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Intensive Care Medicine

, Volume 32, Issue 1, pp 80–86 | Cite as

Early isovolaemic haemofiltration in oliguric patients with septic shock

  • Pasquale Piccinni
  • Maurizio Dan
  • Stefano Barbacini
  • Rizzieri Carraro
  • Emanuela Lieta
  • Silvio Marafon
  • Nereo Zamperetti
  • Alessandra Brendolan
  • Vincenzo D’Intini
  • Ciro Tetta
  • Rinaldo Bellomo
  • Claudio Ronco
Original

Abstract

Objective: To evaluate the effects of early short-term, isovolaemic haemofiltration at 45 ml/kg/h on physiological and clinical outcomes in patients with septic shock. Design: Retrospective study before and after a change of unit protocol (study period 8 years). Setting: Intensive care unit of metropolitan hospital. Patients: Eighty patients with septic shock. Interventions: Introduction of a new septic shock protocol based on early isovolaemic haemofiltration (EIHF). In the pre-EIHF period (before), 40 patients received conventional supportive therapy. In the post-EIHF period (after), 40 patients received EIHF at 45 ml/kg/h of plasma-water exchange over 6 h followed by conventional continuous venovenous haemofiltration (CVVH). Anticoagulation policy remained unchanged. Measurements and main results: The two groups were comparable for age, gender and baseline APACHE II score. Delivered haemofiltration dose was above 85% of prescription in all patients. PaO2/FiO2 ratio increased from 117±59 to 240±50 in EIHF, while it changed from 125±55 to 160±50 in the control group ( p <0.05). In EIHF patients, mean arterial pressure increased (95±10 vs 60±12 mmHg; p <0.05), and norepinephrine dose decreased (0.20±2 vs 0.02±0.2 µg/kg/min; p <0.05). Among EIHF patients, 28 (70%) were successfully weaned from the ventilator compared with 15 (37%) in the control group ( p <0.01). Similarly, 28-day survival was 55% compared with 27.5% ( p <0.05). Length of stay in the ICU was 9±5 days compared with 16±4 days ( p <0.002). Conclusions: In patients with septic shock, EIHF was associated with improved gas exchange, haemodynamics, greater likelihood of successful weaning and greater 28-day survival compared with conventional therapy.

Keywords

Acute renal failure Acute respiratory distress syndrome Continuous renal replacement therapy Haemofiltration Sepsis Uraemia 

Notes

Acknowledgements

We are indebted to several dedicated physicians and nurses in our ICU and Nephrology Department for their support and to Luca Marinoni for his help with data analysis and management.

