Predictors and Prognostic Impact of Early Acute Kidney Injury in Cardiogenic Shock: Results from a Monocentric, Prospective Registry.

INTRODUCTION: The presence of acute kidney injury (AKI) was shown to increase the risk of mortality following acute myocardial infarction; however, data regarding the prognostic impact of early AKI in patients with concomitant cardiogenic shock (CS) is limited. The study investigates predictors and the prognostic impact of AKI in patients with CS. METHODS: Consecutive patients with CS from 2019 to 2021 were included at one institution. Laboratory values were retrieved from day of disease onset (day 1) and days 2, 3, 4, and 8 thereafter. Predictors for AKI (defined as an increase of plasma creatinine >50% within 48 h referring to pre-admission or baseline creatinine on day 1 and/or the need for continuous veno-venous hemodiafiltration [CVVHDF]) and the prognostic impact of early AKI with regard to 30-day all-cause mortality were assessed. Statistical analyses included t test, Spearman's correlation, C-statistics, Kaplan-Meier, and Cox proportional regression analyses. RESULTS: A total of 219 CS patients were included with an incidence of early CS-related AKI of 52%. With an area under the curve of up to 0.689 (p = 0.001), creatine discriminated 30-day mortality in CS. Increasing lactate levels (OR = 1.194; 95% CI: 1.083-1.316; p = 0.001; per increase of 1 mmol/L) was associated with the occurrence of AKI. The presence of AKI was associated with an increased risk of 30-day all-cause mortality (63% vs. 36%; HR = 2.138; 95% CI: 1.441-3.171; p = 0.001), even after multivariable adjustment (HR = 1.861; 95% CI: 1.207-2.869; p = 0.005). Finally, highest risk of all-cause mortality was observed in patients with AKI requiring CVVHDF (75% vs. 44%; log rank p = 0.001; HR = 2.211; 95% CI: 1.315-3.718; p = 0.003). CONCLUSION: Early AKI affects more than half of patients with CS and is independently associated with 30-day all-cause mortality in CS, with highest risk of death among patients with AKI requiring CVVHDF.

A pilot study of intensive short-time continuous renal replacement therapy to substitute maintenance hemodialysis during transitional period of COVID-19.

INTRODUCTION: There is a lack of perfect solutions for maintenance hemodialysis (MHD) in patients with a high transmission risk of SARS-CoV-2. METHODS: MHD patients with a high risk of SARS-CoV-2 transmission from April 1 to June 30, 2022, were recruited. We performed 4-h continuous renal replacement therapy with Prismaflex dialysis machine and ST100 suite using continuous venovenous hemodiafiltration (CVVHDF) mode with a fluid exchange volume of 8000 mL/h. RESULTS: Forty-five MHD patients were included with a median dialysis age of 91 months. Overall spKt/V reached 0.96 ± 0.19. Urea reduction ratio was 50.29 ± 7.60% with the ultrafiltration of 2.18 ± 0.79 kg. Dry weight was significantly inversely correlated with spKt/V (R = -0.563, p < 0.001). Female gender was a significant positive factor of spKt/V. Preheating of replacement solution using an incubator solved the complication of shivering in most patients. CONCLUSION: Intensive short-time CVVHDF may be considered as an alternative for routine MHD during COVID-19 transitional period.

Real-Time TDM-Based Expert Clinical Pharmacological Advice Program for Attaining Aggressive Pharmacokinetic/Pharmacodynamic Target of Continuous Infusion Meropenem in the Treatment of Critically Ill Patients with Documented Gram-Negative Infections Undergoing Continuous Veno-Venous Hemodiafiltration.

