title: Aiming for a negative fluid balance in patients with acute lung injury and increased intra-abdominal pressure: a pilot study looking at the effects of PAL-treatment.
abstract: BACKGROUND
  Achievement of a negative fluid balance in patients with capillary leak is associated with improved outcome. We investigated the effects of a multi-modal restrictive fluid strategy aiming for negative fluid balance in patients with acute lung injury (ALI).
  
  
  METHODS
  In this retrospective matched case-control study, we included 114 mechanically ventilated (MV) patients with ALI. We compared outcomes between a group of 57 patients receiving PAL-treatment (PAL group) and a matched control group, abstracted from a historical cohort. PAL-treatment combines high levels of positive end-expiratory pressure, small volume resuscitation with hyperoncotic albumin, and fluid removal with furosemide (Lasix®) or ultrafiltration. Effects on extravascular lung water index (EVLWI), intra-abdominal pressure (IAP), organ function, and vasopressor therapy were recorded during 1 week. The primary outcome parameter was 28-day mortality.
  
  
  RESULTS
  At baseline, no significant intergroup differences were found, except for lower PaO2/FIO2 and increased IAP in the PAL group (174.5 ± 84.5 vs 256.5 ± 152.7, p = 0.001; 10.0 ± 4.2 vs 8.0 ± 3.7 mmHg, p = 0.013, respectively). After 1 week, PAL-treated patients had a greater reduction of EVLWI, IAP, and cumulative fluid balance (-4.2 ± 5.6 vs -1.1 ± 3.7 mL/kg, p = 0.006; -0.4 ± 3.6 vs 1.8 ± 3.8 mmHg, p = 0.007; -1,451 ± 7,761 vs 8,027 ± 5,254 mL, p < 0.001). Repercussions on cardiovascular and renal function were limited. PAL-treated patients required fewer days of intensive care unit admission and days on MV (23.6 ± 15 vs 37.1 ± 19.9 days, p = 0.006; 14.6 ± 10.7 vs 25.5 ± 20.2 days, respectively) and had a lower 28-day mortality (28.1% vs 49.1%, p = 0.034).
  
  
  CONCLUSIONS
  PAL-treatment in patients with ALI is associated with a negative fluid balance, a reduction of EVLWI and IAP, and improved clinical outcomes without compromising organ function.
authors.affiliation: Department of Intensive Care, Ziekenhuis Netwerk Antwerpen, ZNA Stuivenberg, Campus Stuivenberg, Lange Beeldekensstraat 267, 2060, Antwerpen 6, Belgium. manu.malbrain@skynet.be.
authors.forename: Colin
authors.initials: C
authors.lastname: Cordemans
authors.forename: Inneke
authors.initials: I
authors.lastname: De Laet
authors.forename: Niels
authors.initials: N
authors.lastname: Van Regenmortel
authors.forename: Karen
authors.initials: K
authors.lastname: Schoonheydt
authors.forename: Hilde
authors.initials: H
authors.lastname: Dits
authors.forename: Greg
authors.initials: G
authors.lastname: Martin
authors.forename: Wolfgang
authors.initials: W
authors.lastname: Huber
authors.forename: Manu Lng
authors.initials: ML
authors.lastname: Malbrain