Impact of hyperhydration on the mortality risk in critically ill patients admitted in intensive care units: comparison between bioelectrical impedance vector analysis and cumulative fluid balance recording

Sara Samoni, Valentina Vigo, Luis Ignacio Bonilla Reséndiz, Gianluca Villa, Silvia De Rosa, Federico Nalesso, Fiorenza Ferrari, Mario Meola, Alessandra Brendolan, Paolo Malacarne, Francesco Forfori, Raffaele Bonato, Carlo Donadio, Claudio Ronco, Sara Samoni, Valentina Vigo, Luis Ignacio Bonilla Reséndiz, Gianluca Villa, Silvia De Rosa, Federico Nalesso, Fiorenza Ferrari, Mario Meola, Alessandra Brendolan, Paolo Malacarne, Francesco Forfori, Raffaele Bonato, Carlo Donadio, Claudio Ronco

Abstract

Background: Studies have demonstrated a positive correlation between fluid overload (FO) and adverse outcomes in critically ill patients. The present study aims at defining the impact of hyperhydration on the Intensive Care Unit (ICU) mortality risk, comparing Bioelectrical Impedance Vector Analysis (BIVA) assessment with cumulative fluid balance (CFB) recording.

Methods: We performed a prospective, dual-centre, clinician-blinded, observational study of consecutive patients admitted to ICU with an expected length of ICU stay of at least 72 hours. During observational period (72-120 hours), CFB was recorded and cumulative FO was calculated. At the admission and daily during the observational period, BIVA was performed. We considered FO between 5% and 9.99% as moderate and a FO ≥ 10% as severe. According to BIVA hydration scale of lean body mass, patients were classified as normohydrated (>72.7%-74.3%), mild (>71%-72.7%), moderate (>69%-71%) and severe (≤ 69%) dehydrated and mild (>74.3%-81%), moderate (>81%-87%) and severe (>87%) hyperhydrated. Two multivariate logistic regression models were performed: the ICU mortality was the response variable, while the predictor variables were hyperhydration, measured by BIVA (BIVA model), and FO (FO model). A p-value <0.05 was considered to indicate statistical significance.

Results: One hundred and twenty-five patients were enrolled (mean age 64.8 ± 16.0 years, 65.6% male). Five hundred and fifteen BIVA measurements were performed. The mean CFB recorded at the end of the observational period was 2.7 ± 4.1 L, while the maximum hydration of lean body mass estimated by BIVA was 83.67 ± 6.39%. Severe hyperhydration measured by BIVA was the only variable found to be significantly associated with ICU mortality (OR 22.91; 95% CI 2.38-220.07; p < 0.01).

Conclusions: The hydration status measured by BIVA seems to predict mortality risk in ICU patients better than the conventional method of fluid balance recording. Moreover, it appears to be safe, easy to use and adequate for bedside evaluation. Randomized clinical trials with an adequate sample size are needed to validate the diagnostic properties of BIVA in the goal-directed fluid management of critically ill patients in ICU.

Keywords: Bioelectrical impedance vector analysis; Cumulative fluid balance; Fluid overload; Hyperhydration; Intensive care unit; Mortality.

Figures

Fig. 1
Fig. 1
Distribution of hydration status, in classes, at admission in intensive care unit. Classes of hydration status are defined, according to a numerical scale for BIVA as follow: -3) severe dehydration (≤69 %), -2) moderate dehydration (>69 %–71 %), -1) mild dehydration (>71 %–72.7 %), 0) normohydration (>72.7 %–74.3 %), +1) mild hyperhydration (>74.3 %–81 %), +2) moderate hyperhydration (>81 %–87 %) +3) severe hyperhydration (>87 %). BIVA bioelectric impedance vector analysis
Fig. 2
Fig. 2
Box-plot of daily BIVA hydration values during the observation period. The horizontal lines represent the minimum value, first quartile, median, third quartile and maximum value. The dashed lines correspond to accepted limits of normohydration. BIVA bioelectric impedance vector analysis
Fig. 3
Fig. 3
Box-plot of trend of fluid overload in the different classes of hydration. Classes of hydration status are defined, according to a numerical scale for BIVA as follow: 0) normohydration (>72.7 %–74.3 %), +1) mild hyperhydration (>74.3 %–81 %), +2) moderate hyperhydration (>81 %–87 %), +3) severe hyperhydration (>87 %). The horizontal lines represent the minimum value, first quartile, median, third quartile and maximum value. BIVA bioelectric impedance vector analysis
Fig. 4
Fig. 4
Kaplan-Meier survival curves showing relation between hydration status and long-term mortality. The vertical lines represent censored subjects. The follow-up duration is different for each subject because it is censored at the end of the study. Patients were defined as hyperhydrated (HH) if they overreached the value of 74.3 % of lean body mass at least once during the observation period. NH normohydrated, HH hyperhydrated, time (days)
Fig. 5
Fig. 5
ROC curves for the two models. BIVA bioelectrical impedance vector analysis, CFB cumulative fluid balance; AUC area under the ROC curve, ROC receiver operating characteristic

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