Alain Combes, Nicolas Bréchot, Julien Amour, Nathalie Cozic, Guillaume Lebreton, Catherine Guidon, Elie Zogheib, Jean-Claude Thiranos, Jean-Christophe Rigal, Olivier Bastien, Hamina Benhaoua, Bernard Abry, Alexandre Ouattara, Jean-Louis Trouillet, Alain Mallet, Jean Chastre, Pascal Leprince, and Charles-Edouard Luyt Am. J. Resp. Crit. Care Med. Nov 15, 2015, vol. 192, no. 10: 1179-1190
Rationale: Post–cardiac surgery shock is associated with high morbidity and mortality. By removing toxins and proinflammatory mediators and correcting metabolic acidosis, high-volume hemofiltration (HVHF) might halt the vicious circle leading to death by improving myocardial performance and reducing vasopressor dependence.
Objectives: To determine whether early HVHF decreases all-cause mortality 30 days after randomization.
Methods: This prospective, multicenter randomized controlled trial included patients with severe shock requiring high-dose catecholamines 3–24 hours post–cardiac surgery who were randomized to early HVHF (80 ml/kg/h for 48 h), followed by standard-volume continuous venovenous hemodiafiltration (CVVHDF) until resolution of shock and recovery of renal function, or conservative standard care, with delayed CVVHDF only for persistent, severe acute kidney injury.
Measurements and Main Results: On Day 30, 40 of 112 (36%) HVHF and 40 of 112 (36%) control subjects (odds ratio, 1.00; 95% confidence interval, 0.64–1.56; P = 1.00) had died; only 57% of the control subjects had received renal-replacement therapy. Between-group survivors’ Day-60, Day-90, intensive care unit, and in-hospital mortality rates, Day-30 ventilator-free days, and renal function recovery were comparable. HVHF patients experienced faster correction of metabolic acidosis and tended to be more rapidly weaned off catecholamines but had more frequent hypophosphatemia, metabolic alkalosis, and thrombocytopenia.
Conclusions: For patients with post–cardiac surgery shock requiring high-dose catecholamines, the early HVHF onset for 48 hours, followed by standard volume until resolution of shock and recovery of renal function, did not lower Day-30 mortality and did not impact other important patient-centered outcomes compared with a conservative strategy with delayed CVVHDF initiation only for patients with persistent, severe acute kidney injury.