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Hemodynamic goal-directed intermittent hemodialysis

Introduction

Intermittent hemodialysis (IH) is the commonest form of renal replacement therapy (RRT) in the majority of Indian ICUs as each continuous veno-venous hemofiltration session for 24 hours costs around €250, against IH that costs around €25/4 hour session. The major concern of IH in septic shock patients is hemodynamic instability. Whether stringent hemodynamic monitoring and maintaining preset goals would reduce these instabilities and deliver optimal RRT is not clear. We undertook a prospective study to evaluate this concept.

Methods

Preset goals of keeping the mean arterial pressure (MAP) > 75 mm, cardiac output (CO) > 5 l/min and cardiac index (CI) > 2.5 l/min/m2 throughout the session were attempted to achieve by a stepwise protocol as follows: (1) fluid boluses, (2) increase in vasopressor/inotrope dose, (3) adjustment in the ultrafiltration rate between 250 and 700 ml/hour, and (4) adjustment in the blood flow rate between 150 and 300 ml/minute on a hemodialysis machine. Dopamine, norepinephrine, vasopressin and dobutamine were used alone or in combination to achieve these goals. Hemodynamic monitoring and data collection were done with Datex S-5 and Flo-Trac Vigileo monitors.

Results

Nineteen IH sessions of seven patients with septic shock were monitored and managed in the ICU. The baseline APACHE II score was 24.10 ± 4.98 and all patients had at least three organ failures. The average duration was 4.42 ± 1.30 hours and fluid removal was 2,000 ± 527 ml per IH session. The preIH MAP, CO and CI were 81.10 ± 10.80 mmHg, 6.23 ± 2.24 l/min and 3.45 ± 1.07 l/min/m2, respectively. The MAP, CO, CI were 81.42 ± 8.44 mmHg, 6.27 ± 2.24 l/min and 3.49 ± 1.07 l/min/m2 at 60 minutes; 79.36 ± 15.33 mmHg, 6.24 ± 2.65 l/min and 3.46 ± 1.31 l/min/m2 at 120 minutes; 82.83 ± 14.00 mmHg, 6.48 ± 2.36 l/min and 3.60 ± 1.06 l/min/m2 at 180 minutes; and 84.44 ± 13.98 mmHg, 6.46 ± 2.17 l/min and 3.6 ± 0.95 l/min/m2 at 240 minutes, respectively. Preset goals were maintained with fluids alone in four patients, fluids and escalation of vasopressor was required in seven patients, and fluids, vasopressor escalation with ultrafiltration and blood flow adjustments in six patients. Only 2/19 sessions were terminated at 120 and 90 minutes, due to development of new myocardial infarction in one and persistent hypotension in other.

Conclusion

Goal-directed hemodynamic management during IH can reduce hemodynamic instability and deliver reasonably optimum RRT in the absence of continuous veno-venous hemofiltration facilities.

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Jog, S., Akole, P., Gogate, N. et al. Hemodynamic goal-directed intermittent hemodialysis. Crit Care 11, P388 (2007). https://doi.org/10.1186/cc5548

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Keywords

  • Septic Shock
  • Mean Arterial Pressure
  • Cardiac Index
  • Renal Replacement Therapy
  • Dobutamine