Management of Renal Replacement Therapy in ICU Patients: an International Survey

Matthieu Legrand et al.

Supplementary appendix
Questionnaire sent via ESICM newletter

Q1. How many years have you been in clinical practice? |__|__| year(s)

Q2. What is your position?

Resident□

Fellow□

Attending physician□

Faculty □

Head of the unit□

Q3. Country of the ICU you are currently working in: |__|__|__|__|__|__|__|__|__|__|__|__|__|__|__|

Q3. What percent of your time is spent in clinical practice (taking care of ICU patients)? |__|__|__| %

Q4. What are your areas of specialization? (Please check ALL that apply).

□ Emergency Medicine□ Cardiology

□ Anesthesia□ Internal Medicine

□ Surgery (any)□ Respirology

□ Critical Care Medicine □Nephrology

□ Other, please specify ______

Q5. What type of ICU(s) are you working in?

(Please check ALL that apply).

□ Combined Medical/Surgical □ Medical ICU□ Surgical ICU

□ Multidisciplinary ICU □ Neurosurgical□ Pediatric

□ Coronary Care Unit □Burn Unit□ Trauma

□ Cardiac Surgery Unit □Nephrologic ICU □Other, ______

Q6. The ICU(s) you refer to when completing the survey is ?

University hospital □University-affiliated hospital □Non university hospital □

Q7. How many ICU beds are in the ICU(s) you referred to when completing the survey? |__|__|__|

Q8. What is the ratio clinicians/patients and nurse/patients in the ICU(s) you referred to when completing the survey?

Senior Physician / Junior residents (rotating through the ICU) / Nurses
Ratio clinicians/patients
(eg 1 senior physician for 5 patients...: 1/5)

Q9. How many patients are being treated each month with RRT in you ICU?

□ ≤1□ 1-5 □ 5-10 □>10

Q10. Which modalities of renal replacement therapy are available in the ICU(s) you refer to?

(Please check ALL that apply).

□ intermittent hemodialysis

□ Continous renal replacement therapy

□Peritoneal dialysis

□Extended daily dialysis

□Other ______

Q11. Who is responsible for the initiation of RRT in your ICU?

□ICU Staff members

□Nephrologists consultant

Q12. In you ICU, RRT can be initiated :

□24/7

□Only during day-time (8am-6pm) including Sunday

□Only during day-time (8am-6pm) only during the week

Q13. Is there a written protocol in your ICU regarding management of RRT? (Please check only ONE).

□No

□Yes, with technical guidance for management of RRT

□Yes, indicating medical situations for RRT initiation

□Yes, indicating medical situations for choosing the RRT technique (CRRT vs IHD vs SLED vs SCUF)?

Q14. overallwhat percentage of your RRT are represented by the following techniques?

CVVH _│___│___│___│%

CVVHD__│___│___│___│%

IHD __│___│___│___│%

Extended DD _│___│___│___│%

Q15. What are the most common reasonfor choosing theRRT modality?

(Please check ALL that apply). Totally disagree------Totally agree

12345

Not applicable, CRRT is not available in my ICU□□□□□

IHD is not available in my ICU□□□□□

CRRT induces less hypotension than intermittent hemodialysis does□□□□□

IHD induces less hypotension than intermittent hemodialysis does□□□□□

Fluid balance control is easier using CRRT than IHD□□□□□

Fluid balance control is easier using IHD than CRRT□□□□□

Temperature control is easier using IHDthan CRRT□□□□□

Temperature control is easier using CRRT than IHD□□□□□

CRRT allows a better control of inflammatory or septic shock than IHD does(cytokines removal) □ □ □ □ □

IHD is safer in patients with high risk of bleeding□□□□□

CRRTis safer in patients with high risk of bleeding□□□□□

Management of IHD is easier than CRRT regarding potential surgical and radiological procedures (i.e. transport outside the ICU) □ □ □ □ □

IHD is less expensive than CRRT □□□□□

CRRT is less expensive than IHD□□□□□

IHD is less time consuming for nurses than CRRT □□□□□

CRRT is less expensive than IHD□□□□□

I am not comfortable with CRRT □□□□□

I am not comfortable with IHD□□□□□

The following questions refer to your preferences in choosing the technique for renal replacement therapy you apply when managing patients with AKI.

