Datasheet1_Fluid deresuscitation in critically ill children: comparing perspectives of intensivists and nephrologists.pdf

IntroductionFluid accumulation, presently defined as a pathologic state of overhydration/volume overload associated with clinical impact, is common and associated with worse outcomes. At times, deresuscitation, the active removal of fluid via diuretics or ultrafiltration, is necessary. There is no consensus regarding deresuscitation in children admitted to the pediatric intensive care unit. Little is known regarding perceptions and practices among pediatric intensivists and nephrologists regarding fluid provision and deresuscitation.
MethodsCross-sectional electronic survey of pediatric nephrologists and intensivists from academic societies in the United States designed to better understand fluid management between disciplines. A clinical vignette was used to characterize the perceptions of optimal timing and method of deresuscitation initiation at four timepoints that correspond to different stages of shock.
ResultsIn total, 179 respondents (140 intensivists, 39 nephrologists) completed the survey. Most 75.4% (135/179) providers believe discussing fluid balance and initiating fluid deresuscitation in pediatric intensive care unit (PICU) patients is “very important”. The first clinical vignette time point (corresponding to resuscitation phase of early shock) had the most dissimilarity between intensivists and nephrologists (p = 0.01) with regards to initiation of deresuscitation. However, providers demonstrated increasing agreement in their responses to initiate deresuscitation as the clinical vignette progressed. Compared to intensivists, nephrologists were more likely to choose “dialysis or ultrafiltration” as a deresuscitation method during the optimization [10.3 vs. 2.9% (p = 0.07)], stabilization [18.0% vs. 3.6% (p < 0.01)], and evacuation [48.7% vs. 23.6% (p < 0.01)] phases of shock. Conversely, intensivists were more likely to utilize scheduled diuretics than nephrologists [47.1% vs. 28.2% (p = 0.04)] later on in the patient course.
DiscussionMost physicians believe that discussing fluid balance and deresuscitation is important. Nevertheless, when to initiate deresuscitation and how to accomplish it differed between nephrologist and intensivists. Widely understood and operationalizable definitions, further research, and eventually evidence-based guidelines are needed to help guide care.

引言：体液潴留目前被定义为一种与临床不良影响相关的过度水化/容量超负荷病理状态，其发病率较高，且与不良预后相关。在某些情况下，通过利尿剂或超滤主动清除体液的液体去复苏（deresuscitation）治疗是必要的。目前针对儿童重症监护病房（pediatric intensive care unit, PICU）收治患儿的液体去复苏治疗，尚无统一共识。目前对于儿科重症医师与肾脏科医师在体液管理与液体去复苏治疗方面的认知与实践现状，尚缺乏相关研究。
方法：本研究针对美国学术学会旗下的儿科肾脏科医师与重症医师开展横断面电子问卷调查，旨在深入了解不同学科间的体液管理实践差异。研究采用临床情景案例，以对应休克不同阶段的四个时间节点，来刻画受试者对于液体去复苏治疗启动时机与最优方式的认知情况。
结果：总计179名受访者（140名儿科重症医师、39名儿科肾脏科医师）完成了本次调查。75.4%（135/179）的受访医师认为，在PICU患儿中讨论体液平衡情况并启动液体去复苏治疗属于"极为重要"的临床工作。首个临床情景对应的时间节点（即早期休克的复苏阶段），在液体去复苏治疗启动时机的认知上，儿科重症医师与肾脏科医师之间的差异最为显著（p=0.01）。不过，随着临床情景的推进，受访者对于启动液体去复苏治疗的观点逐渐趋于一致。与儿科重症医师相比，肾脏科医师在休克优化阶段[10.3% vs. 2.9%（p=0.07）]、稳定阶段[18.0% vs. 3.6%（p<0.01）]以及清除阶段[48.7% vs. 23.6%（p<0.01）]，更倾向于选择"透析或超滤"作为液体去复苏的治疗方式。反之，在患儿病程后期，儿科重症医师相较于肾脏科医师更倾向于使用计划性利尿剂治疗[47.1% vs. 28.2%（p=0.04）]。
讨论：多数受访医师认为，讨论体液平衡与液体去复苏治疗具有重要临床意义。然而，儿科肾脏科医师与重症医师在液体去复苏治疗的启动时机与实施方式上仍存在分歧。未来亟需制定可广泛推广且具备临床可操作性的统一定义，开展更多相关研究，并最终形成基于证据的临床指南，以指导临床实践。