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Objective:To explore the effect of quality improvement based on action research study to reduce unplanned interruption during continuous renal replacement therapy.Methods:From June 2020 to December 2021, 175 patients who were treated CRRT in SICU of Beijing Chaoyang Hospital Affiliated to Capital Medical University were selected as research objects. The objects were divided into control group, observation group 1 and observation group 2 according to the time of admission. Routine nursing was used in the control group (55 cases), the first cycle of plan-action-observation-reflection according to the problems of unplanned interruption was used in the observation group 1(62 cases), the quality improvement was carried out on the basis of the first cycle, and then formulated the second cycle used in the observation group 2(58 cases). The incidence of unplanned interruption of CRRT, the duration of hemofiltration line and the ability of nurses to prevent unplanned interruption of CRRT were compared before and after implementation.Results:The baseline data of CRRT patients in the three groups were comparable ( P>0.05). After cycle quality improvement, the alarm frequencies of unplanned interruption in the observation group 1 and 2 was (8.87 ± 2.66) times and (8.07 ± 2.80) times respectively, which was significant lower than the (12.04 ± 4.23) times in the control group ( t = 3.17 and 3.97, both P<0.01). The cases of coagulation filter≥Ⅱ in the observation group 1 and 2 were 25 cases and 20 cases, which were significant lower than the 32 cases in the control group ( χ2 = 3.72, 6.38, both P<0.05). The duration of blood purification line use was (15.04 ± 7.51) h and (18.16 ± 7.67) h in the observation group 1 and 2, which were significant better than the (11.75 ± 6.84) h in the control group ( t = 3.29 and 6.41, both P<0.01). The ability of nurse to prevent unplanned interruption of CRRT in the control group, the observation group 1 and 2 were (72.62 ± 6.03), (84.77 ± 5.59) and (89.64 ± 4.54), the difference was sigaificant ( F = 146.97, P<0.001). Conclusions:The application of action research study in CRRT quality improvement could reduce the occurrence of unplanned interruption of CRRT and related complications, prolong the use time of hemofiltration line, improve the therapeutic effect of CRRT, improve the quality of nursing, and is worthy of clinical promotion.
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Objective:To explore the role of continuous renal replacement therapy (CRRT) combined with extracorporeal carbon dioxide removal (ECCO 2R) in the treatment of children with respiratory failure. Methods:The clinical data of 12 children with respiratory failure who were treated with CRRT+ECCO 2R in PICU of Jinan Children's Hospital from July 2020 to August 2022 were collected and analyzed retrospectively. The outcomes and the external pipeline usage of the patients were observed, and the blood gas analysis and ventilator parameters before 1 h and after 1, 6, 12 and 24 h of the treatment were compared by one-way ANOVA with LSD post hoc correction. Results:Six patients successfully withdrew from CRRT+ECCO 2R and mechanical ventilation, three patients were transferred to ECMO treatment. Three cases died after voluntary withdrawal of treatment, and two cases died due to treatment failure. The mortality rate was 41.7%. After continuous treatment of CRRT+ECCO 2R for 15 to 112 h, two cases experienced extracorporeal circuit obstruction. After 1 h of treatment, PaCO 2 decreased from (64.67±24.4) mmHg to (49.42±15.54) mmHg, pH increased from (7.28±0.20) to (7.38±0.11), FiO 2 decreased from (0.85±0.13) to (0.78±0.15), PC decreased from (19.42±4.34) cmH 2O to (17.75±4.00) cmH 2O. After 24 h of treatment, PaCO 2 decreased to (39.2±5.55) mmHg, pH increased to (7.41±0.04), FiO 2 decreased to (0.46±0.11), and PC decreased to (13.8±3.36) cmH 2O, and the differences were statistically significant compared with before treatment ( P < 0.05). Conclusions:The combination of CRRT and ECCO 2R therapy can safely substitute for partial lung ventilation/perfusion function, and play a role in protecting right heart function and improving lung-kidney interaction. It can be considered as an option for extracorporeal respiratory, circulatory, and renal support, and consequently has broad prospects.