Supplementary material

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References

  1. 1.
    Brivet FG, Kleinknecht DJ, Loirat P, Landais PJ (1996) Acute renal failure in intensive care units—causes, outcome, and prognostic factors of hospital mortality; a prospective, multicenter study. French Study Group on Acute Renal Failure. Crit Care Med 24(2):192–198CrossRefPubMedGoogle Scholar
  2. 2.
    de Mendonca A, Vincent JL, Suter PM,Moreno R, Dearden NM, Antonelli M, Takala J, Sprung C, Cantraine F (2000) Acute renal failure in the ICU: risk factors and outcome evaluated by the SOFA score. Intensive Care Med 26(7):915–921CrossRefPubMedGoogle Scholar
  3. 3.
    Wheeler AP, Bernard GR (1999) Treating patients with severe sepsis. N Engl J Med 21 340(3):207–214CrossRefGoogle Scholar
  4. 4.
    Liano G, Pascual J (1996) Acute renal failure. Madrid Acute Renal Failure Study Group. Lancet 17:347:479Google Scholar
  5. 5.
    Tonelli M, Manns B, Feller-Kopman D (2002) Acute renal failure in the intensive care unit: a systematic review of the impact of dialytic modality on mortality and renal recovery. Am J Kidney Dis 40:875–885CrossRefPubMedGoogle Scholar
  6. 6.
    Bernard GR, Vincent JL, Laterre PF, LaRosa SP, Dhainaut JF, Lopez-Rodriquez A, Steingrub JS, Garber GE, Helterbrand JD, Ely EW, Fisher CJ for the Recombinant Human Activated Protein C Worldwide Evaluation in Severe Sepsis (PROWESS) Study Group (2001) Efficacy and safety of recombinant human activated protein C for severe sepsis. New Engl J Med 344:699–709CrossRefPubMedGoogle Scholar
  7. 7.
    Noble JS, MacKirdy FN, Donaldson SI, Howie JC (2001) Renal and respiratory failure in Scottish ICUs. Anaesthesia 56:124–129CrossRefPubMedGoogle Scholar
  8. 8.
    Kramer AA, Postler G, Salhab KF, Mendez C, Carey LC, Rabb H (1999) Renal ischemia/reperfusion leads to macrophage-mediated increase in pulmonary vascular permeability. Kidney Int 55(6):2362–2367CrossRefPubMedGoogle Scholar
  9. 9.
    Rocker GM, Morgan AG, Shale D (1988) Pulmonary oedema and renal failure. Nephrol Dial Transplant 3:244–246PubMedGoogle Scholar
  10. 10.
    Honore PM, Jamez J, Wauthier M et al (2000) Prospective evaluation of short-term, high-volume isovolemic hemofiltration on the hemodynamic course and outcome inpatients with intractable circulatory failure resulting from septic shock. Crit Care Med 28:3581–3587CrossRefPubMedGoogle Scholar
  11. 11.
    Bellomo R, Kellum JA, Gandhi CR, Pinsky MR (2000)The effect of intensive plasma water exchange by hemofiltration on hemodynamics and soluble mediators in canine endotoxemia. Am J Respir Crit Care Med 161:1429–1436PubMedGoogle Scholar
  12. 12.
    Bernard GR, Artigas A, Brigman KL, Carlet G, Falke K, Hudson L, Lamy M, Le Gall JR, Morris A, Spragg R (1994) The American-European Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination. Am J Respir Crit Care Med 149:818–824PubMedGoogle Scholar
  13. 13.
    Vincent JL, Moreno R, Takala J, Willatts S, de Mendonca A, Bruining H, Reinhart CK, Suter PM, Thijs LG (1996) The SOFA (Sepsis-related Organ Failure Assessment) score describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Med. Intensive Care Med 22:707–710PubMedGoogle Scholar
  14. 14.
    Bellomo R, Ronco C (1998) Indications and criteria for initiating renal replacement therapy in the intensive care unit. Kidney Int 53 [Suppl 66]: S106–109Google Scholar
  15. 15.
    Bellomo R, Kellum J, Ronco C (2001) Acute renal failure: time for consensus. Intensive Care Med 27:1685–1688CrossRefPubMedGoogle Scholar
  16. 16.
    Knaus WA, Draper EA, Wagner DP, Zimmerman JE (1985) APACHE II: A severity of disease classification system. Crit Care Med 13:818–829PubMedGoogle Scholar
  17. 17.
    Cole L, Bellomo R, Journois D, Davenport P, Baldwin I, Tipping P (2001) High-volume hemofiltration in human septic shock. Intensive Care Med 27:978–986CrossRefPubMedGoogle Scholar
  18. 18.