(1) Objectives: to describe the pharmacokinetic/pharmacodynamic (PK/PD) profile of continuous infusion (CI) meropenem in critical patients with documented Gram-negative infections undergoing continuous veno-venous hemodiafiltration (CVVHDF) and to assess the relationship with microbiological outcome. (2) Methods: Data were retrospectively retrieved for patients admitted to the general and the post-transplant intensive care units in the period October 2022-May 2023 who underwent CVVHDF during treatment with CI meropenem optimized by means of a real-time therapeutic drug monitoring (TDM)-based expert clinical pharmacological advice (ECPA) program for documented Gram-negative infections. Steady-state meropenem plasma concentrations were measured, and the free fractions (fCss) were calculated. Meropenem total clearance (CLtot) was calculated at each TDM assessment, and the impact of CVVHDF dose intensity and of residual diuresis on CLtot was investigated by means of linear regression. Optimal meropenem PK/PD target attainment was defined as an fCss/MIC ratio > 4. The relationship between meropenem PK/PD target attainment and microbiological outcome was assessed. (3) Results: A total of 24 critical patients (median age 68 years; male 62.5%) with documented Gram-negative infections were included. Median (IQR) meropenem fCss was 19.9 mg/L (17.4-28.0 mg/L). Median (IQR) CLtot was 3.89 L/h (3.28-5.29 L/h), and median (IQR) CVVHDF dose intensity was 37.4 mL/kg/h (33.8-44.6 mL/kg/h). Meropenem dosing adjustments were provided in 20 out of 24 first TDM assessments (83.3%, all decreases) and overall in 26 out of the 51 total ECPA cases (51.0%). Meropenem PK/PD target attainment was always optimal, and microbiological eradication was achieved in 90.5% of assessable cases. (4) Conclusion: the real-time TDM-guided ECPA program was useful in attaining aggressive PK/PD targeting with CI meropenem in critically ill patients undergoing high-intensity CVVHDF and allowed microbiological eradication in most cases with dosing regimens ranging between 125 and 500 mg q6h over 6 h.

A simplified protocol of regional citrate anticoagulation with phosphate-containing solutions in infants and children treated with continuous kidney replacement therapy.

BACKGROUND: Regional citrate anticoagulation (RCA) is the preferred modality of anticoagulation used in continuous kidney replacement therapy (CKRT) in adults and less extensively in children. Potential metabolic complications limit widespread use in infants, neonates, and in children with liver failure. METHODS: We report our experience with a simplified protocol in 50 critically ill children, infants, and neonates, some of them with liver failure, with commercially available solutions containing phosphorous and higher concentration of potassium and magnesium. RESULTS: RCA allowed attainment of a mean filter lifetime of 54.5 ± 18.2 h, 42.5% of circuits lasted more than 70 h, and scheduled change was the most frequent cause of CKRT interruption. Patient Ca++ and circuit Ca++ were maintained in the target range with mean values of 1.15 ± 0.13 mmol/l and 0.38 ± 0.07 mmol/l, respectively. No session had to be stopped because of metabolic complications. The most frequent complications were hyponatremia, hypomagnesemia, and metabolic acidosis mostly related to primary disease and critical illness. No session had to be stopped because of citrate accumulation (CA). Transitory CA occurred in 6 patients and was managed without requiring RCA interruption. No patients with liver failure presented CA episodes. CONCLUSIONS: In our experience, RCA with commercially available solutions was easily applied and managed in critically ill children, even in patients with low weight or with liver failure. Solutions containing phosphate and higher concentrations of magnesium and potassium allowed reduction of metabolic derangement during CKRT. Prolonged filter life was ensured with no detrimental effects on patients and reduced staff workload. A higher resolution version of the Graphical abstract is available as Supplementary information.

