The edition · Emergency & Critical Care
On CRRT, the fluid balance achieved mattered — not how fast fluid was pulled off
In 973 ICU patients, net ultrafiltration rate had no independent link with death once fluid balance was accounted for. Also: what happens to patients who fail to wean, a better trauma score for injured children, and who leaves septic shock frail.
The edition in brief
A two-centre European cohort of 973 critically ill adults on continuous renal replacement therapy found net ultrafiltration rate was not independently associated with 28-day mortality once daily fluid balance was accounted for; the apparent benefit of higher rates ran through achieving a more negative balance, while positive balance was linked to death. A secondary analysis of the WEAN SAFE cohort of 5,664 ventilated patients found 15% of those who began weaning failed by day 90, with ICU mortality of 78% against 2% in those who weaned; a failed first separation attempt was strongly associated with decisions to withhold or withdraw life support. A meta-analysis of paediatric trauma found the reverse shock index multiplied by Glasgow Coma Scale predicted mortality more strongly and more consistently than the age-adjusted shock index, which remained useful for transfusion need. A post hoc analysis of a Japanese trial in 339 older survivors of septic shock found 36% severely frail at 90 days, associated with pre-sepsis frailty, organ failure severity and corticosteroid use.
Failed weaning carried 78% ICU mortality, and the first failed attempt often set the course
After a failed first weaning attempt, look for reversible causes before letting it shape decisions to limit care.
Paediatric trauma: shock index combined with GCS predicted death better
In paediatric trauma, combining the shock index with GCS better identifies children at risk of death.
Over a third of older septic shock survivors were severely frail at 90 days
Assess pre-sepsis frailty in older patients with septic shock; it predicted severe frailty in survivors.
Write the daily fluid target on the CRRT chart
Prescribe a daily fluid balance target for every patient on CRRT, and titrate ultrafiltration to it.
On CRRT, target the fluid balance, not the ultrafiltration rate
Consider managing CRRT by daily fluid balance targets rather than fixed ultrafiltration rate limits.
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