Can Ultrasonographically Inferior Vena Cava Measured Parameters Guide Fluid Management and Improve the Prognosis AND Renal Outcome IN Patients with Acute Kidney Injury IN Intensive Care Unit?

Abstract

Background: It is clear that AKI is a major ICU syndrome with an incidence of some degree of renal dysfunction being reported in greater than 50%. Objective: In patients with AKI, if fluid therapy guided with IVC dimensions, as assessed by bedside ultrasound can be associated with improved renal function and outcome compared to fluid therapy guided with CVP. Patients and methods: A prospective single blinded randomized observational cohort study (Prospective observational study) was carried out on forty (40) patients with AKI during 24 months who admitted to ICU at Ain Shams University Hospitals, Cairo, Egypt. Full history taking, clinical examination, Ultrasonography, and Fluid balances were studied for each patent included in this study. In this study, 40 ICU patients with AKI - according to (KDIGO 2012) criteria - was included and divided into groups 1 and 2, each group included 20 patients matched as regard age, BMI and sex. Patient in group 1 was managed with fluid challenge in concordance with their IVC – CI > 50% in spontaneously breathing patients and in mechanically ventilated patients with a ∆ IVC > 12% and then each patient was received 250 ml normal saline infusion as fluid challenge and repeated every 4 hours with repeated IVC diameter measurement. In group 2, patients were managed also with fluid challenge in concordance with their CVP; where a CVP of 8 – 12 cm H2O was considered a target and CVP less than 8 cm H2O an indicator for fluid challenge, and each patient was received 250 ml normal saline infusion as fluid challenge and repeated every 4 hours with repeated CVP diameter measurement also. Both group also followed by repeated serum creatinine and renal urine output every 8 hours too. Results: In group 1 the mean of IVC collapsibility at the start point was 59.75 + 4.58% and after the first 24 hours was 34.8 + 4.99% and after 48 hours was 26.85 + 1.35% while in patients on mechanical ventilator the first Δ IVC at the start point was 51.55 + 3.68% and after 24 hours was 27.55 + 139% and after 48 hours was 17.15 + 1.57%. and in group 2 the mean of CVP at the start of study was 4.3 + 3.37 cm H2O and after 24 hours with fluid therapy was 7.2 + 1.77 cm H2O and after 48 hours was 11.15 + 1.46 cm H2O. At the start point of this study, the mean of patient’s creatinine were 2.78 + 0.39 mg/dl in group 1 and were 2.93 + 0.51 mg/dl in group 2 and after 24 hours of fluid therapy challenge, the mean of serum creatinine in group 1 were 1.95 + 0.32 mg/dl and in group 2 were 1.94 + 0.51 mg/dl, and after 48 hours the mean of serum creatinine in group 1 were 1.15 + 0.28 mg/dl and in group 2 were 1.2 + 0.33 mg/dl. Also, in group 1 the mean of urine output rate at zero time after diagnosis and before fluid therapy were0.46 + 0.25 ml/kg/h and in group 2 were 0.51 + 0.36 ml/kg/h and after 24 hours, the mean of urine output were 0.6 + 0.34 ml/kg/h in group 1 and were 0,57 + 0.49 ml/kg/h and after 48 hours were 1.53 + 0.22 ml/kg/h in group 1 and were 1.74 + 0.68 ml/kg/h in group 2. In conclusion, in patients with AKI, the only indication for fluid administration is correction or prevention of intravascular hypovolemia. If fluids are considered to be necessary, boluses of small aliquots should be considered instead of rapid high volume fluid administration. Follow up of correction of hypovolemia in such state can be effective by measuring IVC diameter by Ultrasound or by measuring CVP; both are good and kidney function outcome also is improved.