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Objective:To investigate the effect of early continuous renal replacement therapy (CRRT) within 24 h on in-hospital mortality in patients with sepsis.Methods:This study retrospectively analyzed the patients diagnosed as sepsis in the Emergency Intensive Care Unit of the First Affiliated Hospital of Wenzhou Medical University from January 2013 to December 2017. According to the prognosis, the patients were divided into the survival group and death group. The clinical baseline data of the two groups were compared, and multivariate logistic regression analysis was performed to screen out the risk factors of death in patients with sepsis and evaluate the effect of CRRT on mortality. According to whether CRRT was performed within 24 h after admission, the patients were divided into the CRRT group and non-CRRT group to compare fluid balance.Results:Among the 612 patients, 416 (67.9%) patients were male, the median age was 66 years; 362 patients survived and 250 patients died, with a mortality rate of 40.8%. Multivariate logistic regression analysis showed that the independent risk factors for death in patients with sepsis were: sex, simplified acute physiology score Ⅱ, sequential organ failure assessment, lactate, procalcitonin, and complicated with chronic obstructive pulmonary disease. Multivariate logistic regression analysis showed that patients received CRRT within 24 h had a higher risk of mortality ( OR=1.981 95% CI: 1.120-3.504, P=0.019). There was a statistically significant difference in fluid balance between the CRRT group and the non-CRRT group on the first day ( P<0.05), and there was no significant difference in total fluid balance in the first 3 days ( P>0.05). Conclusions:Early CRRT within 24 h cannot reduce the in-hospital mortality of patients with sepsis. The failure of CRRT which did not timely correct the volume overload state of patients with sepsis after fluid resuscitation may affect the outcome.
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SUMMARY OBJECTIVE: A few pediatric studies were present which focused on renal replacement therapy used for critically ill children. This research aimed to determine the ratio of utilization of intermittent hemodialysis, continuous renal replacement therapy, and peritoneal dialysis, and to study the properties and outcomes of critically ill pediatric patients who underwent renal replacement therapy. METHODS: Critically ill children admitted to the intensive care unit and received renal replacement therapy from February 2020 to May 2022 were included. The children were divided into three groups: hemodialysis, continuous renal replacement therapy, and peritoneal dialysis. RESULTS: A total of 37 patients (22 boys and 15 girls) who received renal replacement therapy met the criteria for this study. Continuous renal replacement therapy was used in 43%, hemodialysis in 38%, and peritoneal dialysis in 19%. In all, 28 (73%) children survived and 9 (27%) died in intensive care unit. The mean systolic blood pressure was significantly lower among children who received continuous renal replacement therapy (p<0.001). The need for inotropic medications and a higher PRISM III score were found to be the greatest indicators of mortality. CONCLUSION: The outcome of children receiving renal replacement therapy seems to be related to their needs for vasoactive drugs and the severity of the underlying disease in the continuous renal replacement therapy group relative to the other groups.
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Objective To evaluate the effect of renal insufficiency before heart transplantation on perioperative death, complications and long-term survival, and to compare the differences between preoperative serum creatinine (Scr) and estimated glomerular filtration rate (eGFR) in preoperative risk assessment. Methods Clinical data of 1 095 heart transplant recipients were retrospectively analyzed. According to preoperative Scr level, all recipients were divided into the Scr < 133 μmol/L(n=980), Scr 133-176 μmol/L (n=83) and Scr≥177 μmol/L groups (n=32). According to preoperative eGFR, all recipients were divided into eGFR≥90 mL/(min·1.73m2) (n=436), eGFR 60-89 mL/(min·1.73m2) (n=418) and eGFR < 60 mL/(min·1.73m2) groups (n=241). Clinical prognosis of postoperative renal function, perioperative and long-term outcomes of recipients were compared among different groups. The effect of eGFR and Scr level on renal function injury and long-term survival after heart transplantation was assessed. Results With the increase of preoperative Scr level, the proportion of recipients undergoing postoperative continuous renal replacement therapy (CRRT) was increased, the proportion of recipients receiving postoperative mechanical circulatory support was elevated, the incidence of postoperative complications was increased, the duration of mechanical ventilation and intensive care unit(ICU) stay was prolonged, and the in-hospital fatality was increased. The differences among three groups were statistically significant (all P < 0.05). With the decrease of preoperative eGFR, the proportion of recipients receiving postoperative CRRT was increased, the proportion of recipients using postoperative intra-aortic balloon pump (IABP) was elevated, the duration of mechanical ventilation and ICU stay was prolonged, and the in-hospital fatality was increased. The differences among three groups were statistically significant (all P < 0.05). Scr≥177 μmol/L was an independent risk factor for postoperative death [adjusted hazard ratio (HR) 3.64, 95% confidence interval (CI) 1.89-6.99, P < 0.01]. Among different groups classified by Scr and eGFR, the cumulative incidence rate of postoperative renal function injury and long-term survival rate were statistically significant among three groups (all P < 0.05). In patients with preoperative Scr < 133 μmol/L, the cumulative incidence rate of postoperative long-term renal function injury was significantly increased with the decrease of preoperative eGFR (P < 0.01). There was no significant difference in postoperative long-term survival rate among patients stratified by different eGFR (P > 0.05). Conclusions Renal insufficiency before heart transplantation is associated with poor perioperative and long-term prognosis. Preoperative Scr and eGFR are the independent risk factors for postoperative renal function injury. Scr yields low sensitivity in the assessment of preoperative renal function, whereas it has high accuracy in predicting perioperative death risk. And eGFR is a more sensitive parameter to evaluate preoperative renal function, which may identify early-stage renal functional abnormality and take effective measures during early stage to reduce adverse effect on prognosis.
