Aiming for a negative fluid balance in patients with acute lung injury and increased intra-abdominal pressure: A pilot study looking at the effects of PAL-treatment
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AuthorsColin Cordemans, Inneke De Laet, Niels Van Regenmortel, Karen Schoonheydt, Hilde Dits, Greg Martin, Wolfgang Huber, Manu L. N. G. Malbrain
- Tags: abdominal pressure, albumin, capillary leak, conservative late fluid management, extravascular lung water, fluid balance, fluid management, organ failure, PEEP, treatment
Achievement of a negative fluid balance in patients with capillary leak is associated with improved outcome. We investigated the effects of a multi-modal restrictive fluid strategy aiming for negative fluid balance in patients with acute lung injury (ALI)
In this retrospective matched casecontrol study, we included 114 mechanically ventilated (MV) patients with ALI. We compared outcomes between a group of 57 patients receiving PAL-treatment (PAL group) and a matched control group, abstracted from a historical cohort. PAL-treatment combines high levels of positive end-expiratory pressure, small volume resuscitation with hyperoncotic albumin, and fluid removal with furosemide (Lasix®) or ultrafiltration. Effects on extravascular lung water index (EVLWI), intra-abdominal pressure (IAP), organ function, and vasopressor therapy were recorded during 1 week. The primary outcome parameter was 28-day mortality.
At baseline, no significant intergroup differences were found, except for lower Pa0/FI02 and increased IAP in the PAL group (174.5±84.5 vs 256.5±152.7,p=0.001; 10.0±4.2 vs 8.0±3.7 mmHg, p=0.013, respectively). After 1 week, PAL-treated patients had a greater reduction of EVLWI, IAP, and cumulative fluid balance (-4.2±5.6 vs -1.1 ±3.7 mL/kg, p=0.006; -0.4±3.6 vs 1.8±3.8 mmHg, p=0.007; -1.451±7.761 vs 8.027±5.254 mL,p<0.001). Repercussions on cardiovascular and renal function were limited. PAL-treated patients required fewer days of intensive care unit admission and days on MV (23.6±15 vs 37.1±19.9 days,p=0.006; 14.6±10.7 vs 25.5±20.2 days, respectively) and had a lower 28-day mortality (28.l % vs 49.l %, p=0.034)
PAL-treatment in patients with ALI is associated with a negative fluid balance, a reduction of EVLWI and IAP, and improved clinical outcomes without compromising organ function.