Effect of hemopurification on acute chlorfenapyr poisoning / 中华急诊医学杂志

Objective:To evaluate the therapeutic effect of hemopurification on acute chlorfenapyr poisoning according to the blood concentration of chlorfenapyr and to provide experience for clinical treatment.Methods:Two patients who presented to our Emergency Department following an ingestion of chlorfenapyr and then were treated with hemopurification in 2022 were included. The concentrations of chlorfenapyr and its highly toxic metabolite tralopyril were dynamically monitored, and the clinical data of the patients were collected.Results:Case 1 was given hemoperfusion for the first time 13 hours after ingestion. During l hour hemoperfusion, the tralopyril decreased by 28.82%. The concentration increased and exceeded the pre-perfusion level after 2 hours of hemoperfusion. After three times of hemoperfusion, the concentrations of chlorfenapyr and tralopyril were still higher than those before the first time, reaching 248 ng/mL and 1 307 ng/mL respectively. The concentration of chlorfenapyr showed a downward trend after 130 h, and the tralopyril in blood reached the peak 3 164 ng/mL at 130 h and decreased to 2 707 ng/mL at 178 h. In case 2, the blood chlorfenapyr and tralopyril concentration was 392 ng/mL and 7 598 ng/mL respectively 150 hours after ingestion. The blood chlorfenapyr concentration decreased by 37.75% respectively after first hemoperfusion, and the tralopyril concentration decreased by 38.02% respectively. During 85 hours of continuous veno-venous hemodiafiltration (CVVHDF), the concentration of tralopyril was maintained at 4 234~6 410 ng/mL. Case 1 was followed up to 12 days and lost follow-up. Case 2 died and the survival time was 247 hours.Conclusions:Hemoperfusion can scavenge tralopyril, but CVVHDF has poor scavenging ability for tralopyril. And the apparent volume of distribution (Vd) of chlorfenapyr and tralopyril are large. After ingestion, chlorfenapyr spreads to various tissues quickly, and it is easy to accumulate in the adipose tissue. The chlorfenapyr in the tissue slowly is released back to the blood and stays in the blood for a long time. The peak concentration of chlorfenapyr appeared earlier than that of tralopyril. Clinicians should pay attention to the early removal of toxins from the digestive tract.

Síndrome hemolítico urémico atípico secundario a infección neumocócica invasiva / Atypical hemolytic uremic syndrome secondary to invasive pneumococcal infection

Introducción: El síndrome hemolítico urémico (SHU) es una patología infrecuente y grave en pediatría. Se clasifica en SHU “típico” o “atípico” en función de su etiopatogenia. Se caracteriza por la triada: anemia hemolítica microangiopática, trombopenia e insuficiencia renal, siendo característica la presencia de esquistocitos en sangre periférica. Caso clínico: Varón de 13 meses sin antecedentes personales ni familiares de interés. Consulta por fiebre alta de 5 días, sintomatología catarral, astenia, ictericia, vómitos, diarrea y oliguria. Exploración física: mal estado general, HTA estadio I, coloración pálido-ictérica, taquicardia, polipnea, hipoventilación basal pulmonar derecha y edemas pretibiales. Pruebas complementarias: analítica sanguínea: Hb 8,4 g/dl, 20.000/mm3 plaquetas, leucocitosis con desviación izquierda, urea 186 mg/dl, creatinina 3,27 mg/dl [FGe(Schwartz_2009): 10,5 ml/min/1,73 m2], PCR, PCT y LDH elevadas, haptoglobina baja. Sistemático/sedimento urinario: proteinuria 0,95 mg/mg, hematuria glomerular. Frotis sangre periférica: 5% Esquistocitos. Test de Coombs directo: positivo. Radiografía torácica: condensación basal pulmonar derecha. Ante presencia de la triada: anemia hemolítica microangiopática, trombopenia e insuficiencia renal es diagnosticado de SHU en contexto de neumonía, iniciando tratamiento de soporte en UCIP, furosemida y antibioterapia empírica. Actividad ADAMTS13 y determinación de Shiga-toxina: negativas. Hemocultivo: + Streptococcus pneumoniae. Estudio de complemento normal. Empeoramiento funcional renal, precisando hemodialfiltración veno-venosa continua y administración de eculizumab. Presentó mejoría progresiva y alta con diagnóstico final de SHU secundario a sepsis neumocócica. Seguimiento en consulta de Nefrología Pediátrica, actualmente padece enfermedad renal crónica en estadio G3A2. Conclusiones: Es importante realizar un diagnóstico y tratamiento precoces para mejorar su pronóstico vital y funcional renal, estableciendo protocolos de manejo inicial y seguimiento multidisciplinar.(AU)