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Acute kidney injury is a common complication after liver transplantation, which severely affects clinical prognosis of liver transplant recipients. Multiple factors before, during and after liver transplantation may cause kidney injury. If not properly treated, it may progress into chronic kidney diseases, which significantly increases postoperative fatality and negatively affects clinical efficacy of liver transplantation. Therefore, prevention, diagnosis and treatment of acute kidney injury after liver transplantation is a hot topic for clinicians. In this article, the definition, diagnosis, risk factors, prevention and treatment of acute kidney injury after liver transplantation were reviewed, and potential risk factors and related therapeutic strategies during different stages of acute kidney injury after liver transplantation were analyzed, aiming to lower the risk of acute kidney injury after liver transplantation and further improve clinical prognosis of liver transplant recipients by optimizing treatment regimens.
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Objective:To investigate the risk factors of postoperative continuous renal replacement therapy application in Stanford type A acute aortic dissection.Methods:This retrospective study included 527 patients with Stanford type A acute aortic dissection from November 2015 to February 2018 in Beijing Anzhen Hospital. They were divided into 2 groups according to whether or not needed postoperative continuous renal replacement therapy, group CRRT(78 cases) and group None CRRT(449 cases). Binary logistic regression analysis was used to analyze the risk factors of continuous renal replacement therapy. Results:Of all the patients, the percentage of using continuous renal replacement therapy was 14.8%(78/527), and the mortality of 30 days after surgery was 8.5%(45/527). The independent risk factors associated with CRRT were preoperative serum creatinine(sCr)( OR=1.012, 95% CI: 1.005-1.019, P<0.001), transfusion of red blood cell in surgery( OR=1.141, 95% CI: 1.071-1.216, P<0.001), transfusion of platelet in surgery( OR=1.307, 95% CI: 1.084-1.576, P=0.005), the total amount of drainage( OR=1.000, 95% CI: 1.000-1.000, P=0.036), and the time of extubation after surgery( OR=1.004, 95% CI: 1.001-1.008, P=0.013). Conclusion:The risk factors of CRRT after emergency surgery of Stanford type A acute aortic dissection are preoperative serum creatinine, transfusion of red blood cell in surgery, transfusion of platelet in surgery, the total amount of drainage and the time of tracheal extubation after surgery. We need to focus on those risk factors in our daily job and manage them timely and properly, in order to improve patients’ prognosis.
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Objective:To investigate the clinical features, treatment, and prognosis of transient hyperammonemia of the newborn (THAN).Methods:Data of two infants with severe THAN admitted to the Department of Neonatology of Shanghai Children's Hospital in September 2021 and August 2022 were retrospectively investigated. Clinical data of confirmed THAN cases (blood ammonia>400 μmol/L) were collected from relevant literature retrieved from the Wanfang Database, China National Knowledge Infrastructure, Chinese Medical Journal Database, and PubMed up to July 2022. A descriptive method was used for statistical analysis.Results:A total of 24 cases were involved (two in the present study, and 22 in 12 retrieved articles), including 19 (79.2%) premature newborns and five term infants. The average birth weight was (2 237±608) g and the average onset time was 27 h (4-55 h) after birth. The early clinical symptoms included respiratory distress and hyporesponsiveness (drowsiness, lethargy, coma or hypotonia) in 18 cases (75.0%), metabolic acidosis in 11 cases (45.8%), hypocalcemia in seven cases (29.2%), pupil fixation/dilation in six cases (25.0%), convulsion in five cases (20.8%), apnea in three cases (12.5%) and sinus bradycardia in one case (4.2%). The serum ammonia levels were 1 422.8 μmol/L (547.2-4 494.1 μmol/L). Treatments included peritoneal dialysis plus exchange transfusion in eight cases (33.3%), exchange transfusion in seven cases (29.2%), continuous renal replacement therapy (CRRT) in four cases (16.7%), arginine in two cases (8.3%), peritoneal dialysis in two cases (8.3%), and CRRT+peritoneal dialysis in one case (4.2%). During follow-ups of four months (one month to six years), 13 cases (54.2%) showed no abnormalities in development; two (8.3%) had a neurodevelopmental delay, and six (25.0%) died. The follow-up of the other three cases (12.5%) were not reported in the literature.Conclusions:The early clinical manifestation of severe THAN is atypical. A good prognosis can be expected through early exclusion of possible hyperammonemia-related genetic metabolic diseases and lowering the serum ammonia level. Long-term follow-up is needed for neurological evaluation.
