Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_999_Библиотеки_им_академика_М_И_Перельмана

In deresuscitation strategy, uid removal consists of an intravascular volume with­drawal by the way of diuretics or net ultraltration. Thus, whether the intravascular volume will keep constant or decrease depends on the vascular relling rate, which in critically ill patients, as previously discussed, is probably low. Such an assump­tion is reinforced by the J-shaped association between net ultraltration intensity and prognosis in patients with continuous renal replacement therapy reported by several cohort studies [33]. On the one hand, in patients with intravascular hyper­volemia, targeting a decrease in circulating blood volume makes sense. Indeed, it may participate in reducing venous congestion and thus improve end-organ func­tion as the kidney or the liver [34]. But, on the other hand, in patients without intravascular hypervolemia, decreasing intravascular volume exposes to iatrogenic hypovolemia and hypoperfusion [33]. In this situation, the adequacy between the vascular relling rate and the uid removal rate is probably the cornerstone of hemodynamic tolerance during deresuscitation. However, such an approach remains simplistic regarding the complexity of the interaction between intravascu­lar volume status and hemodynamic. Various strategies have been proposed to safely guide the uid removal: passive leg raising predicts arterial hypotension dur­ing intermittent hemodialysis with high rate ultraltration [35] and peripheral per­fusion index during continuous renal replacement therapy [36]; central venous pressure and cardiac output may be associated to estimate both efciency and toler­ance [37]; clinical and biological peripheral perfusion monitoring allows a more efcient uid removal without sign of harm [38]. In any event, an individualization of the uid removal rate associated with a frequent re-assessment of its tolerance reaches consensus [39, 40].