Raghavan Murugan1,2, Marlies Ostermann3, Zhiyong Peng4, Koichi Kitamura5, Shigeki Fujitani6, Stefano Romagnoli7,8, Luca Di Lullo9, Nattachai Srisawat10, Subhash Todi11, Nagarajan Ramakrishnan12, Eric Hoste13, Chethan M Puttarajappa14, Sean M Bagshaw15, Steven Weisbord1,14,16, Paul M Palevsky1,14,16, John A Kellum1,2, Rinaldo Bellomo17, Claudio Ronco18. 1. The Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA. 2. 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. 3. Department of Critical Care, King's College London, Guy's & St Thomas' Hospital, London, United Kingdom. 4. Department of Critical Care Medicine, Wuhan University Zhongnan Hospital, Wuhan, Hubei Province, China. 5. Department of Nephrology, Endocrinology and Diabetes, Tokyo Bay Urayasu Ichikawa Medical Center, Urayasu, Chiba, Japan. 6. Emergency and Critical Care Medicine Department, St. Marianna University, Kawasaki-city, Kanagawa, Japan. 7. Department of Health Science, University of Florence, Florence, Italy. 8. Department of Anesthesia and Critical Care, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy. 9. Department of Nephrology and Dialysis, L. Parodi-Delfino Hospital, Colleferro, Italy. 10. Excellence Center for Critical Care Nephrology, Division of Nephrology, Department of Medicine, Chulalongkorn University, Bangkok, Thailand. 11. Department of Critical Care, AMRI Hospitals, Kolkata, West Bengal, India. 12. Department of Critical Care Medicine, Apollo Hospitals, Chennai, Tamil Nadu, India. 13. Department of Intensive Care Medicine, Ghent University, Ghent, Belgium. 14. Renal-Electrolyte Division, Department of Medicine, University of Pittsburgh, Pittsburgh, PA. 15. Department of Critical Care Medicine, Faculty of Medicine and Dentistry and School of Public Health, University of Alberta, Edmonton, AB, Canada. 16. Renal Section, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, PA. 17. Department of Intensive Care Medicine, Austin Hospital, The University of Melbourne, Melbourne, VIC, Australia. 18. Department of Medicine, University of Padova, International Renal Research Institute of Vicenza and Department of Clinical Nephrology, San Bortolo Hospital, Vicenza, Italy.
Abstract
OBJECTIVES: 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. DESIGN: Multinational internet-assisted survey. SETTING: Critical care practitioners involved with 14 societies in 80 countries. SUBJECTS: 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. CONCLUSIONS: 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.
OBJECTIVES: To assess the attitudes of practitioners with respect to net ultrafiltration prescription and practice among critically illpatients with acute kidney injury treated with renal replacement therapy. DESIGN: Multinational internet-assisted survey. SETTING: Critical care practitioners involved with 14 societies in 80 countries. SUBJECTS: 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. CONCLUSIONS: 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.
Authors: Javier A Neyra; Joshua Lambert; Victor Ortiz-Soriano; Daniel Cleland; Jon Colquitt; Paul Adams; Brittany D Bissell; Lili Chan; Girish N Nadkarni; Ashita Tolwani; Stuart L Goldstein Journal: PLoS One Date: 2022-08-25 Impact factor: 3.752
Authors: Anna Hall; Siobhan Crichton; Alison Dixon; Ilia Skorniakov; John A Kellum; Marlies Ostermann Journal: Crit Care Date: 2020-06-01 Impact factor: 9.097