset | 0.68† [0.53–0.83] | 1.6 | 0.91 [0.59–1.00] | 0.53 [0.42–0.63] | 42 | 1 | 0.19 | 0.98 | 1.93 | 0.17 | 0.44 |
Mechanical ventilation at IHD onset | 0.69† [0.54–0.85] | NA | 0.64 [0.32–0.88] | 0.75 [0.65–0.83] | 24 | 4 | 0.23 | 0.95 | 2.55 | 0.15 | 0.39 |
HR at IHD onset (min-1) | 0.60 [0.38–0.81] | 105 | 0.36 [0.11–0.69] | 0.91 [0.83–0.96] | 9 | 7 | 0.31 | 0.93 | 3.88 | 0.70 | 0.27 |
Dialysate sodium concentration at IHD onset (mmol.L-1) | 0.63 [0.45–0.81] | 145 | 0.82 [0.48–0.98] | 0.45 [0.45–0.55] | 53 | 2 | 0.15 | 0.96 | 1.48 | 0.41 | 0.27 |
SAPS II | 0.46 [0.30–0.62] | 38 | 0.91 [0.59–1.00] | 0.27 [0.19–0.37] | 53 | 2 | 0.13 | 0.96 | 1.24 | 0.34 | 0.18 |
Discussion
Statistical methodology
Hypotension during IHD sessions
Association between hypotension and preload dependence during IHD sessions
Limitations
Clinical implications
Conclusions
Key messages
-
Lower arterial pressure at dialysis onset, higher SOFA score, and shorter time lag between ICU admission and IHD session are the main risk factors for hypotension during intermittent hemodialysis
-
The majority of hypotensive episodes occurring during intermittent hemodialysis are unrelated to preload dependence and should not necessarily lead to reduction of fluid removal by hemodialysis.
-
Identified risk factors for preload dependence-associated hypotension during IHD are high pulmonary vascular permeability index at hemodialysis onset and mechanical ventilation, and may prompt reduction of planned fluid removal during the session, or an increase in session duration.