Hemodynamic tolerance of intermittent hemodialysis in critically ill patients - Usefulness of practice guidelines

Poor hemodynamic tolerance of intermittent hemodialysis (IHD) is a common p roblem for patients in an intensive care unit (ICU). New dialysis strategie s have been adapted to chronic hemodialysis patients with cardiovascular in sufficiency. To improve hemodynamic tolerance of IHD, specific guidelines w ere progressively implemented into practice through the year 1996 in our 26 -bed medical ICU. To evaluate the efficiency of these guidelines we retrosp ectively compared all IHD performed during the years before (1995) and afte r (1997) implementation of these recommendations. Forty-five patients under went 248 IHD sessions in 1995 and 76 patients underwent 289 IHD sessions in 1997. The two populations were similar for age, sex, chronic hemodialysis (26% versus 17%), and secondary acute renal failure. In 1997, patients were more severely ill with a higher SAPS II (50 +/- 17 versus 59 +/- 24; p = 0 .036), and more patients required epinephrine or norepinephrine infusion be fore dialysis sessions (16% versus 34%; p < 0.0001). The compliance to guid elines was high, inducing a significant change in IHD modalities. As a resu lt, hemodynamic tolerance was significantly better in 1997, with less systo lic blood pressure drop at onset (33% versus 21%, p = 0.002) and during the sessions (68% versus 56%, p = 0.002). IHD with hypotensive episode or need for therapeutic interventions were less frequent in 1997 (71% versus 61%, p = 0.015). The ICU mortality was similar (53.3% in 1995 versus 47.3% in 19 97; p = 0.52) but death rate in 1997, but not in 1995, was significantly le ss than predicted from SAPS II (47.3% versus 65.6%; p = 0.02). Length of IC U stay was also reduced for survivors in 1997 (p = 0.04). Implementation of practice guidelines for intermittent hemodialysis in ICU patients lessens hemodynamic instability and may improve outcome.