Continuous renal replacement therapy with an automated monitor is superior to a free-flow system during extracorporeal life support. (Paden)

Symons JM, McMahon MW, Karamlou T, Parrish AR, McMullan DM. Continuous Renal Replacement Therapy With an Automated Monitor Is Superior to a Free-Flow System During Extracorporeal Life Support. Pediatr Crit Care Med. 2013 Aug 20. [Epub ahead of print]

OBJECTIVES: To determine whether integrated continuous renal replacement therapy provides more accurate fluid management than IV pump free-flow ultrafiltration in pediatric patients on extracorporeal life support.

DESIGN: Retrospective study.

SETTING: PICU and neonatal ICU in a tertiary academic center.

PATIENTS: Infants and children less than 18 years old.

INTERVENTIONS: Extracorporeal membrane oxygenation and continuous renal replacement therapy.

MEASUREMENTS AND MAIN RESULTS: Clinical data collected on patients who received free-flow or integrated renal replacement therapy while on extracorporeal life support. Normalized ultrafiltration error was calculated as: (physician specified fluid loss per 24-hr period – actual fluid loss per 24-hr period) divided by patient body weight (kg). Mixed linear regression analyses were used to model longitudinal ultrafiltration error trajectories within each mode of ultrafiltration. Based on an analysis of 458 serial ultrafiltration fluid balance measurements, integrated ultrafiltration was significantly more accurate than free-flow ultrafiltration (normalized ultrafiltration error of 1.2 vs 13.1 mL; p < 0.001). After adjusting for patient factors and time, integrated ultrafiltration was associated with a significantly lower normalized ultrafiltration error (variable estimate, -24 ± 6; p < 0.001). The use of integrated ultrafiltration was associated with shorter duration of extracorporeal life support (384 vs 583 hr, p < 0.001) and renal replacement therapy (185 vs 477 hr, p < 0.001) than free-flow patients. Overall ICU and hospital length of stay and in-hospital mortality were similar between the groups.

CONCLUSIONS: While free-flow ultrafiltration has the advantages of simplicity and low cost, integrated renal replacement therapy provides more accurate fluid management during extracorporeal life support. Better fluid status management with integrated renal replacement therapy may contribute to shorter duration of extracorporeal life support.

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Physician staffing models impact the timing of decisions to limit life support in the ICU. (from CHEST, March 2013 – Wittkamp)

CHEST. 2013;143(3):656-663. doi:10.1378/chest.12-1173.

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BACKGROUND:  A growing trend is the implementation of 24-h attending physician coverage in the ICU. Our aim was to measure the impact of 24-h, in-house, attending intensivist coverage on the quality of end-of-life care and the timing of end-of-life decision-making.

METHODS:  A retrospective cohort study was conducted of all ICU deaths 6 months before and 6 months after the implementation of mandatory 24-h attending intensivist coverage in a medical ICU. Data relevant to end-of-life care per established consensus recommendations were abstracted from the medical record.

RESULTS:  The following changes were observed after implementation of 24-h intensivist coverage: Time from ICU admission to decision to withdraw mechanical ventilation and time to decision to change to do-not-resuscitate code status both were shortened by 2 days (both P = .03). Quality measures, such as increased family presence around time of death (P = .01) also improved. Other findings, which did not reach statistical significance, included the following: Time to family conference was shortened by 2 days (P = .09), time to decision to limit any life support was shortened by 1 day (P = .08), time to death was shortened by 2 days (P = .08), and intubations against patient wishes decreased (from three to none; P = .12).

CONCLUSIONS:  The implementation of mandatory 24-h, in-house, attending intensivist coverage was associated with earlier decision-making across a number of domains related to end-of-life care. Positive trends were noted in quality of end-of-life care as reflected in the presence of family at the time of death.

Decisions to withdraw or withhold life support are routinely made in the ICU when patients, surrogate decision-makers, and the health-care team transition from curative to comfort care.1 The two most important factors influencing such decisions are patient preferences and patient prognosis.2,3 Numerous additional patient-, provider-, and surrogate-related factors impact such decisions and create significant variability in decision-making.4‐6 In an era when up to 20% of all adults die in the ICU and one-third of all health-care dollars in the United States are used in the last year of life, understanding how decisions to limit life support are made and implementing strategies to improve decision-making have been the subjects of continued research.1,7‐10

Additionally, there has been a growing trend and recommendations toward the use of continuous, 24-h, intensivist staffing of ICUs.11 This is typically accomplished by alternating daytime and nighttime intensivist shifts. The impact of adding continuous, attending intensivist coverage in the ICU has been associated with improvement in a number of patient outcomes including decreased hospital length of stay; decreased ICU complication rate; increased staff satisfaction; improvement in a number of evidence-based care processes, such as ventilator bundle compliance; and decreased mortality rates in some care settings.12‐14

In this single-center study, we sought to measure the impact of intensivist staffing models on decisions to limit life support in the ICU. We hypothesized that the continuous (24-h) presence of an attending intensivist would be associated with improved care at the end of life and improved end-of-life decision-making.