    Oudemans van Straaten HM, Bosman RJ, van der Spoe JI, Zandstra DF (1999) Outcome of critically ill patients treated with intermittent high-volume haemofiltration: a prospective cohort analysis. Intensive Care Med 25:814–821CrossRefPubMedGoogle Scholar
  19. 19.
    Bouman CS, Oudemans van Straaten HM, Tijssen J (2002) Effects of early high-volume continuous venovenous hemofiltration on survival and recovery of renal function in intensive care patients with acute renal failure: a prospective randomized trial. Crit Care Med 30:2205–2211CrossRefPubMedGoogle Scholar
  20. 20.
    Ronco C, Bellomo R, Homel P, Brendolan A, Dan M, Piccinni P, La Greca G (2000) Effects of different doses in continuous veno-venous haemofiltration on outcomes of acute renal failure: a prospective randomised trial. Lancet 356(9223):26–30CrossRefPubMedGoogle Scholar
  21. 21.
    De Vriese AS, Colardyn FA, Philippe JJ, Vanholder RC, De Sutter JH, Lameire NH (1999)Cytokine removal during continuous hemofiltration in septic patients. J Am Soc Nephrol 10(4):846–853PubMedGoogle Scholar
  22. 22.
    Li Wan, Rinaldo Bellomo, David Di Giantomasso, Claudio Ronco (2003) The pathogenesis of septic acute renal failure. Curr Opin Crit Care 9:496–502PubMedGoogle Scholar
  23. 23.
    Van Biesen W, Vanholder R, Lameire N (2003) Dialysis strategies in critically ill acute renal failure patients Curr Opin Crit Care 9:491–495Google Scholar
  24. 24.
    Busund R, Koukline V, Utrobin U, Nedashkovsky E (2002) Plasmapheresis in severe sepsis and septic shock: a prospective, randomised, controlled trial. Intensive Care Med 28(10):1434–1439CrossRefPubMedGoogle Scholar
  25. 25.
    Ronco C, Brendolan A, Lonnemann G (2002) A pilot study of coupled plasma filtration with adsorption in septic shock. Crit Care Med 30:1250–1255CrossRefPubMedGoogle Scholar
  26. 26.
    Tetta C, Gianotti L, Cavaillon JM et al(2000). Coupled plasmafiltration-adsorption in a rabbit model of endotoxic shock. Crit Care Med 28:1526–1533CrossRefPubMedGoogle Scholar
  27. 27.
    Cole L, Bellomo R, Silvester W, Reeves JH (2000) A prospective, multicenter study of the epidemiology, management, and outcome of severe acute renal failure in a “closed” ICU system. Am J Respir Crit Care Med 162:191–196PubMedGoogle Scholar
  28. 28.
    Reeves JH, Butt WW, Shann F, and the Plasmafiltration in Sepsis Study Group (1999) Continuous plasmafiltration in sepsis syndrome. Crit Care Med 27:2096–2104CrossRefPubMedGoogle Scholar
  29. 29.
    Joannes-Boyau O, Rapaport S, Bazin R, Fleureau C, Janvier G (2004) Impact of high-volume hemofiltration on hemodynamic disturbance and outcome during septic shock. ASAIO J 50(1):102–109CrossRefPubMedGoogle Scholar
  30. 30.
    Yekebas EF, Strate T, Zolmaid S, Eisemberger CF, Erbersdobler A, Saalmuller A, Steffani K, Busch C, Elsner HA (2002) Impact of different modalities of continuous venovenous hemofiltration on sepsis-induced alterations in experimental pancreatitis. Kidney Int 62(5):1806–1818CrossRefPubMedGoogle Scholar
  31. 31.
    Ronco C, Bonello M, Bordoni V, Ricci Z, D’Intini V, BellomoR, Levi NW (2004) Extracorporeal therapies in non-renal disease: treatment of shock and the peak concentration hypothesis. Blood Purif 22(1):164–174CrossRefPubMedGoogle Scholar

Copyright information

© Springer-Verlag 2005

Authors and Affiliations

  • Pasquale Piccinni
    • 1
  • Maurizio Dan
    • 1
  • Stefano Barbacini
    • 1
  • Rizzieri Carraro
    • 1
  • Emanuela Lieta
    • 1
  • Silvio Marafon
    • 1
  • Nereo Zamperetti
    • 1
  • Alessandra Brendolan
    • 2
  • Vincenzo D’Intini
    • 2
  • Ciro Tetta
    • 2
  • Rinaldo Bellomo
    • 3
  • Claudio Ronco
    • 2
  1. 1.Department of Anesthesiology and Intensive Care MedicineSt. Bortolo HospitalVicenzaItaly
  2. 2.Department of NephrologyOspedale San BortoloVicenzaItaly
  3. 3.Department of Intensive Care and Department of MedicineAustin Hospital and Melbourne UniversityMelbourneAustralia

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