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

• Type of Material: Article
• Authors: Colin Cordemans, Campus Stuivenberg; Inneke De laet, Campus Stuivenberg; Niels Van Regenmortel, Campus Stuivenberg; Karen Schoonheydt, Campus Stuivenberg; Hilde Dits, Emory University; Greg Martin, Emory University; Wolfgang Huber, Technische Universität München; Manu LNG Malbrain, Campus Stuivenberg
• Language: English
• Date: 2012
• Publisher: BioMed Central
• Publication Version: Final Published Version
• Copyright Statement: © 2012 Cordemans et al.; licensee Springer
• License: Creative Commons Attribution 2.0 Generic
• Final Published Version (URL): http://www.annalsofintensivecare.com/content/2/S1/S15
• Title of Journal or Parent Work: Annals of Intensive Care
• ISSN: 2110-5820
• Volume: 2
• Issue: Suppl 1
• Start Page: S15
• End Page: S15
• Grant/Funding Information: There was no funding for this study.; The study is supported by the Council of Internal Medicine (head Prof Dr Pierre Zachée, MD, PhD), ZNA Stuivenberg Hospital, who paid for the open access publication fee.
• Keywords: conservative late fluid management; fluid management; abdominal pressure; albumin; treatment; capillary leak; PEEP; organ failure; extravascular lung water; fluid balance
• Research Categories: Health Sciences, General

Abstract

Introduction 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). Methods In this retrospective matched case-control 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. Results At baseline, no significant intergroup differences were found, except for lower PaO2/FIO2 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 (28.1% vs 49.1%, p = 0.034). Conclusion 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.