Bedside prediction of intradialytic hemodynamic instability in critically ill patients: the SOCRATE study

• Main Authors: Naïke Bigé, Jean-Rémi Lavillegrand, Julien Dang, Philippe Attias, Stéphanie Deryckere, Jérémie Joffre, Vincent Dubée, Gabriel Preda, Guillaume Dumas, Geoffroy Hariri, Claire Pichereau, Jean-Luc Baudel, Bertrand Guidet, Eric Maury, Pierre-Yves Boelle, Hafid Ait-Oufella
• Format: Article
• Language: English
• Published: SpringerOpen 2020-04-01
• Series: Annals of Intensive Care
• Subjects: Hemodialysis; Acute kidney injury; Hemodynamic instability; Tissue perfusion; Lactate; Capillary refill time
• Online Access: http://link.springer.com/article/10.1186/s13613-020-00663-x

Abstract Background Despite improvements in intermittent hemodialysis management, intradialytic hemodynamic instability (IHI) remains a common issue that could account for increased mortality and delayed renal recovery. However, predictive factors of IHI remain poorly explored. The objective of this study was to evaluate the relationship between baseline macrohemodynamic, tissue hypoperfusion parameters and IHI occurrence. Methods Prospective observational study conducted in a 18-bed medical ICU of a tertiary teaching hospital. Cardiovascular SOFA score, index capillary refill time (CRT) and lactate level were measured just before (T0) consecutive intermittent hemodialysis sessions performed for AKI. The occurrence of IHI requiring a therapeutic intervention was recorded. Results Two hundred eleven sessions, corresponding to 72 (34%) first sessions and 139 (66%) later sessions, were included. As IHI mostly occurred during first sessions (43% vs 12%, P < 0.0001), following analyses were performed on the 72 first sessions. At T0, cardiovascular SOFA score ≥1 (87% vs 51%, P = 0.0021) was more frequent before IHI sessions, as well as index CRT ≥ 3 s (55% vs 15%, P = 0.0004), and hyperlactatemia > 2 mmol/L (68% vs 29%, P = 0.0018). Moreover, the occurrence of IHI increased with the number of macrohemodynamic and tissue perfusion impaired parameters, named SOCRATE score (cardiovascular SOFA, index CRT and lactATE): 10% (95% CI [3%, 30%]), 33% (95% CI [15%, 58%]), 55% (95% CI [35%, 73%]) and 80% (95% CI [55%, 93%]) for 0, 1, 2 and 3 parameters, respectively (AUC = 0.79 [0.69–0.89], P < 0.0001). These results were confirmed by analyzing the 139 later sessions included in the study. Conclusions The SOCRATE score based on 3 easy-to-use bedside parameters correlates with the risk of IHI. By improving risk stratification of IHI, this score could help clinicians to manage intermittent hemodialysis initiation in critically ill AKI patients.