Fig.1
Fig.2
Fig.3
Attitudes Toward Timing, Use of a Protocol and Willingness to Enroll Patients in a Clinical Trial of Protocol-based Net Ultrafiltration
| Characteristic | No. (%) | P value | ||
|---|---|---|---|---|
| All (N=465) | Physician (N=196) | Nurse & Nurse Practitioners (N=269) | ||
| I believe early fluid removal is beneficial | ||||
| Strongly agree | 148 (31.8) | 56 (28.6) | 92 (34.2) | |
| Agree | 195 (41.9) | 68 (34.7) | 127 (47.2) | |
| Somewhat agree | 71 (15.3) | 42 (21.4) | 29 (10.8) | |
| Neither agree nor disagree | 37 (8.0) | 19 (9.7) | 18 (6.7) | <0.001 |
| Somewhat disagree | 7 (1.5) | 6 (3.1) | 1 (0.4) | |
| Disagree | 3 (0.6) | 2 (1.0) | 1 (0.4) | |
| Strongly disagree | 4 (0.9) | 3 (1.5) | 1(0.4) | |
| I believe a protocol-based fluid removal strategy would be beneficial | ||||
| Strongly agree Agree | 113 (24.4) 160 (34.6) | 28 (14.3) 60 (30.6) | 85 (31.5) 100 (37.2) | |
| Somewhat agree | 108 (23.3) | 57(29.1) | 51 (20.0) | <0.001 |
| Neither agree nor disagree | 52 (11.2) | 33 (16.8) | 19 (7.1) | |
| Somewhat disagree | 18 (3.9) | 9 (4.6) | 9 (3.3) | |
| Disagree | 11 (2.4) | 7 (3.6) | 4 (1.5) | |
| Strongly disagree | 3 (0.6) | 2 (1.0) | 1 (0.4) | |
| I would enroll my patient in a clinical trial comparing protocol-based | versus usual | care | ||
| Strongly agree | 108 (23.2) | 46 (23.5) | 62 (23.0) | 0.001 |
| Agree | 168 (36.1) | 84 (42.9) | 84 (31.2) | |
| Somewhat agree | 52 (11.2) | 24 (12.2) | 28 (10.4) | |
| Neither agree nor disagree | 107 (23.0) | 26 (13.3) | 81 (30.1) | |
| Somewhat disagree | 4 (0.9) | 3 (1.5) | 1 (0.4) | |
| Disagree | 15 (3.2) | 9 (4.6) | 6 (2.2) | |
| Strongly disagree | 9 (1.9) | 4 (2.0) | 5 (1.9) | |
Hemodynamic Management and Perceived Barriers to Net Ultrafiltration
| Characteristic | No. (%) | P value | ||
|---|---|---|---|---|
| All (n=465) | Physician (n=196) | Nurse & Nurse Practitioners (n=269) | ||
| Percentage of patients developing new hemodynamic instability during UFNET median (IQR) | 25.0 (10.0-100.0) | 25.0 (13.2-35.0) | 20.5 (10.0-50.0) | 0.79 |
| interventions performed for hemodynamic instabilitya | ||||
| Decrease the rate of fluid removal | 331 (71.2) | 128 (65.3) | 203 (75.5) | 0 .02 |
| Completely stop fluid removal | 206 (44.3) | 93 (47.4) | 113 (43) | 0.24 |
| Make no changes to fluid removal rate | 17 (3.7) | 11 (5.6) | 6 (2.2) | 0.05 |
| Administer fluid bolus | 133 (28.6) | 51 (26) | 82 (30.5) | 0.29 |
| Start or increase the dose of a vasopressor | 263 (56.6) | 93 (47.4) | 170 (63.2) | <0.001 |
| Switch to alternative modality | 26 (5.6) | 14 (7.1) | 12 (4.5) | 0.21 |
| Administer albumin or mannitol bolus | 157 (33.8) | 56 (28.6) | 101 (37.5) | 0.04 |
| Perceived barriersa | ||||
| Patient intolerance (e.g., hypotension) | 371 (79.8) | 156 (80.0) | 215 (79.9) | 0.93 |
| Under prescription | 83 (17.8) | 32(16.3) | 51 (19.0) | 0.47 |
| Frequent interruptions (e.g., trip to CT scan, operating room, filter clotting, catheter malfunction) | 233 (50.1) | 96 (49.0) | 137 (50.9) | 0.67 |
| Inability to titrate fluid removal | 47 (10.1) | 24 (12.2) | 23 (8.6) | 0.19 |
| Unavailability of adequately trained nursing staff | 79 (17.0) | 28 (14.3) | 51 (19.0) | 0.18 |
| Unavailability of dialysis machines | 40 (8.6) | 27 (13.8) | 13 (4.8) | 0.001 |
| Cost associated with treatment | 11 (2.0) | 5 (2.5) | 6 (3.1) | 0.83 |
Characteristics of U_S_ Survey Respondents and Practice of Net Ultrafiltration
| Characteristic | No. (%) | P value | ||
|---|---|---|---|---|
| All (n=465) | Physician (n=196) | Nurse & Nurse Practitioner (n=269) | ||
