Preventive Versus Curative Treatment of Fluid Overload

  • STATUS
    Recruiting
  • End date
    Dec 1, 2022
  • participants needed
    410
  • sponsor
    Assistance Publique - Hôpitaux de Paris
Updated on 28 July 2021
mechanical ventilation
intubation
diuretics
critical illness
FIO2
positive end expiratory pressure
assisted ventilation
positive end-expiratory pressure

Summary

Fluid overload is associated with a poor prognosis in critically ill patients, especially during weaning from mechanical ventilation as it may promote weaning induced pulmonary edema. Previous data suggest that early administration of diuretics ("preventive depletion") could shorten the duration of mechanical ventilation. However, this strategy may expose patients to a risk of metabolic complications. On the other hand, initiating fluid removal only in case of weaning induced pulmonary edema (curative depletion) may reduce the risk of metabolic complications, but prolong the duration of mechanical ventilation. Currently, there is no recommendation for a preventive or curative use of diuretics during weaning. There is therefore an equipoise on the timing of initiation of diuretics during weaning from mechanical ventilation.

Description

Mechanical ventilation is a cornerstone treatment for critically ill patients that is however associated with complications that may alter the prognosis. A major objective is therefore to separate patients from the ventilator as quickly as possible, but without exposing them to the risk of extubation failure. Pulmonary edema is a frequent cause of extubation failure (up to 60% in recent series) and a positive fluid balance has been identified as an important risk factor for extubation failure.

Studies have tested the effect of a conservative strategy regarding the administration of fluids in patients with acute respiratory distress syndrome. This strategy is associated with an improvement in hemodynamic parameters despite an increase in urine output with a negative fluid balance and a significant weight loss as compared to a liberal strategy. The conservative approach also shows a significant improvement in oxygenation with a nonsignificant trend towards a shorter duration of artificial ventilation and ICU stay. During the specific phase of weaning from mechanical ventilation, a randomized trial (BMW trial) demonstrated that a strategy of fluid removal guided by measurement of the plasmatic B-type natriuretic peptide significantly reduced the duration of weaning. Likewise, the interest of obtaining a negative fluid balance through the administration of diuretics in weaning induced pulmonary edema has been established for decades ("curative depletion").

In this context, the hypothesis of the present study is that a preventive and systematic strategy of fluid removal through the use of diuretics initiated just before the weaning phase, as soon as the patients is stabilized would shorten the duration of weaning from mechanical ventilation as compared to a curative strategy of fluid removal, only initiated after a failure of the spontaneous breathing trial associated with weaning induced pulmonary edema.

The design of the study will be a randomized (1:1) controlled trial, open label, with 2 arms, to evaluate the superiority of the preventive strategy.

The weaning process will be protocolized and similar for the two groups.

Details
Condition Respiratory Failure, respiratory impairment, respiratory insufficiency, pulmonary regurgitation, Pulmonary insufficiency, pulmonic valve insufficiency
Treatment Preventive initiation of fluid removal, Curative initiation of fluid removal
Clinical Study IdentifierNCT04050007
SponsorAssistance Publique - Hôpitaux de Paris
Last Modified on28 July 2021

Eligibility

Yes No Not Sure

Inclusion Criteria

age>18
intubation and mechanical ventilation >= 24 hours
positive cumulated fluid balance or increase in body weight since admission
clinical stability as defined by: 4.1. stable oxygenation (SpO2 90 % with FiO2 50 % and positive end-expiratory pressure (PEEP) 8 cm H2O) 4.2. stable hemodynamics (no pressors, no fluid expansion within the last 12 hours) 4.3. stopped or decreased sedation within the last 48 hours and stable neurologic state
4. temperature >36,0 C and < 39C
\. consent signed by the patient or next of kin or emergency procedure

Exclusion Criteria

extracorporal membrane oxygenation
pregnancy or breastfeeding
allergy to furosemide, sulfamides or spironolactone
tracheotomy
hydrocephaly
acute right ventricle failure
cardiac arrest with estimated poor prognosis
already enrolled in an interventional study on weaning from mechanical ventilation
Guillain Barre, myasthenia crisis
planned extubation on the day
criteria of clinical stability (as described above) present since more than 24 hours
natremia > 150 mEq/L, kaliemia < 3.5 mEq/L, metabolic alkalosis with pH>7.5
administration of iodinated contrast within the last 6 hours
ongoing or planned use of artificial kidney within the next 48 hours
no affiliation to the health insurance system
patient under curatorship
imprisoned patient
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