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In the process of continuous renal replacement therapy (CRRT), various factors such as the temperature of replacement fluid, the flow of fluid and the circulation of blood in cardiopulmonary bypass, lead to the temperature of the blood injected back into the body is often lower than normal. It leads to the decrease of body temperature and the occurrence of hypothermia, which can be life-threatening in severe cases. In clinical practice, medical staff mostly reduces the occurrence of hypothermia in patients with CRRT by means of the heating device of the machine, the heating of the liquid temperature box for cardiopulmonary bypass, and the application of heating blankets, but the effect is not ideal. Therefore, medical staff of the department of critical care medicine of the Second Affiliated Hospital of Anhui Medical University designed a heating device and temperature control system for CRRT dialysis fluid bag, and obtained the National Invention Patent of China (ZL 2021 1 0334906.7). The device includes a heating and thermal insulation device and a temperature control system, wherein the heating and thermal insulation device is composed of the body of the heating dialysis fluid bag and the temperature control structure, which solves the problems of safe and efficient liquid heating and thermal insulation during the CRRT process. The temperature control system can display the dynamic state of the patient's body temperature, adjust the temperature of the dialysis fluid bag in time, and monitor the temperature of the blood transfusion in real time through the cooperation of the five modules of data collection, data handle, data analysis, regulation and display. This design is applied to CRRT, which can achieve precise control of body temperature of critically ill patients, and has certain clinical significance.
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Objective:To investigate the effects of continuous renal replacement therapy (CRRT) on plasma concentration, clinical efficacy and safety of colistin sulfate.Methods:Clinical data of patients received with colistin sulfate were retrospectively analyzed from our group's previous clinical registration study, which was a prospective, multicenter observation study on the efficacy and pharmacokinetic characteristics of colistin sulfate in patients with severe infection in intensive care unit (ICU). According to whether patients received blood purification treatment, they were divided into CRRT group and non-CRRT group. Baseline data (gender, age, whether complicated with diabetes, chronic nervous system disease, etc), general data (infection of pathogens and sites, steady-state trough concentration, steady-state peak concentration, clinical efficacy, 28-day all-cause mortality, etc) and adverse event (renal injury, nervous system, skin pigmentation, etc) were collected from the two groups.Results:A total of 90 patients were enrolled, including 22 patients in the CRRT group and 68 patients in the non-CRRT group. ① There was no significant difference in gender, age, basic diseases, liver function, infection of pathogens and sites, colistin sulfate dose between the two groups. Compared with the non-CRRT group, the acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) and sequential organ failure assessment (SOFA) were higher in the CRRT group [APACHE Ⅱ: 21.77±8.26 vs. 18.01±6.34, P < 0.05; SOFA: 8.5 (7.8, 11.0) vs. 6.0 (4.0, 9.0), P < 0.01], serum creatinine level was higher [μmol/L: 162.0 (119.5, 210.5) vs. 72.0 (52.0, 117.0), P < 0.01]. ② Plasma concentration: there was no significant difference in steady-state trough concentration between CRRT group and non-CRRT group (mg/L: 0.58±0.30 vs. 0.64±0.25, P = 0.328), nor was there significant difference in steady-state peak concentration (mg/L: 1.02±0.37 vs. 1.18±0.45, P = 0.133). ③ Clinical efficacy: there was no significant difference in clinical response rate between CRRT group and non-CRRT group [68.2% (15/22) vs. 80.9% (55/68), P = 0.213]. ④ Safety: acute kidney injury occurred in 2 patients (2.9%) in the non-CRRT group. No obvious neurological symptoms and skin pigmentation were found in the two groups. Conclusions:CRRT had little effect on the elimination of colistin sulfate. Routine blood concentration monitoring (TDM) is warranted in patients received with CRRT.
