title: Early High-Volume Hemofiltration versus Standard Care for Post-Cardiac Surgery Shock. The HEROICS Study.
abstract: BACKGROUND
  Post-cardiac surgery shock is associated with high morbidity and mortality. By removing toxins and proinflammatory mediators and correcting metabolic acidosis, high-volume hemofiltration (HVHF) might halt the vicious circle leading to death by improving myocardial performance and reducing vasopressor dependence.
  
  
  OBJECTIVE
  To determine whether early HVHF decreases all-cause mortality 30 days after randomization.
  
  
  METHODS
  This prospective, multicenter randomized controlled trial included patients with severe shock requiring high-dose catecholamines 3-24 hours post-cardiac surgery who were randomized to early HVHF (80 ml/kg/h for 48 h), followed by standard-volume continuous venovenous hemodiafiltration (CVVHDF) until resolution of shock and recovery of renal function, or conservative standard care, with delayed CVVHDF only for persistent, severe acute kidney injury.
  
  
  RESULTS
  On Day 30, 40 of 112 (36%) HVHF and 40 of 112 (36%) control subjects (odds ratio, 1.00; 95% confidence interval, 0.64-1.56; P = 1.00) had died; only 57% of the control subjects had received renal-replacement therapy. Between-group survivors' Day-60, Day-90, intensive care unit, and in-hospital mortality rates, Day-30 ventilator-free days, and renal function recovery were comparable. HVHF patients experienced faster correction of metabolic acidosis and tended to be more rapidly weaned off catecholamines but had more frequent hypophosphatemia, metabolic alkalosis, and thrombocytopenia.
  
  
  CONCLUSIONS
  For patients with post-cardiac surgery shock requiring high-dose catecholamines, the early HVHF onset for 48 hours, followed by standard volume until resolution of shock and recovery of renal function, did not lower Day-30 mortality and did not impact other important patient-centered outcomes compared with a conservative strategy with delayed CVVHDF initiation only for patients with persistent, severe acute kidney injury. Clinical trial registered with www.clinicaltrials.gov (NCT 01077349).
authors.affiliation: 1 Medical-Surgical Intensive Care Unit.
authors.forename: Alain
authors.initials: A
authors.lastname: Combes
authors.affiliation: 1 Medical-Surgical Intensive Care Unit.
authors.forename: Nicolas
authors.initials: N
authors.lastname: Bréchot
authors.affiliation: 2 Anesthesiology and Critical Care Medicine Department.
authors.forename: Julien
authors.initials: J
authors.lastname: Amour
authors.affiliation: 3 Unité de Recherche Clinique, and.
authors.forename: Nathalie
authors.initials: N
authors.lastname: Cozic
authors.affiliation: 4 Cardiac Surgery Department, Institute of Cardiometabolism and Nutrition, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Université Pierre et Marie Curie-Paris 6, Paris, France.
authors.forename: Guillaume
authors.initials: G
authors.lastname: Lebreton
authors.affiliation: 5 Anesthesiology and Critical Care Medicine Department, CHU La Timone, Marseille, France.
authors.forename: Catherine
authors.initials: C
authors.lastname: Guidon
authors.affiliation: 6 Anesthesiology and Critical Care Medicine Department, Amiens University Hospital, INSERM U-1088, Université de Picardie Jules-Verne, Amiens, France.
authors.forename: Elie
authors.initials: E
authors.lastname: Zogheib
authors.affiliation: 7 Anesthesiology and Critical Care Medicine Department, CHU de Strasbourg, Strasbourg, France.
authors.forename: Jean-Claude
authors.initials: JC
authors.lastname: Thiranos
authors.affiliation: 8 Department d'Anesthésiologie et Réanimation, CHU de Nantes, Nantes, France.
authors.forename: Jean-Christophe
authors.initials: JC
authors.lastname: Rigal
authors.affiliation: 9 Anesthesiology and Critical Care Medicine Department, CHU de Lyon, Lyon, France.
authors.forename: Olivier
authors.initials: O
authors.lastname: Bastien
authors.affiliation: 10 Anesthesiology and Critical Care Medicine Department, CHU de Toulouse, Toulouse, France.
authors.forename: Hamina
authors.initials: H
authors.lastname: Benhaoua
authors.affiliation: 11 Anesthesiology and Critical Care Medicine Department, Clinique Jacques Cartier, Massy, France; and.
authors.forename: Bernard
authors.initials: B
authors.lastname: Abry
authors.affiliation: 12 Department of Anesthesia and Critical Care II, CHU de Bordeaux, and Université de Bordeaux, Adaptation Cardiovasculaire à l'Ischémie, U1034, Pessac, France.
authors.forename: Alexandre
authors.initials: A
authors.lastname: Ouattara
authors.affiliation: 1 Medical-Surgical Intensive Care Unit.
authors.forename: Jean-Louis
authors.initials: JL
authors.lastname: Trouillet
authors.affiliation: 3 Unité de Recherche Clinique, and.
authors.forename: Alain
authors.initials: A
authors.lastname: Mallet
authors.affiliation: 1 Medical-Surgical Intensive Care Unit.
authors.forename: Jean
authors.initials: J
authors.lastname: Chastre
authors.affiliation: 4 Cardiac Surgery Department, Institute of Cardiometabolism and Nutrition, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Université Pierre et Marie Curie-Paris 6, Paris, France.
authors.forename: Pascal
authors.initials: P
authors.lastname: Leprince
authors.affiliation: 1 Medical-Surgical Intensive Care Unit.
authors.forename: Charles-Edouard
authors.initials: CE
authors.lastname: Luyt
mesh_terms: D006348:Cardiac Surgical Procedures / Q000009:adverse effects* / Q000401:mortality; D002395:Catecholamines / Q000008:administration & dosage* / Q000627:therapeutic use; D002423:Cause of Death; D005260:Female; D005602:France; D006440:Hemofiltration / Q000379:methods*; D017052:Hospital Mortality; D006801:Humans; D008297:Male; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care / Q000706:statistics & numerical data; D016016:Proportional Hazards Models; D011446:Prospective Studies; D017582:Renal Replacement Therapy / Q000379:methods / Q000706:statistics & numerical data*; D012773:Shock, Surgical / Q000401:mortality / Q000517:prevention & control*; D059039:Standard of Care
chemical_list: D002395:Catecholamines
keywords: cardiac surgery; high-volume hemofiltration; mortality; randomized controlled trial