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Feasibility of conservative fluid administration and deresuscitation compared with usual care in critical illness: the Role of Active Deresuscitation After Resuscitation-2 (RADAR-2) randomised clinical trial

Silversides, J. A., McMullan, R., Emerson, L. M. ORCID: 0000-0002-4250-5758 , Bradbury, I., Bannard-Smith, J., Szakmany, T., Trinder, J., Rostron, A. J., Johnston, P., Ferguson, A. J., Boyle, A. J., Blackwood, B., Marshall, J. C. & McAuley, D. F. (2021). Feasibility of conservative fluid administration and deresuscitation compared with usual care in critical illness: the Role of Active Deresuscitation After Resuscitation-2 (RADAR-2) randomised clinical trial. Intensive Care Medicine, doi: 10.1007/s00134-021-06596-8

Abstract

Purpose. Fluid overload is common in critical illness and is associated with mortality. This study investigated the feasibility of a randomised trial comparing conservative fluid administration and deresuscitation (active removal of accumulated fluid using diuretics or ultrafiltration) with usual care in critical illness.

Methods. Open-label, parallel-group, allocation-concealed randomised clinical feasibility trial. Mechanically ventilated adult patients expected to require critical care beyond the next calendar day were enrolled between 24 and 48 hours following ICU admission. Patients were randomised to either a 2-stage fluid strategy comprising conservative fluid administration and, if fluid overload was present, active deresuscitation; or usual care. The primary endpoint was fluid balance in the 24 hours up to the start of study day 3. Secondary endpoints included cumulative fluid balance; mortality; and duration of mechanical ventilation.

Results. 180 patients were randomised. After withdrawal of 1 patient, 89 patients assigned to the intervention were compared with 90 patients assigned to the usual care group. The mean (SD) 24-hour fluid balance up to study day 3 was lower in the intervention group (-840  1746 mL) than the usual care group (+130  1401 ml; p<0.01). Cumulative fluid balance was lower in the intervention group at days 3 and 5. Overall, clinical outcomes did not differ significantly between the two groups, although the point estimate for 30-day mortality favoured the usual care group (intervention arm: 19 of 90 (21.6%) versus usual care: 14 of 89 (15.6%), P=0.32). Baseline imbalances between groups and lack of statistical power limit interpretation of clinical outcomes.

Conclusions. A strategy of conservative fluid administration and active deresuscitation is feasible, reduces fluid balance compared with usual care, and may cause benefit or harm. In view of wide variations in contemporary clincal practice, large, adequately powered trials investigating the clinical effectiveness of conservative fluid strategies in critically ill patients are warranted.

Publication Type: Article
Additional Information: This version of the article has been accepted for publication, after peer review (when applicable) and is subject to Springer Nature’s AM terms of use, but is not the Version of Record and does not reflect post-acceptance improvements, or any corrections. The Version of Record is available online at: https://doi.org/10.1007/s00134-021-06596-8
Publisher Keywords: Critical illness, Fluid therapy, Water–electrolyte balance, Infusions, Intravenous, Diuretics, Oedema, Deresuscitation
Subjects: R Medicine > RC Internal medicine
R Medicine > RT Nursing
Departments: School of Health Sciences > Nursing
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