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@#BACKGROUND: This study aims to evaluate the effect of continuous renal replacement therapy (CRRT) on inflammation-related anemia, iron metabolism, and the prognosis in sepsis patients with acute kidney injury (AKI). METHODS: Sepsis patients with AKI were prospectively enrolled and randomized into the CRRT and control groups. The clinical and laboratory data on days 1, 3 and 7 after intensive care unit (ICU) admission were collected. The serum interleukin (IL)-6, hepcidin, erythropoietin, ferritin, and soluble transferrin receptor (sTfR) were determined by enzyme-linked immunosorbent assay. The Sequential Organ Failure Assessment (SOFA) score and 28-day mortality were recorded. Data were analyzed using Pearson’s Chi-square test or Fisher’s exact test (categorical variables), and Mann-Whitney U-test or t-test (continuous variables). RESULTS: The hemoglobin and serum erythropoietin levels did not significantly differ between the CRRT and control groups though gradually decreased within the first week of ICU admission. On days 3 and 7, the serum IL-6, hepcidin, ferritin, and red blood cell distribution width significantly decreased in the CRRT group compared to the control group (all P<0.05). On day 7, the serum iron was significantly elevated in the CRRT group compared to the control group (P<0.05). However, the serum sTfR did not significantly differ between the groups over time. In addition, the SOFA scores were significantly lower in the CRRT group compared to the control group on day 7. The 28-day mortality did not significantly differ between the control and CRRT groups (38.0% vs. 28.2%, P=0.332). CONCLUSION: CRRT might have beneficial effects on the improvement in inflammation-related iron metabolism and disease severity during the first week of ICU admission but not anemia and 28-day mortality in sepsis patients with AKI.
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INTRODUCCIÓN. La incorporación de nuevas tecnologías como la hemodiafiltración en línea, han mejorado parámetros metabólicos/nutricionales en los pacientes que se encontraban en hemodiálisis convencional; en la actualidad no existen datos registrados en la población ecuatoriana que se encuentra sometida a esta clase de tecnologías. OBJETIVO. Comparar la evolución clínico-metabólica de pacientes que estaban en hemodiálisis convencional y cambiaron a hemodiafiltración en línea, determinar si es favorable la migración de la terapia hemodialítica difusiva a convectiva y establecer si el cambio de terapia dialítica ocasionó resultados favorables. MATERIALES Y MÉTODOS. Estudio analítico retrospectivo. Población y muestra de 38 pacientes enfermos renales crónicos en terapia de sustitución renal modalidad hemodiálisis convencional que cambiaron a hemodiafiltración en línea, independientemente del tiempo de diagnóstico y tratamiento en la unidad de hemodiálisis del Hospital de Especialidades Carlos Andrade Marín, Quito-Ecuador, durante el periodo marzo 2016 a marzo 2017. RESULTADOS. Los efectos nutricionales y metabólicos pudieron denotar mayor ponderación de resultados favorables en la modalidad de hemodiafiltración. En la estabilidad hemodinámica y la dosis de diálisis se evidenció una leve superioridad en la modalidad de hemodiafiltración en comparación a la Hemodiálisis. En las dosis administradas de Calcio, Hierro, Eritropoyetina y Calcitriol no existieron diferencias significativas entre las dos modalidades de tratamientos. CONCLUSIÓN. El cambio de modalidad de Hemodiálisis convencional a Hemodiafiltración en línea fue favorable, y mejoró los parámetros clínicos/metabólicos de los pacientes que requieren terapia de sustitución renal.
INTRODUCTION. The incorporation of new technologies such as online haemodiafiltration have improved metabolic/nutritional parameters in patients who were on conventional haemodialysis; At present, there are no registered data on the Ecuadorian population that is subjected to this kind of technology. OBJECTIVE. To compare the clinical-metabolic evolution of patients who were on conventional hemodialysis and changed to online hemodiafiltration, to determine if the migration from diffusive to convective hemodialysis therapy is favorable and to establish if the change in dialysis therapy caused favorable results. MATERIALS AND METHODS. Retrospective analytical study. Population and sample of 38 patients with chronic kidney disease in conventional hemodialysis modality renal replacement therapy who changed to online hemodiafiltration, regardless of the time of diagnosis and treatment in the hemodialysis unit of the Hospital de Especialidades Carlos Andrade Marín, Quito-Ecuador, during the period March 2016 to March 2017. RESULTS. The nutritional and metabolic effects could denote a greater weighting of favorable results in the hemodiafiltration modality. In hemodynamic stability and dialysis dose, a slight superiority was evidenced in the hemodiafiltration modality compared to hemodialysis. In the administered doses of Calcium, Iron, Erythropoietin and Calcitriol there were no significant differences between the two treatment modalities. CONCLUSION. The change of modality from conventional hemodialysis to online hemodiafiltration was favorable, and improved the clinical/metabolic parameters of patients requiring renal replacement therapy.
