Perfusion-based deresuscitation during continuous renal replacement therapy: A before-after pilot study (The early dry Cohort).

BACKGROUND: Active fluid removal has been suggested to improve prognosis following the resolution of acute circulatory failure. We have implemented a routine care protocol to guide fluid removal during continuous renal replacement therapy (CRRT). We designed a before-after pilot study to evaluate the impact of this deresuscitation strategy on the fluid balance. METHODS: Consecutive ICU patients suffering from fluid overload and undergoing CRRT for acute kidney injury underwent a perfusion-based deresuscitation protocol combining a restrictive intake, net ultrafiltration (UFnet) of 2 mL/kg/h, and monitoring of perfusion (early dry group, N = 42) and were compared to a historical group managed according to usual practices (control group, N = 45). The primary outcome was the cumulative fluid balance at day 5 or at discharge. RESULTS: Adjusted cumulative fluid balance was significantly lower in the early dry group (median [IQR]: -7784 [-11,833 to -2933] mL) compared to the control group (-3492 [-9935 to -1736] mL; p = 0.04). The difference was mainly driven by a greater daily UFnet (31 [22-46] mL/kg/day vs. 24 [15-32] mL/kg/day; p = 0.01). There was no significant difference between both groups regarding hemodynamic tolerance. CONCLUSION: Our perfusion-based deresuscitation protocol achieved a greater negative cumulative fluid balance compared to standard practices and was hemodynamically well tolerated.

A modified TOF-ratio to assess rocuronium-induced neuromuscular block: a comparison with the usual TOF-ratio.

BACKGROUND: The TOFscan is an acceleromyographic neuromuscular monitor that calculates and displays two measurements: first, a train-of-four (TOF) ratio, or ratio of the fourth twitch in the TOF-sequence, T4, and the first twitch, T1 (T4/T1). In addition, a second, modified ratio is displayed (T4/Tr), which refers to the ratio between T4 and a reference twitch (Tr), calculated as the mean value of the four twitches in a TOF-sequence [Tr = (T1 + T2 + T3 + T4)/4]. T4/Tr is calculated before establishment of neuromuscular block. METHODS: This prospective observational study included 35 adult patients. NMB induced by a rocuronium bolus of 0.6 mg/kg was continuously monitored at the adductor pollicis with the TOFscan and both TOF-ratios were simultaneously assessed. Primary outcome was the comparison of recovery to a TOF-ratio ≥ 0.9 calculated as T4/T1 and T4/Tr. RESULTS: The first value of the T4/T1 ≥ 90% was 90.9 (1.1) % and the simultaneously calculated T4/Tr was 69.6 (9.3) %, P < 0.001. The first value of the T4/Tr ≥ 90% was 90.5 (1.1) %, the simultaneously T4/T1 was 97.3 (2.5) %, P < 0.001. Time from injection of rocuronium to a TOF-ratio ≥ 90% was 56.2 ± 17.1 min for the T4/T1 and 65.3 ± 19.3 min for the T4/Tr, P < 0.001. During onset, a TOF ratio ≤ 20% was reached 145.5 (50.5) s after rocuronium when considering T4/T1, and 114.5 (45) s with the T4/Tr, P < 0.001. CONCLUSION: The present study shows the limitations of the usually determined acceleromyographic TOF ratio (T4/T1) in determining adequate neuromuscular recovery. The T4/T1 ratio significantly overestimates recovery compared with the T4/Tr ratio. Clinical decisions of adequate neuromuscular recovery based on the new T4/Tr ratio may reduce the incidence of residual paralysis and improve patient safety.

Neuromuscular block in patients 80 years and older: a prospective, controlled study.

BACKGROUND: An increasing number of patients older than 80 years are undergoing anesthesia, but little information is available regarding pharmacodynamic effects of myorelaxants in this population. This study aims to compare the time course of rocuronium neuromuscular block in patients ≥ 80 years with those of younger adults. METHODS: Under total intravenous anesthesia with propofol and sufentanil, time course of a bolus of rocuronium 0.6 mg/kg neuromuscular block was assessed with acceleromyography in patients ≥ 80 and in patients 20-50 years old. Onset time, clinical duration, duration until 90% and 100% recovery of baseline were determined. RESULTS: Data from 32 patients were analyzed, 16 were ≥ 80 years and 16 were 20-50 years old. Demographic data are shown in Table 1. In the group ≥ 80, onset time was 190 s ± 46 s compared to 123 s ± 40 s in the group 20-50, P < 0.001 and the clinical duration was 52 [48-69.5] min and 36 [34-41] min, respectively, P < 0.001. Duration to 90% recovery of baseline was 77.5 [71-88.5] min and duration to 100% recovery of baseline was 91.2 [82.2-98] min in patients ≥ 80 years and the corresponding values in the patients 20-50 years old were 53.5 [49-55.5] min and 59.5 [56.5-70.25] min, respectively, P < 0.001. CONCLUSION: Compared to younger adults rocuronium shifted in patients ≥ 80 years from a rapid onset, intermediate acting compound to a slower onset, long-acting compound. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT03551652 (29/05/2018).