| Years of practice, median (IQR) | 8.7 (4.2-19.4) | 8.8 (4.4-16.7) | 8.7 (4.1- 21.0) | 0.41 |
| Hospital typea | ||||
| University-based | 295 (64.8) | 128 (66.3) | 167 (63.7) | |
| Community-based | 140 (30.8) | 50 (25.9) | 90 (34.4) | 0.003 |
| Government | 20 (4.4) | 15(7.7) | 5(1.5) | |
| Maximum dose of loop diuretic in milligrams equivalent to furosemide dosing before determining diuretic resistance, mgs/dayb | ||||
| <100 | 10 (4.8) | 8 (4.4) | 2(8) | |
| 100-250 | 131 (63.0) | 114(62.3) | 17 (68) | |
| 251-500 | 53 (25.5) | 50 (27.3) | 3 (12) | 0.30 |
| 501-750 | 4(1.9) | 4(2.2) | 0 | |
| <751-1000 | 9 (4.3) | 6 (3.3) | 3 (12) | |
| >1000 | 1 (0.5) | 1 (0.55) | 0 | |
| Criteria for initiating fluid removalb,c | ||||
| Cumulative fluid balance (i.e., >1000 mL) | 14 (7.4) | 13 (7.8) | 1 (4.3) | |
| Fluid overload>10% of body weight | 10 (5.3) | 9 (5.4) | 1 (4.3) | |
| Ongoing need for fluid administration in the presence of oliguria | 19 (10.0) | 18 (10.8) | 1 (4.3) | 0.72 |
| Persistent oliguria or anuria (i.e., urine output <0.5ml/kg/h for >12 hours) | 55 (28.9) | 49 (29.4) | 6 (26.1) | |
| Pulmonary edema with or without hypoxemia | 28 (14.7) | 25 (15.0) | 3 (13.0) | |
| Severe hypoxemia (i.e., PaO2/FiO2 ratio < 150) | 64 (33.7) | 53 (31.7) | 11 (47.8) | |
| Criteria used for prescribing UFNETb,c | ||||
| 24-hour fluid balance | 21 (10.6) | 20 (11.5) | 1 (4.2) | |
| Cumulative fluid balance since ICU admission | 24 (12.1) | 23 (13.2) | 1 (4.2) | |
| Hemodynamic status (i.e., HR, BP, CVP, PPV, dose of vasopressors) Radiographic features suggestive of fluid overload | 141 (71.2) 6 (3.0) | 121 (69.5) 5(2.9) | 20 (83.3) 1 (4.2) | 0.61 |
| Volume of anticipated fluid administration in the next 24 hours | 1 (0.5) | 1 (0.6) | 0 | |
| Weight gain since ICU admission | 5(2.5) | 4(2.3) | 1 (4.2) | |
| Intermittent hemodialysis, median (IQR) | ||||
| Percent use last month | 10.0 (2.2-30.0) | 10.0 (5.0-30.0) | 10.0 (2.0-30.0) | 0.29 |
| Typical prescription, liters per session | 2.0 (2.0-3.0) | 2.0 (2.0-3.0) | 2.0 (1.6-2.4) | 0.07 |
| Slow forms of IHD, median (IQR) | ||||
| Percent use last month | 1.0 (1.0-15.0) | 2.0(0-23.0) | 1.0(0-10.5) | 0.08 |
| Typical prescription, liters per session | 2.0 (1Ό-2.5) | 2.0 (1.0-2.5) | 2.0 (1.2-2.4) | 0.17 |
| Percent of assessment of prescribed-to- delivered dose, median (IQR) | 90.0(20.0-100.0) | 90.0 (50.0-100.0) | 72.5 (2.7-100.0) | 0.02 |
| CKRT, median (IQR) | ||||
| Percent use last month | 60.0 (20.0-90.0) | 80.0(50.0-90.0) | 50.0(10.0-80.0) | <0.001 |
| Initial UFNET rate for hemodynamically stable patient, mL per hour | 100.0 (79.0-200.0) | 100.0 (100.0-197.0) | 100.0(52.0-200.0) | 0.96 |
| Maximal UFNET rate for hemodynamically stable patient, ml per hour | 285.0(200.0-341.0) | 298.0 (200.0-351.0) | 253.5 (200.0-310.5) | 0.22 |
| UFNETrate for hemodynamically unstable patient, ml per hour | 51.0(25.0-100.0) | 52.0 (49.0-100.0) | 51.0 (10.0-100.0) | 0.91 |
| Method used to achieve UFNET d | ||||
| By varying ultrafiltration rate only | 205 (61.9) | 75 (54.3) | 130(67.4) | |
| By varying replacement fluid rate only | 13 (3.9) | 8 (5.8) | 5(2.6) | 0.04 |
| By varying both ultrafiltration and replacement fluid rate | 113 (34.1) | 55(39.9) | 58 (30.1) | |
| How frequently did you check net fluid balancee | ||||
| 1 hour | 211 (58.2) | 43 (28.7) | 168 (79.2) | |
| 2 hours | 19 (5.2) | 10(6.7) | 9 (4.2) | |
| 4 hours | 34 (9.4) | 24 (16.0) | 10 (4.7) | |
| 6 hours | 13 (3.6) | 11 (7.3) | 2 (0.9) | <0.001 |
| 8 hours | 16 (4.4) | 9 (6.0) | 7(3.3) | |
| 12 hours | 34 (9.4) | 24 (16.0) | 10 (4.7) | |
| 24 hours | 35 (9.7) | 29 (19.3) | 6(2.8) | |