Epidemiology of acute kidney injury in Hungarian intensive care units: a multicenter, prospective, observational study.

BACKGROUND: Despite the substantial progress in the quality of critical care, the incidence and mortality of acute kidney injury (AKI) continues to rise during hospital admissions. We conducted a national, multicenter, prospective, epidemiological survey to evaluate the importance of AKI in intensive care units (ICUs) in Hungary. The objectives of this study were to determine the incidence of AKI in ICU patients; to characterize the differences in aetiology, illness severity and clinical practice; and to determine the influencing factors of the development of AKI and the patients' outcomes. METHODS: We analysed the demographic, morbidity, treatment modality and outcome data of patients (n = 459) admitted to ICUs between October 1st, 2009 and November 30th, 2009 using a prospectively filled in electronic survey form in 7 representative ICUs. RESULTS: The major reason for ICU admission was surgical in 64.3% of patients and medical in the remaining 35.7%. One-hundred-twelve patients (24.4%) had AKI. By AKIN criteria 11.5% had Stage 1, 5.4% had Stage 2 and 7.4% had Stage 3. In 44.0% of patients, AKI was associated with septic shock. Vasopressor treatment, SAPS II score, serum creatinine on ICU admission and sepsis were the independent risk factors for development of any stage of AKI. Among the Stage 3 patients (34) 50% received renal replacement therapy. The overall utilization of intermittent renal replacement therapy was high (64.8%). The overall in-hospital mortality rate of AKI was 49% (55/112). The ICU mortality rate was 39.3% (44/112). The independent risk factors for ICU mortality were age, mechanical ventilation, SOFA score and AKI Stage 3. CONCLUSIONS: For the first time we have established the incidence of AKI using the AKIN criteria in Hungarian ICUs. Results of the present study confirm that AKI has a high incidence and is associated with high ICU and in-hospital mortality.

Short-term effectiveness of different volume replacement therapies in postoperative hypovolaemic patients.

BACKGROUND AND OBJECTIVE: To examine the kinetics of volume loading with crystalloid and colloid infusions in critically ill patients after major surgery, using the pulse contour cardiac output (PiCCO) monitoring technique. METHODS: This prospective, randomized, multicentre study of 11 ICUs involved 200 mixed postoperative hypovolaemic patients (50 patients per group) in Hungary. Patients received 10 ml kg of lactated Ringer's solution, succinylated gelatin 4% w/v, 130/0.4 hydroxyethyl starch 6% w/v (HES) or human albumin 5% w/v over 30 min. A complete haemodynamic profile was obtained at 30, 45, 60, 90 and 120 min after baseline. The peak haemodynamic effects, the 120 min changes compared with baseline, the area under the curve (AUC) for the haemodynamic parameters over 120 min and the haemodilution effect of the solutions were analysed. The primary outcome was to compare the AUCs and the secondary outcome was to evaluate the haemodynamic changes at 120 min. RESULTS: There were significant differences in the AUCs of the haemodynamic parameters between colloids and lactated Ringer's solution in the cardiac index and global end-diastolic volume index (GEDVI); human albumin vs. lactated Ringer's solution in stroke volume variation (SVV); and succinylated gelatin, HES vs. lactated Ringer's solution in the oxygen delivery index (DO2I). Colloid infusions (mainly HES and human albumin) at 120 min caused significant changes in central venous pressure, cardiac index, GEDVI, SVV, DO2I and central venous oxygen saturation compared with baseline. The haemodilution effect was significantly greater in colloids vs. lactated Ringer's solution. CONCLUSION: In postoperative hypovolaemic patients, lactated Ringer's solution can significantly improve haemodynamics at the end of volume loading, but this effect completely disappears at 120 min. Ten millilitres per kilogram of colloid bolus (especially HES) improved the haemodynamics at 120 min; however, this was by only 5-25% compared with baseline. The colloids caused significantly larger AUCs than lactated Ringer's solution, but only in the cardiac index, GEDVI and DO2I, plus human albumin in the SVV.

Precision of transpulmonary thermodilution: how many measurements are necessary?

BACKGROUND AND OBJECTIVES: To analyse the precision of transpulmonary thermodilution from the PiCCO technique (Pulsion Medical System, Munich, Germany) in everyday intensive care practice in order to ascertain the minimum number of measurements necessary for scientific precision. METHODS: An observational study in the medical-surgical ICU of a teaching hospital was performed. Thirty consecutive patients from a mixed intensive care population using the PiCCO haemodynamic monitor were included. Five thermodilution measurements were repeated at 2 min intervals. The variability of the cardiac index and the global end-diastolic volume index was analysed with respect to the five consecutive measurements and the mean of the first two, first three, first four and all five measurements. RESULTS: There was similar distribution among the different measurements and means. The variability of the cardiac index and global end-diastolic volume index, represented by the standard error of means, the coefficient of errors and the confidence intervals, revealed a similar precision in separate measurements and in the different averaging techniques. The coefficient of errors was less than 5% even when calculating the mean of the first two measurements, meeting the criterion of scientific precision, and including patients with arrhythmia and varying blood pressure. CONCLUSION: Calculating the mean of two good-quality transpulmonary thermodilution measurements is equivalent to the other averaging techniques (three to five measurements) for the cardiac index and global end-diastolic volume index. Any further repeated measurements may be unnecessary and may contribute to volume overloading.