Application Study On Goal-directed Volume Management In Continuous Blood Purification Treatment

Objective: The purpose of this study is to examine the role and advantages of goal-directed volume management(GDVM)strategies in continuous blood purification treatment(CBPT,also known as CRRT)volume management,and to provide guidance for volume management during CBPT.Measurements: GDVM is an optimized CBPT volume management strategy with the core of setting,titrating,and feedback adjusting the volume balance goals.In December 2017,we conducted centralized GDVM training for the medical staff in the Department of Critical Care Medicine,Dalian Central Hospital,Dalian Medical University.In this study,the patients who underwent CBPT from January 2016 to November 2017(before GDVM training)were used as the conventional volume management group;the patients who underwent CBPT from January 2018 to November2019(after GDVM training)were used as the GDVM group.Exclusion criteria: the patients with paraquat poisoning;patients who were given up by their family;patients with incomplete clinical data;and patients under 18 years old.Data were collected on the general conditions,disease severity scores,clinical treatments(mainly including CBPT treatment,booster drug use,and mechanical ventilation time)and survival of patients during ICU hospitalization.Statistical analysis was performed on the overall data of the two groups of patients and the related data of the AKI subgroup.Statistical analysis was performed using SPSS 23.0 software.Results:(?)Overall comparison of two groups of patients1.A total of 136 patients met the selection criteria,90 in the conventional volume management group and 46 in the GDVM group.There were no statistically significant differences between the two groups in general indicators such as gender,age,diseaseseverity score,underlying disease,and diagnostic classification.There were no significant differences in the number of cases of invasive mechanical ventilation before CBPT,the number of cases of using booster medication,the dose of booster medication before CBPT,lactic acid,and central venous pressure before CBPT(all P> 0.05).2.There were no significant differences in the number of new invasive mechanical ventilation and the number of invasive mechanical ventilation days,ICU days,and total hospitalization days between the two groups of patients during CBPT(P> 0.05).Compared with the conventional volume management group,the GDVM group had fewer days of booster drug dependence during CBPT(6.42 ± 3.37 vs 9.21 ± 5.88,P =0.031);fewer CBPT days were needed(6.13 ± 2.22 vs 8.08 ± 4.90,P = 0.022).3.There was no statistically significant difference in the ICU 28-day survival rate between the conventional volume management group and the GDVM group(60.87% vs46.67%,P> 0.05).Regression analysis of survival between the two groups of patients showed that there was no correlation between the volume management method during CBPT and the number of days of survival after admission to the ICU(P = 0.104).(?)Comparison of AKI subgroups between two groups of patients4.Compared with the AKI conventional volume management subgroup(n = 36)and the AKI GDVM subgroup(n = 72),there were no significant differences in general indicators of patients,the number of cases of invasive mechanical ventilation before CBPT,the booster drug dose before CBPT,lactic acid and CVP before CBPT(P> 0.05).Among them,in the AKI etiology statistics,septic shock/sepsis was the main cause(53.70%),followed by hemorrhagic shock(26.85%),cardiogenic shock(12.04%),and other causes(7.41%).5.There were no statistically significant differences in the number of new invasive mechanical ventilation,the number of days of ICU,the total number of days of hospitalization,and the 28-day survival rate of ICU in the two subgroups during the CBPT period(P> 0.05).Collect the CVP values during the CBPT process of two groups of patients and analyze the variance of repeated measurement datas to draw a CVP change trend chart,which shows that the AKI GDVM subgroup has smaller fluctuationsin CVP values than the AKI conventional volume management subgroup(P = 0.043).Compared with the AKI conventional volume management subgroup,the AKI GDVM subgroup has fewer days of booster drug dependence(6.70 ± 3.20 vs 9.44 ± 5.21,P =0.025),fewer days of invasive mechanical ventilation(8.00 ± 3.82 vs 10.93 ± 5.29,P =0.037),and fewer days of CBPT(6.27 ± 2.35 vs 8.30 ± 5.11,P = 0.043).The number of dialysis dependent patients in the AKI GDVM subgroup was lower than that in the AKI conventional volume management subgroup(33.33% vs 59.46%,P = 0.046).6.The 28-day ICU survival rate of the AKI GDVM group and the AKI conventional volume management group was not significantly different(66.67% vs51.39%,P> 0.05).Survival regression analysis showed that there was no significant correlation between volume management methods and survival days during CBPT(P =0.101).Conclusions:1.GDVM can safely achieve dehydration in CBPT critically ill patients,thereby reducing mechanical ventilation time.2.GDVM can prevent dehydration and insufficient volume in CBPT patients,which can contribute to correct the shock status of CBPT patients earlier.3.Although the GDVM strategy does not reduce the length of ICU stay,the total length of hospital stay and the survival rate,it can reduce the CBPT time of AKI patients,reduce the rate of dialysis dependence and play a positive role in the recovery of renal function in AKI patients,and can reduce the medical expenses of patients and save social medical resources.