A Case of Acute on Chronic Salicylate Poisoned Elderly Patient with Early Utilization of Continuous Venovenous Hemodiafiltration: A Case Report / 대한구급학회지

Salicylate poisonings are divided into acute and chronic syndromes. The most challenging aspect of the management of aspirin-poisoning may be recognition of subtle signs and symptoms of chronic, unintentional overdose. Chronic poisoning typically occurs in elderly as a result of unintentional overdosing on salicylates used to treat chronic conditions. Treatment is directed toward preventing intestinal absorption of the drugs and enhanced elimination. After the first-line treatments, aspirin overdose with its complications of hemodynamic, electrolyte and acid-base issues, is best managed by prompt hemodialysis. We report a case of a 87-year-old woman, who presented with acute on chronic salicylate poisoning. After early continuous venovenous hemodiafiltration, old woman made a good recovery from the salicylism but suffered paralytic ileus caused by aspirin enteroliths. Physician can decide a prompt hemodialysis for salicylate-poisoned patients, who worsen clinical courses despite of first-line therapies.

Successful Treatment of Severe Lactic Acidosis by Continuous Venovenous Hemodiafiltration / 대한신장학회잡지

Lactic acidosis is often associated with a strikingly high mortality. The effective therapy involves treatment of the underlying cause and correction of acidemia by infusion of sodium bicarbonate. When lactic acidosis is accompanied by oliguric renal failure, bicarbonate therapy becomes more complex with volume overload and hypernatremia. Hemodialysis against a bicarbonate-buffered dialysate will achieve this. However, it is generally tolerated poorly by hemodynamically unstable patients. We report here three hemodynamically unstable patients with severe lactic acidosis, which was treated successfully by the use of continuous venovenous hemodiafiltration with bicarbonate based dialysate and replacement solution. We would suggest that continuous renal replacement with bicarbonate buffer should be indicated in the treatment of severe lactic acidosis.

Clinical Significance of Continuous Veno-Venous Hemodiafiltration as an Initial Renal Replacement Therapy for Acute Renal Failure after Cardiovascular Surgery / 대한신장학회잡지

BACKGOUND: Although continuous venovenous hemodiafiltration (CVVHDF) has many therapeutic advantages, previous studies did not report the improvement of survival rate by CVVHDF compared to that by hemodialysis (HD). It could be attributed to that they did not analyze the results under the appropriate stratification of severity and to multiorgan failure. METHODS: We performed retrospective study to compare the outcomes of 88 patients with acute renal failure after major cardiovascular surgery(s). Among them, 48 patients (M:F=32:16, Age 58+/-11 years) were treated by CVVHDF and 40 patients (M:F=27:13, Age 59+/-10 years) were treated by HD. The severity of illness was estimated by APACHE III score system at the initiation of renal replacement therapy (RRT) and we also evaluated renal outcome and survival. RESULTS: There was no significant difference between two groups in baseline characteristics, cause of surgery, survival rate and renal outcome. However, compared with those of HD group, CVVHDF group showed longer period of application with mechanical ventilator (p=0.001), longer period of vasopressor use (p<0.001), longer stay in intensive care unit (p=0.004) and higher APACHE III score at the initiation of renal replacement therapy (p=0.009). Among those with APACHE III scores over 90, survivors existed in CVVHDF group with the survival rate of 50%. In contrast, there was no one who survived in HD group (p=NS). CONCLUSION: Although this study revealed that CVVHDF could be more useful than HD as an initial RRT for the patients with renal failure after major cardiovascular surgery, the randomized prospective study will be required to accept clinical usefulness of CVVHDF.

Removal of Amikacin in Patients Undergoing Continuous Venovenous Hemodiafiltration / 대한신장학회잡지

BACKGROUND: The purpose of this study was to investigate the pharmacokinetics of amikacin in critically ill patients undergoing continuous venovenous hemodiafiltration (CVVHDF). METHODS: Pharmacokinetic parameters in each of six renal failure patients were estimated by measurement of amikacin levels in serum and effluent samples. RESULTS: Average clearance of amikacin by CV VHDF was 28.5+/-4.6 mL/min (mean+/-standard deviation). The sieving coefficient was 0.62+/-0.2 in the hemodiafiltration system of Gambro AN69 membrane set. Volume of distribution of amikacin was estimated to be 0.47+/-0.08 L/kg lean body weight. The half-life of amikacin was significantly reduced by hemodiafiltration to 11.4+/-1.6 hr. 40% of the administered amikacin was removed by CVVHDF over the 24 hour study period. CONCLUSION: We recommend that 10 mg/kg of amikacin should be given i.v. every 48 hours to critically ill patients during CVVHDF. However, individualized approach based on therapeutic drug monitoring of plasma amikacin concentration is necessary for optimum amikacin therapy during CVVHDF due to the varying nature of critically ill patients.

Influencing Factors to the Filter Life on Continuous Venovenous Hemodiafiltration without Anticoagulantion / 대한신장학회잡지

BACKGROUND: Continuous venovenous hemodiafiltration (CVVHDF) is advantageous in ARF patients with the unstable emodynamics and multiorgan failure. However, use of anticoagulation is sometimes hampered by their concurrent bleeding tendency. We performed the retrospective analysis to investigate the factors that could influence on the filter life. METHODS: The patients on CVVHDF without anticoagulation who required exchange of filter 8 times or more due to clotting were included. We measured filter life, clotting time, hemoglobin, platelet count, blood flow rate, dialysate flow rate, replacement fluid flow rate and blood pressure just before the initiation of every filter. We also measured mechanical pressures relevant to the filter, such as access pressures, filter pressure, return pressure and transmembrane pressure (TMP) within the last 6 hours before termination of every filter. RESULTS: Twenty-three patients (age 57+/-16, M: F=19: 4) showed the median filter life of 9 hours 20 minutes. The filter life was not influenced by the included variables. TMP significantly increased every hour during the last 6 hours before the end of filter life (p<0.01). When TMP was greater than 120 mmHg, TMP significantly increased every hour thereafter and CVVHDF was terminated within 4 hours. CONCLUSION: This study suggested that the possibility of filter clotting should be suspected when TMP is greater than 120 mmHg in the setting of CVVHDF without anticoagulation.