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Title: Net Ultrafiltration Prescription and Practice Among Critically Ill Patients Receiving Renal Replacement Therapy: A Multinational Survey of Critical Care Practitioners.
Austin Authors: Murugan, Raghavan;Ostermann, Marlies;Peng, Zhiyong;Kitamura, Koichi;Fujitani, Shigeki;Romagnoli, Stefano;Di Lullo, Luca;Srisawat, Nattachai;Todi, Subhash;Ramakrishnan, Nagarajan;Hoste, Eric;Puttarajappa, Chethan M;Bagshaw, Sean M;Weisbord, Steven;Palevsky, Paul M;Kellum, John A;Bellomo, Rinaldo ;Ronco, Claudio
Affiliation: Renal Section, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA
Department of Critical Care, King's College London, Guy's & St Thomas' Hospital, London, United Kingdom
The Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
Department of Health Science, University of Florence, Florence, Italy
Department of Anesthesia and Critical Care, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
Department of Critical Care Medicine, Wuhan University Zhongnan Hospital, Wuhan, Hubei Province, China
Department of Nephrology, Endocrinology and Diabetes, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu, Chiba, Japan
Emergency and Critical Care Medicine Department, St. Marianna University, Kawasaki-city, Kanagawa, Japan
Department of Nephrology and Dialysis, L. Parodi-Delfino Hospital, Colleferro, Italy
Excellence Center for Critical Care Nephrology, Division of Nephrology, Department of Medicine, Chulalongkorn University, Bangkok, Thailand
Department of Critical Care, AMRI Hospitals, Kolkata, West Bengal, India
Department of Critical Care Medicine, Apollo Hospitals, Chennai, Tamil Nadu, India
Department of Intensive Care Medicine, Ghent University, Ghent, Belgium
Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
Department of Critical Care Medicine, Faculty of Medicine and Dentistry and School of Public Health, University of Alberta, Edmonton, AB, Canada
Intensive Care
Department of Medicine, University of Padova, International Renal Research Institute of Vicenza and Department of Clinical Nephrology, San Bortolo Hospital, Vicenza, Italy
Issue Date: Feb-2020
Publication information: Critical Care Medicine 2020; 48(2): e87-e97
Abstract: To assess the attitudes of practitioners with respect to net ultrafiltration prescription and practice among critically ill patients with acute kidney injury treated with renal replacement therapy. Multinational internet-assisted survey. Critical care practitioners involved with 14 societies in 80 countries. Intervention: MEASUREMENT AND MAIN RESULTS:: Of 2,567 practitioners who initiated the survey, 1,569 (61.1%) completed the survey. Most practitioners were intensivists (72.7%) with a median duration of 13.2 years of practice (interquartile range, 7.2-22.0 yr). Two third of practitioners (71.0%; regional range, 55.0-95.5%) reported using continuous renal replacement therapy with a net ultrafiltration rate prescription of median 80.0 mL/hr (interquartile range, 49.0-111.0 mL/hr) for hemodynamically unstable and a maximal rate of 299.0 mL/hr (interquartile range, 200.0-365.0 mL/hr) for hemodynamically stable patients, with regional variation. Only a third of practitioners (31.5%; range, 13.7-47.8%) assessed hourly net fluid balance during continuous renal replacement therapy. Hemodynamic instability was reported in 20% (range, 20-38%) of patients and practitioners decreased the rate of fluid removal (70.3%); started or increased the dose of a vasopressor (51.5%); completely stopped fluid removal (35.8%); and administered a fluid bolus (31.6%), with significant regional variation. Compared with physicians, nurses were most likely to report patient intolerance to net ultrafiltration (73.4% vs 81.3%; p = 0.002), frequent interruptions (40.4% vs 54.5%; p < 0.001), and unavailability of trained staff (11.9% vs 15.6%; p = 0.04), whereas physicians reported unavailability of dialysis machines (14.3% vs 6.1%; p < 0.001) and costs associated with treatment as barriers (12.1% vs 3.0%; p < 0.001) with significant regional variation. Our study provides new knowledge about the presence and extent of international practice variation in net ultrafiltration. We also identified barriers and specific targets for quality improvement initiatives. Our data reflect the need for evidence-based practice guidelines for net ultrafiltration.
DOI: 10.1097/CCM.0000000000004092
ORCID: 0000-0002-1650-8939
PubMed URL: 31939807
Type: Journal Article
Appears in Collections:Journal articles

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