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Humans , Male , Female , Ultrafiltration , Renal Dialysis , Hemodiafiltration , Continuous Renal Replacement Therapy , Hemodialysis Units, Hospital , Kidney DiseasesABSTRACT
Background: Anticoagulation in continuous renal replacement therapy (CRRT) is essential to counteract the coagulation cascade activation, induced by the dialysis circuit. Heparin is the most widely used anticoagulant, followed by regional citrate anticoagulation (RCA). Aim: To determine the effectiveness and safety of anticoagulant treatment with citrate in CRRT. Material and Methods: Retrospective study of adults in CRRT hospitalized between the years 2014 and 2020 in critical units, who required change to RCA according to established protocols. Results: We studied 24 patients aged 63 ± 13 years (12 females). The reasons for admission were acute kidney injury (AKI) in 80% and stage 5 chronic kidney disease in 20%. The indication of RCA in 75% of patients was by coagulation of more than 3 circuits in 24 hours. The duration of the circuit in RCA was 18.5 ± 4.8 hours versus 11.9 ± 4.9 hours with heparin (p < 0.0001). There were 19 mild complications that did not affect the RCA. Conclusions: RCA is feasible to perform, it is a safe and efficient procedure if it is protocolized, allowing a longer duration of the dialysis circuit.
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Sepsis is one of the leading causes of death in critically ill patients with COVID-19 and blood purification therapies have a role to immunomodulate the excessive inflammatory response and improve clinical results. One of the devices designed for these therapies is the oXiris® filter, allowing to perform renal replacement therapy combined with selective adsorption of endotoxins and cytokines. We report a 55-year-old male with COVID who developed a septic shock secondary to a sepsis caused by Pseudomona aeruginosa, refractory to the usual management. A veno-venous continuous hemofiltration was started using the oXiris® filter for 48 hours. Subsequently, there was an improvement in clinical perfusion parameters and a reduction in inflammatory markers. The patient was discharged from the intensive care one month later.
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Humans , Male , Middle Aged , Shock, Septic/complications , Shock, Septic/therapy , Sepsis/complications , COVID-19/complications , Cytokines , EndotoxinsABSTRACT
Objective:To investigate the effects of different connection schemes of continuous renal replacement therapy (CRRT) and extracorporeal membrane oxygenation (ECMO) on arterial pressure (PA), venous pressure (PV), and transmembrane pressure (TMP), and to provide a theoretical basis for choosing a suitable connection scheme.Methods:① In vitro study: the different connection schemes of CRRT and ECMO were simulated and divided into 6 schemes according to the connection between CRRT and ECMO circuits at different positions. Scheme A: connected to the front and back points of the oxygenator; scheme B: connected to the points behind and in front of the oxygenator; scheme C: connected to the points in front of the oxygenator and in front of the centrifugal pump; scheme D: connected to the points behind the oxygenator and in front of the centrifugal pump; scheme E: connected to the points in front of the oxygenator and the return catheter; scheme F: connected to the points after the oxygenator and the return catheter. Each set of ECMO circuits was measured 5 times under each connection scheme and different flow rates (2, 3, 4, 5, 5.5 L/min). Six ECMO circuits for a total of 30 measurements, and the PA, PV, and TMP of the 6 schemes were compared. ② In vivo study: the patients who were treated with ECMO combined with CRRT in the department of critical care medicine of the First Affiliated Hospital of Wannan Medical College from August 2017 to August 2021 changed the connection scheme due to high PA or PV (from scheme A or B to scheme E or F) were retrospectively analyzed. The changes of PA and PV before and after changing the scheme were compared. Results:① In vitro study results: there was no significant difference in PA between schemes A and B, C and D, E and F under different ECMO blood flow (2-5.5 L/min). The PA of schemes C and D was the lowest, followed by schemes E and F. PV of scheme B was higher than that of scheme A under different ECMO blood flow (2-5.5 L/min). There was no significant difference in PV between schemes C and D, E and F under high ECMO blood flow (3-5.5 L/min), and the absolute value of PV was lowest in schemes E and F. Compared with schemes A and B [partial PA > 300 mmHg (1 mmHg≈0.133 kPa) at high flow rate], C and D (partial PV > 350 mmHg at high flow rate), schemes E and F were more reasonable connection schemes. TMP was negative in schemes C and D at ECMO blood flow of 5 L/min and 5.5 L/min (mmHg; 5 L/min: scheme C was -29.14±11.42, scheme D was -42.45±15.70; 5.5 L/min: scheme C was -35.75±13.21, scheme D was -41.58±15.42), which indicated the presence of dialysate reverse filtration. Most of the differences in TMP among schemes A, B, E, and F under different ECMO blood flow (2-5.5 L/min) were statistically significant, and the absolute value of mean fluctuation was 9.89-49.55 mmHg, all within the normal range. ② In vivo study results: a total of 10 patients who changed the connection scheme (from scheme A or B to E or F) due to high PA or PV were enrolled, including 8 males and 2 females; 7 cases of venous-arterial ECMO (VA-ECMO) and 3 cases of venous-venous ECMO (VV-ECMO), all used continuous veno-venous hemodiafiltration (CVVHDF) mode. After changing the scheme, both PA and PV decreased significantly as compared with those before changing [PA (mmHg): 244.00±22.58 vs. 257.20±21.92, PV (mmHg): 257.20±18.43 vs. 326.40±15.41, both P < 0.01], and PV decreased more significantly than PA [difference (mmHg): 69.20±6.55 vs. 13.20±5.45, P < 0.01]. Conclusion:For patients treated with ECMO in combination with CRRT, the scheme of connecting the access line of CRRT to the pre-oxygenator or post-oxygenator and connecting the return line to the point of the return catheter can significantly reduce PA and PV and maintains normal CRRT operation even running high-flow ECMO.
