Purpose of review

The incidence of acute kidney injury (AKI) is increasing dramatically, and despite advances in dialytic therapy and critical care, there has been little improvement in associated morbidity and mortality. Recently, several articles have suggested that fluid overload in patients with AKI is associated with an increased risk of death.

Recent findings

Observational studies have demonstrated an association between fluid overload and poor outcomes (including death) in patients with AKI; however, whether this association is causal or due to residual confounding is unknown. A recent study testing the impact of fluid overload and diuretics on outcomes in the context of a randomized controlled trial suggests that the beneficial impact of diuretics in those with AKI is mediated by reducing fluid overload. Finally, potential mechanisms by which fluid overload may contribute to death include failure to recognize AKI due to creatinine dilution, direct tissue edema leading to decreased renal perfusion, and an increased risk of other complications such as sepsis.

Summary

On the basis of the current literature, the relative contributions of the direct effects of fluid overload versus the association of fluid overload with other patient characteristics associated with adverse outcome (e.g. sepsis) remain unknown. Additional human studies, including randomized controlled trials, are warranted to further clarify these issues.

Background

The impact of rapid response teams (RRT) on patient outcomes remains uncertain.

Objective

To examine the effect of proactive rounding by an RRT on outcomes of hospitalized adults discharged from intensive care.

Design

Retrospective, observational study.

Setting

Academic medical center.

Patients

All adult patients discharged alive from the intensive care unit (ICU) at the University of California San Francisco Medical Center between January 2006 and June 2009.

Intervention

Introduction of proactive rounding by an RRT.

Measurements

Outcomes included the ICU readmission rate, ICU average length of stay (LOS), and in-hospital mortality of patients discharged from the ICU. Data were obtained from administrative billing databases and analyzed using an interrupted time series (ITS) model.

Results

We analyzed 17 months of preintervention data and 25 months of postintervention data. Introduction of proactive rounding by the RRT did not change the ICU readmission rate (6.7% before vs 7.3% after; P = 0.24), the ICU LOS (5.1 days vs 4.9 days; P = 0.24), or the in-hospital mortality of patients discharged from the ICU (6.0% vs 5.5%; P = 0.24). ITS models testing the impact of proactive rounding on secular trends found no improvement in any of the 3 clinical outcomes relative to their preintervention trends.

Conclusions

Proactive rounding by an RRT did not improve patient outcomes, raising further questions about RRT benefits.