Introduction. Hemolytic uremic syndrome (HUS) is a rare and serious pathology in pediatrics. It is classified as “typical” or “atypical” HUS depending on its etiopathogenesis. It is characterized by the triad: microangiopathic hemolytic anemia, thrombopenia and renal failure, with the presence of schistocytes in peripheral blood being characteristic. Case report: 13-month-old male with no personal or family history of interest. Consultation due to high fever for 5 days, catarrhal symptoms, asthenia, jaundice, vomiting, diarrhea and oliguria. Physical examination: Poor general condition, Stage-I arterial hypertension, pale-jaundiced muco-cutaneous, tachycardia, polypnea, hypoventilation at the right lung base and pretibial edema. Complementary tests: Blood analysis: Hb 8.4 g/dl, platelets 20,000/mm3, leukocytosis with left deviation, urea 186mg/dl, creatinine 3.27 mg/dl [eGFR(Schwartz_2009): 10.5 ml/min/1.73 m2], elevated CRP, PCT and LDH, low haptoglobin. Systemic/urinary sediment: proteinuria 0.95 mg/mg, glomerular hematuria. Peripheral blood smear: 5% Schistocytes. Direct Coombs test: positive. Chest x-ray: right pulmonary basal condensation. In the presence of the triad: microangiopathic hemolytic anemia, thrombopenia and renal failure, HUS was diagnosed in the context of pneumonia, initiating supportive treatment in the PICU, furosemide and empirical antibiotic therapy. ADAMTS13 activity and Shiga-toxin determination: negative. Blood culture: + Streptococcus pneumoniae. Worsening renal function, requiring continuous veno-venous hemodiafiltration and administration of eculizumab. He showed progressive improvement and was discharged with diagnosis of HUS secondary to pneumococcal sepsis. Follow-up in Pediatric Nephrology consultation, currently suffering from chronic kidney disease (stage G3A2). Conclusions: It is important to carry out early diagnosis and treatment to improve vital and renal functional prognosis, establishing initial management protocols and multidisciplinary follow-up.(AU)

Efficacy of Three Renal Replacement Therapy Modalities for the Treatment of Acute Kidney Injury Caused by Wasp Sting.

BACKGROUND/AIM: This study mainly aimed to explore the therapeutic effects of 3 renal replacement therapy (RRT) modalities on acute kidney injury (AKI) caused by wasp stings. METHODS: A retrospective study from September 2016 to December 2019 was conducted. Thirty-one patients with AKIs caused by wasp sting were selected and divided into 3 groups according to the initial RRT modality received, namely, (1) the intermittent hemodialysis combined with hemoperfusion (IHD + HP) group, (2) the continuous veno-venous hemodiafiltration (CVVHDF) group, and (3) the CVVHDF combined with HP (CVVHDF + HP) group. The laboratory results were measured and analyzed before treatment on the 3rd, 7th, and 14th days of treatment. The renal function outcomes and survival of the patients were investigated at 3 months follow-up. RESULTS: The laboratory results of enzyme measures and inflammatory indicators in wasp sting patients increased significantly in the early stage and 3 RRT modalities were effective in reducing these indicators. In addition, continuous RRT modality (CVVHDF and CVVHDF + HP) showed better clearance of myoglobin than IHD + HP. The serum creatinine levels of patients in the 3 groups did not recover to baseline within 14 days after beginning treatment. Nevertheless, the CVVHDF + HP group was better than the CVVHDF group, and CVVHDF was better than the IHD + HP group on the 3rd day. The interleukin (IL)-6 and IL-10 levels in CVVHDF + HP and IHD + HP groups were obviously lower than those in the CVVHDF group on the 3rd day. In the follow-up study, the recovery rate of renal function in CVVHDF and CVVHDF + HP groups was significantly better than that in the IHD + HP group. CONCLUSION: Early RRT was effective in the treatment of patients with A KI caused by wasp sting. CVVHDF + HP and CVVHDF modalities were better than the IHD + HP group in venom clearance and renal function recovery.