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Continuous renal replacement therapy(CRRT)is an important treatment in the pediatric intensive care unit .However, CRRT needs to establish cardiopulmonary bypass.During the initial period of cardiopulmonary bypass , ultrafiltration and blood return, CRRT causes a rapid change of the body′s circulating blood volume due to the transfer of a large amount of fluid, resulting in hemodynamic instability.So accurate and real-time assessment of volume status during CRRT has an extremely important impact on reducing potential abnormal hemodynamic fluctuations and improving the prognosis of critically ill children.This review summarized the volume status assessment during CRRT in critically ill children.
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Acute respiratory distress syndrome(ARDS) is one of the challenging critical diseases in pediatric intensive care unit.Continuous renal replacement therapy(CRRT), playing important roles in the treatment of critical illness, has also become one of the hot spots in the treatment of patients with ARDS.Although CRRT technology has not been systematically recommended in the guideline of ARDS managements, numerous studies indicated that CRRT could improve survival and prognosis of ARDS, among which the impact on the clearance of inflammatory factors and fluid management of ARDS deserves attention.
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Objective:To evaluate the predictive value of systemic immune inflammation index (SII) for short-term prognosis in patients with sepsis complicated with acute kidney injury who received continuous renal replacement therapy (CRRT) .Methods:From Feb. 2018 to Jan. 2022, 90 patients with sepsis complicated with acute kidney injury who received CRRT in Hangzhou Cancer Hospital were included as the research objects. According to the survival of patients within 90 days, they were grouped into a survival group of 60 cases and a death group of 30 cases. The clinical baseline data such as age, sequential organ failure assessment (SOFA) score, acute physiological function and chronic health status scoring system II (APACHE II), albumin (ALB) were recorded. Automatic blood cell analyzer was applied to detect lymphocyte count, platelet count and neutrophil count in peripheral venous blood of patients with sepsis complicated with acute kidney injury who received CRRT, and the SII was calculated; Pearson correlation analysis was performed to analyze the correlation between SII and clinical baseline data in dead patients with sepsis complicated with acute kidney injury receiving CRRT; ROC curve was drawn to analyze and compare the predictive value of SII, SOFA score and APACHEII for death in patients with sepsis complicated with acute kidney injury receiving CRRT; Kaplan-Meier curve was performed to describe the changes in patient survival; multivariate Cox regression analysis was performed to analyze the factors affecting 90-day death in patients with sepsis complicated with acute kidney injury receiving CRRT.Results:SII (2636.74), C-reactive protein (CRP) [ (92.45±29.74) mg/L], SOFA score (12.83±3.24) and APACHEII (28.30±7.51) in the death group were higher than those in the survival group [341.92, (50.24±16.13) mg/L, 10.00±3.12, 25.13±6.87], and ALB [ (2.50±0.53) g/dl] was lower than that in the survival group [ (2.79±0.61) g/dl] ( P<0.05). SII was significantly positively correlated with CRP, SOFA score and APACHEII, and significantly negatively correlated with ALB in patients with sepsis complicated with acute kidney injury who received CRRT ( P<0.05). The areas under the curve (AUC) of SII, SOFA score, and APACHEII for predicting death in patients with sepsis complicated with acute kidney injury who received CRRT were 0.936, 0.827, and 0.736, respectively, and AUC of SII prediction was greater than that of SOFA score and APACHEII ( P<0.05). The 90-day survival rate of patients with sepsis complicated with acute kidney injury who received CRRT in the high SII group (23/46, 50.00%) was lower than that in the low SII group (37/44, 84.09%) ( P<0.05). SII was an independent risk factor for death within 90 days in patients with sepsis complicated with acute kidney injury who received CRRT ( P<0.05) . Conclusion:SII can better predict the 90-day mortality risk of patients with sepsis complicated with acute kidney injury receiving CRRT, and assist clinical assessment of short-term prognosis.