Q16. How do you commonly set your CRRT technique?

□Not applicable

□Continous venovenousHemofiltration

□ Restitution fluid administred in predilution mode(before the filter)

□ Restitution fluid administred in postdilution mode (after the filter)

□ Restitution fluid administred in predilution+postdilution mode

□Continous venovenous hemodiafiltration

□Continous venovenous hemodialysis

Considering the intensity of RRT

Q17. When using IHD, how often do you prescribe a session?

□Not applicable □Daily □6 days a week □5 days a week □4 days a week

□3 days a week □2 days a week

Q18. When using IHD, what is the typical duration of the session you prescribe?

□2 hours□3 hours□4 hours□5 hours □6 hours

□8 hours □>12 hours (SLED)

Q19. Do you evaluate routinely dialysis dose

No□

Yes, Kt/V□

Yes, Urea reduction rate□

Other (please specify) ______□

Q20. When using CVVH or CVVHD, how do you prescribe a standard ultra filtrationrate

Check also the following box if I you systematically add dialysis (CVVHD) □

Not applicable

CVVH Standard prescription (3000mL/h for example) 

20 ml/kg/h □

25 ml/kg/h□

35 ml/kg/h□

45 ml/kg/h□

>45 ml/kg/h□

Q21. If you do not use a standard prescription, your prescription of ultrafiltration rate is based

On theoretical body weight?

On body weight the day of admission?

On body weight the day of CRRT?

Q22. Considering the fluid balance:

a. Is fluid balance (total fluid intake minus total fluid output) daily assessed in your critically ill patients? yes  no 

b. Do you consider achieving a neutral or negative fluid balance a major goal when managing patients with AKI? yes  no 

b. Is body weight of your critically ill patients routinely measured ?yes no 

Q23. Do you consider using diuretic to increase urine output first BEFORE considering RRT when facing a critically ill patient with AKI?

□No, Never

□Yes, always

□Yes, most of the time (>75% of cases)

□Yes, rarely (25-75% of cases)

□Yes, very rarely (<25% of cases)

□Only if there is a fluid overload

Q24. How do you usually prescribe the net ultrafiltration rate (fluid removal)?

□ona fixed rate (e.g. 2000ml/24h)

□ based on anticipated account fluid delivery over the following 24h.

□ based on fluid balance the day before

□ based on body weight gain

□empirically, based on clinical assessment of extracellular fluid accumulation (oedema)

□ on a algorythm-based adjustment rate with modification of the ultrafiltration rate during the session

□other: ______

Q25. Which of the following hemodynamic parameters do you use to guide fluid removal?

(please check ALL that apply)

□I do not use hemodynamic parameters to guide fluid removal

□Mean arterial pressure

□Central venous pressure

□Pulmonary arterial wedge pressure

□Cardiac ouput

□Arterial pulse pressure respiratory variations

□Inferior vena cava respiratory variations

□Superior vena cava respiratory variations

□On-line blood volume monitoring

Q26. Do you use the RIFLE or AKIN classifications for considering initiation of RRT?yes □ no □

Q28. In which of the following situation do you consider that initiation of RRT should NOT be delayed regardless the use of diuretics?

Urine output < 0.5ml/kg/h x 3 hryes no 

Urine output < 0.5ml/kg/h x 6 hryes no 

Urine output < 0.5ml/kg/h x 12 hryes no 

Urine output < 0.3ml/kg/h x 24 hryes no 

Q29. What are the 3 most common criterion leading to RRT initiation in your ICU?

Oliguria/anuriayes no 

Metabolic acidosisyes no 

Hyperkaliemiayes no 

pulmonay oedemayes no 

Shockyes no 

Increase serum creatinine/ureayes no 

Q30. Which delay from admission to initiation of RRT do you consider as “early initiation of RRT”?

│___│___│___│hours

Q.31

Would you be interested in participating to an international observational cross-sectionnal study concerning RRT management in patients with AKI (total duration: 1 week).

Yes No 

Figure S1:Hemodynamic monitoring used by responders to guide fluid removal during RRT. Results are expressed in % of responders.