The efficiency of continuous renal replacement therapy for rewarming of patients in accidental hypothermia--An experimental study.

Severe accidental hypothermia carries high mortality and morbidity and is often treated with invasive extracorporeal methods. Continuous veno-venous hemodiafiltration (CVVHDF) is widely available in intensive care units. We sought to provide theoretical basis for CVVHDF use in rewarming of hypothermic patients. CVVHDF system was used in the laboratory setting. Heat balance and transferred heat units were evaluated for the system without using blood. We used 5L of crystalloid solution at the temperature of approximately 25°C, placed in a thermally insulated tank (representing the "central compartment" of a hypothermic patient). Time of warming the central compartment from 24.9 to 30.0°C was assessed with different flow combinations: "blood" (central compartment fluid) 50 or 100 or 150 mL/min, dialysate solution 100 or 1500 mL/h, and substitution fluid 0 or 500 mL/h. The total circulation time was 1535 minutes. There were no differences between heat gain values on the filter depending on blood flow (P = .53) or dialysate flow (P = .2). The mean heating time for "blood" flow rates 50, 100, and 150 mL/min was 113.7 minutes (95% CI, 104.9-122.6 minutes), 83.3 minutes (95% CI, 76.2-90.3 minutes), and 74.7 minutes (95% CI, 62.6-86.9 minutes), respectively (P < .01). The respective median rewarming rate for different "blood" flows was 3.6°C/h (IQR, 3.0-4.2°C/h), 4.8 (IQR, 4.2-5.4°C/h), and 5.4 (IQR, 4.8-6.0°C/h), respectively (P < .01). The dialysate flow did not affect the warming rate. Based on our experimental model, CVVHDF may be used for extracorporeal rewarming, with the rewarming rates increasing achieved with higher blood flow rates.

Once-daily 1 g ceftriaxone optimizes exposure in patients with septic shock and hypoalbuminemia receiving continuous veno-venous hemodiafiltration.

PURPOSE: Ceftriaxone total and unbound pharmacokinetics (PK) can be altered in critically ill patients with septic shock and hypoalbuminemia receiving continuous veno-venous hemodiafiltration (CVVHDF). The objective of this study was to determine the dosing strategy of ceftriaxone that maximizes the probability of maintaining the concentration above the MIC of the susceptible bacteria (≤2 mg/L by the EUCAST) for a 100% of the dosing interval (100% ƒuT>MIC). METHODS: In a prospective PK study in the intensive care units of two tertiary Spanish hospitals, six timed blood samples were collected per patient; for each sample, ceftriaxone total and unbound concentrations were measured using a liquid chromatography coupled to tandem mass spectrometry method. Population PK analysis and Monte-Carlo simulations were performed using NONMEMv.7.3®. RESULTS: We enrolled 8 critically ill patients that met the inclusion criteria (47 blood samples). Median age (range) was 70 years (47-85), weight 72.5 kg (40-95), albumin concentration 24.2 g/L (22-34), APACHE II score at admission 26 (17-36), and SOFA score on the day of study 12 (9-15). The unbound fraction (ƒu) of ceftriaxone was 44%, and total CL was 1.27 L/h, 25-30% higher than the CL reported in septic critically ill patients not receiving renal replacement therapies, and dependent on albumin concentration and weight. Despite this increment in ƒu and CL, Monte-Carlo simulations showed that a dose of 1 g once-daily ceftriaxone is sufficient to achieve a 100% ƒuT>MIC for MICs ≤2 mg/L for any range of weight and albumin concentration. CONCLUSION: Once-daily 1 g ceftriaxone provides optimal exposure in critically ill patients with septic shock and hypoalbuminemia receiving CVVHDF.

Acute liver failure secondary to yellow phosphorus rodenticide poisoning: Outcomes at a center with dedicated liver intensive care and transplant unit.

