Natriuretic Peptide-driven Fluid Management during Ventilator Weaning A Randomized Controlled Trial
Por:
Dessap, AM, Roche-Campo, F, Kouatchet, A, Tomicic, V, Beduneau, G, Sonneville, R, Cabello, B, Jaber, S, Azoulay, E, Castanares-Zapatero, D, Devaquet, J, Lellouche, F, Katsahian, S, Brochard, L
Publicada:
15 dic 2012
Resumen:
Rationale: Difficult weaning from mechanical ventilation is often associated with fluid overload. B-type natriuretic peptide (BNP) has been proposed as a tool for predicting and detecting weaning failure of cardiovascular origin.
Objectives: To investigate whether fluid management guided by daily BNP plasma concentrations improves weaning outcomes compared with empirical therapy dictated by clinical acumen.
Methods: In a randomized controlled multicenter study, we allocated 304 patients to either a BNP-driven or physician-driven strategy of fluid management during ventilator weaning. To standardize the weaning process, patients in both groups were ventilated with an automatic computer-driven weaning system. The primary end point was time to successful extubation.
Measurements and Main Results: In the BNP-driven group, furosemide and acetazolamide were given more often and in higher doses than in the control group, resulting in a more negative median (inter-quartile range) fluid balance during weaning (-2,320 [-4,735, 738] vs. -180 [-2,556, 2,832] ml; P < 0.0001). Time to successful extubation was significantly shorter with the BNP-driven strategy (58.6 [23.3, 139.8] vs. 42.4 [20.8, 107.5] h; P = 0.034). The BNP-driven strategy increased the number of ventilator-free days but did not change length of stay or mortality. The effect on weaning time was strongest in patients with left ventricular systolic dysfunction. The two strategies did not differ significantly regarding electrolyte imbalance, renal failure, or shock.
Conclusions: Our results suggest that a BNP-driven fluid management strategy decreases the duration of weaning without increasing adverse events, especially in patients with left ventricular systolic dysfunction.
Filiaciones:
Dessap, AM:
CHU Henri Mondor, AP HP, Serv Reanimat Med, F-94010 Creteil, France
Univ Paris Est Creteil, Fac Med, Creteil, France
Hop Henri Mondor, INSERM, U955, F-94010 Creteil, France
Roche-Campo, F:
CHU Henri Mondor, AP HP, Serv Reanimat Med, F-94010 Creteil, France
Hosp Santa Creu & Sant Pau, Serv Med Intens, Barcelona, Spain
Kouatchet, A:
CHU Angers, Serv Reanimat Med, Angers, France
Tomicic, V:
Clin Alemana, Dept Paciente Crit, Santiago, Chile
Beduneau, G:
CHU Rouen, Serv Reanimat Med, Rouen, France
Equipe Accueil UPRES EA 3830, Unite Propre Rech & Enseignement Super, Rouen, France
Sonneville, R:
Univ Paris Diderot, Serv Reanimat Med & Malad Infect, CHU Bichat Claude Bernard, AP HP, Paris, France
Cabello, B:
Hosp Santa Creu & Sant Pau, Serv Med Intens, Barcelona, Spain
Jaber, S:
CHU St Eloi, Dept Anesthesie Reanimat B, INSERM U1046, Montpellier, France
Azoulay, E:
CHU St Louis, AP HP, Serv Reanimat Med, Paris, France
Castanares-Zapatero, D:
Hop Univ St Luc, Serv Soins Intensifs, Brussels, Belgium
Devaquet, J:
Hop Foch, Serv Reanimat, Suresnes, France
Lellouche, F:
Inst Univ Cardiol & Pneumol Quebec, Quebec City, PQ, Canada
Katsahian, S:
CHU Henri Mondor, AP HP, Unite Rech Clin, F-94010 Creteil, France
Brochard, L:
CHU Henri Mondor, AP HP, Serv Reanimat Med, F-94010 Creteil, France
Univ Paris Est Creteil, Fac Med, Creteil, France
Hop Henri Mondor, INSERM, U955, F-94010 Creteil, France
Univ Geneva, Univ Hosp Geneva, Intens Care Div, Geneva, Switzerland
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