[Renal replacement therapy in Intensive Care Units in Catalonia (Spain)]. / Utilización de las terapias de depuración extracorpórea en los Servicios de Medicina Intensiva de Cataluña (España).

OBJECTIVE: To assess the indications, settings and techniques used in renal replacement therapy (RRT) in Intensive Care Units (ICUs). STUDY DESIGN: A prospective, multicenter observational study was carried out. SETTING: Intensive Care Units. PATIENTS: All patients admitted to ICUs during the two-month study period in 2011 who required RRT. INTERVENTIONS: None. VARIABLES OF INTEREST: Patient demographic characteristics, baseline clinical data, RRT technique and materials used. RESULTS: Thirty-three patients were analyzed. RRT was started within the first 24hours after ICU admission in 17 of the 33 patients (52%). At the start of RRT, 18% of the patients (n=6) presented grade R on the RIFLE acute kidney injury (AKI) scale. The most common disorder associated with AKI was multiple organ dysfunction syndrome (64%; n=21). At the start of RRT, most patients (76%; n=25) presented hemodynamic instability, while the remaining 24% (n=8) were considered hemodynamically stable. The most common RRT technique in hemodynamically stable patients was continuous renal replacement therapy (CRRT) (63%; n=5). CRRT was the technique of choice in all 25 of the hemodynamically unstable patients (100%). Anticoagulation was used in 55% (n=18) of the patients. In most cases (61%, n=20), RRT was administered through the right femoral vein. In 84% (n=28) of the patients, the ultrafiltration effluent flow rate was ≤ 35ml/kg/h. CONCLUSIONS: The ICU physicians in this study followed current RRT guidelines. CRRT was preferred over intermittent renal replacement therapy, regardless of patient hemodynamic status.

Use of B-type natriuretic peptides to detect the existence and severity of diastolic dysfunction in non-cardiac critically ill patients: a pilot study.

BACKGROUND: This observational study was designed to evaluate and compare the usefulness of BNP and NT-proBNP concentrations to detect the existence and severity of left ventricular diastolic dysfunction (LVDD) in critically ill patients. METHODS: A prospective, observational study in a university hospital. The sample included 86 consecutive adult patients. Based on echocardiography data, LVDD were classified into normal, impaired relaxation, pseudonormal or restrictive patterns. Patients were classified according to whether filling pressures were elevated or non-elevated in the echocardiography. Sampling for natriuretic peptides was performed immediately before echocardiography. RESULTS: Fifty patients showed LVDD. The most frequently observed pattern was impaired relaxation (N.=35), followed by the restrictive (N.=9) and the pseudonormal (N.=6) patterns. BNP concentrations in restrictive and pseudonormal patterns were higher than in normal and impaired relaxation patterns, while NT-proBNP only showed differences between normal and pseudonormal or restrictive patterns. Cut-off values using ROC curve analyses to detect LVDD were 125 ng/L for BNP and 390 ng/L NT-proBNP. BNP and NT-proBNP concentrations were higher in the 15 patients with restrictive and pseudonormal patterns, suggesting elevated filling pressures. Cut-off values using ROC curve analyses to detect echocardiography signs of elevated filling pressures were 254 ng/L for BNP and 968 for NT-proBNP. Both natriopeptides performed in a similar way to detect LVDD and elevated filling pressures. CONCLUSION: Both BNP and NT-proBNP are useful screening tools to detect the presence of advanced degrees of LVDD, and especially to rule out elevated filling pressures.

Prognostic indexes and mortality in critically ill patients with acute renal failure treated with different dialytic techniques.

The objective of this study was to compare the evolution of patients with acute renal failure (ARF) treated conservatively or with different dialytic techniques in an intensive care unit (ICU). From June 1992 to November 1994, 1087 consecutive patients were admitted in our ICU. Two hundred and twenty of these presented with ARF, and were divided into three groups; group I (control group): 156 patients with ARF who did not receive substitutive techniques; group II: 21 patients under intermittent hemodialysis (IHD) or peritoneal dialysis (PD); group III: 43 patients under continuous hemodiafiltration (CHDF). The studied variables were age, etiology of renal failure, requirement of dialysis, type of dialysis, length of ICU and hospital stay, and renal function outcome. APACHE II and SAPS scores were recorded on admission and analyzed for hospital mortality. Chi-square test and the analysis of variance were used for the statistical analysis. Results are presented as mean +/- SD. A p value below 0.05 was considered statistically significant. Although etiology of ARF was multifactorial, we found a high frequency of ARF due to sepsis (56.8%), hypoperfusion (58.7%), and acute tubular necrosis (62.5%). Sepsis and heart failure were clinical conditions associated to a greater mortality. We did not find any statistical difference between the two dialyzed groups for all the studied variables, nor between the three groups regarding APACHE II and hospital stay. Significant differences were found between dialyzed and non-dialyzed patients respect to age, group I: 64.1 +/- 13.6, group II: 56.4 +/- 19.7, and group III: 56.0 +/- 14.1 (p < 0.001), creatinine peak serum levels, group I: 260 +/- 130, group II: 494 +/- 209, and group III: 441 +/- 170 mumol/L (p < 0.0001), and mortality, group I: 46.9%, group II: 66.7%, and group III: 76.2% (p < 0.002). SAPS score showed differences between the control group and the CHDF group 13.9 +/- 4.8 and 16.4 +/- 5.4 (p < 0.007), respectively. The use of dialytic techniques in critically ill ARF patients is associated with greater mortality. Prognostic indexes on admission did not correctly classify our patients with ARF. Continuous hemodiafiltration does not involve greater mortality or length of stay as compared to conventional dialysis.

Clonidine overdose.

A case of acute intoxication in a 60-yr-old woman who ingested 20 mg of clonidine is presented. The patient showed CNS depression (bradycardia, hypotonia) with systemic hypertension and peripheral vasoconstriction. She was treated with atropine and sodium nitroprusside. There was no recurrence and the patient recovered in 8 days.