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Objective:To investigate the efficacy of therapeutic plasma exchange with continuous renal replacement therapy in patients with early septic shock.Methods:A total of 55 patients with septic shock admitted to ICU of Mindong Hospital Affiliated to Fujian Medical University from December 2017 to December 2020 were retrospectively analyzed. The patients were divided into the therapeutic plasma exchange group ( n=29) and standard-therapy group ( n=26) according to whether plasma exchange combined with hemofiltration was used. Patients in both groups were treated according to the 2016 Surviving Sepsis Campaign guidelines. No hemofiltration or/and plasma exchange therapy was performed in the standard-therapy group. In the therapeutic plasma exchange group, hemofiltration was performed immediately after plasma exchange within 24 h. The inflammatory indexes, hemodynamic indexes, organ function scores and 28-day mortality were monitored before and 24 h after treatment. χ2 test was used for counting data, t-test was used for measurement data, and Kaplan-Meier curve was used to evaluate 28-day survival status. Results:(1) There were no differences in sex, age, underlying diseases, acute physiology and chronic health evaluationⅡ (APACHEⅡ) score and sequential organ failure assessment (SOFA) score before treatment between the two groups. (2) There were no significant differences in PCT, CRP and IL-6 between the two groups at enrollment. After treatment, PCT, CRP and IL-6 in the therapeutic plasma exchange group were significantly lower than those in the standard-therapy group [PCT (ng/mL): (50.07±14.54) vs. (57.93±13.42), P=0.043; CRP (mg/L): (85.71±46.05) vs. (115.10±44.42), P=0.042; IL-6 (pg/mL): (5 957.45±2 344.48) vs. (7 522.94±3 218.94), P=0.043], but there was no significant difference in WBC between the two groups. (3) There were no significant differences in norepinephrine dose, mean arterial pressure, heart rate, systemic vascular resistance index (SVRI), extravascular lung water index (EVLWI) and Lactate level between the two groups. After treatment, the norepinephrine dose, lactate level and EVLWI in the therapeutic plasma exchange group decreased significantly, while SVRI increased significantly {norepinephrine dose [μg/(kg·min): (0.76±0.39) vs. (0.54±0.39), P=0.044; lactate (μmmol/ L): (7.74±4.22) vs. (4.51±1.62), P<0.001; EVLWI (mL/kg): (10.04±2.77) vs. (8.23±2.23), P=0.008; SVRI (dyn·s/cm 2): (1 103.14±364.94) vs. (1 403.31±264.46), P=0.001}. Compared with the standard-therapy, the 24-h intravenous infusion volume was significantly decreased [(3 852.07±686.43) mL vs. (4 474.81±572.71) mL, P=0.001]. (4) There were no significant differences in APACHEⅡscore and SOFA score between the two groups at enrollment. After treatment, the APACHEⅡscore and SOFA score of the therapeutic plasma exchange group were significantly lower than those of the standard-therapy group [APACHEⅡscore: (14.07±4.30) vs. (19.23±5.44), P<0.001; SOFA score: (9.93±1.16) vs. (11.69±1.81), P<0.001)]. There were no significant differences in ICU mortality and 28-day mortality between the two groups ( P>0.05). Conclusions:Therapeutic plasma exchange with continuous renal replacement therapy can reduce the inflammatory response and improve hemodynamics in patients with septic shock. However, 24 h treatment did not improve the mortality of patients.
ABSTRACT
Neonatal hyperammonemia has great damage to the central nervous system, which can lead to severe disability and even death.Early reduction of blood ammonia and shortening the duration of hyperammonemia coma can improve the poor prognosis of the central nervous system.Renal replacement therapy can reduce blood ammonia quickly and effectively which is an important treatment for neonatal hyperammonemia.Common kidney replacement therapies include peritoneal dialysis, intermittent hemodialysis, continuous renal replacement therapy and hybrid therapy.This review aims to elaborate the indications of renal replacement therapy, the advantages and disadvantages of various renal replacement therapy modes in the treatment of neonatal hyperammonemia and hybrid therapy.