Accidental or suicidal poisoning with yellow phosphorus or metal phosphides (YPMP) such as aluminum (AlP) zinc phosphide (Zn3P2) commonly cause acute liver failure (ALF) and cardiotoxicity. These are used as household, agricultural and industrial rodenticides and in production of ammunitions, firecrackers and fertilizers. In absence of a clinically available laboratory test for diagnosis or toxin measurement or an antidote, managing their poisoning is challenging even at a tertiary care center with a dedicated liver intensive care unit (LICU) and liver transplant facility. PATIENTS AND METHODS: Patients with YPMP related ALF were monitored using standardized clinical, hemodynamic, biochemical, metabolic, neurological, electrocardiography (ECG) and SOFA score and managed using uniform intensive care, treatment and transplant protocols in LICU. Socio-demographic characteristics, clinical and biochemical parameters and scores were summarized and compared between 3 groups i.e. spontaneous survivors, transplanted patients and non-survivors. Predictors of spontaneous survival and the need for liver transplant are also evaluated. RESULTS: Nineteen patients with YPMP related ALF were about 32 years old (63.2% females) and presented to us at a median of 3 (0 - 10) days after poisoning. YPMP related cardiotoxicity was rapidly progressive and fatal whereas liver transplant was therapeutic for ALF. Spontaneous survivors had lower dose ingestion (<17.5 grams), absence of cardiotoxicity, < grade 3 HE, lactate < 5.8, SOFA score < 14.5, and increase in SOFA score by < 5.5. Patients with renal failure need for CVVHDF and KCC positivity on account of PT-INR > 6.5 had higher mortality risk. Patients undergoing liver transplant and with spontaneous recovery required longer ICU and hospital stay. At median follow-up of 3.4 (2.6 - 5.5) years, all spontaneous survivors and transplanted patients are well with normal liver function. CONCLUSIONS: Early transfer to a specialized center, pre-emptive close monitoring, and intensive care and organ support with ventilation, CVVHDF, plasmapheresis and others may maximize their chances of spontaneous recovery, allow accurate prognostication and a timely liver transplant.

Continuous hemodiafiltration as a rescue therapy for patients with cardiopulmonary failure caused by enterovirus-71: a retrospective observational study in a PICU.

BACKGROUND: Hand, foot and mouth disease (HFMD) remains a burdensome health issue in mainland China. Enterovirus71 (EV-A71) is the main pathogen of severe HFMD. Continuous hemofiltration improves fluid overload, restores kidney function and alleviates inflammatory reactions. The aim of the present study was to evaluate the effects of continuous veno-venous hemodiafiltration (CVVHDF) on severe HFMD caused by EV-A71(EV-A71-HFMD) in a pediatric intensive care unit (PICU). METHODS: A retrospective observational study was performed in a tertiary university PICU from January 2012 to December 2016. Children with severe EV-A71-HFMD complicated by cardiopulmonary failure were included. The patients were divided into a CVVHDF group and a conventional therapy (control) group (non-CVVHDF). The demographics, characteristics, and outcomes between the groups were collected and analyzed. RESULTS: Twenty-nine patients with severe EV-A71-HFMD were enrolled. The 28-day mortality was 17.6% (3/17) in the CVVHDF group and 33.3% (4/12) in the non-CVVHDF group, with no statistical significance between the two groups (P = 0.403). The median interval between CVVHDF initiation and PICU admission was 6 (4,8.5) hrs, and the median duration of CVVHDF was 48 (36, 64) hrs. The left ventricular ejection fraction (LVEF) and cardiac index (CI) in the CVVHDF group were improved after treatment. The plasma levels of catecholamines and renin-angiotensin-aldosterone system (RAAS) substances in the CVVHDF group were significantly decreased after treatment. The decreased catecholamines and RAAS substances included adrenalin (169.8 [145.5, 244.6] vs. 148.0 [109.0, 208.1] ng/L, P = 0.033), dopamine (152.7 [97.0, 191.1] vs. 96.0 [68.0, 160.9] ng/L, P = 0.026), angiotensin II (185.9 [125.2, 800.0] vs. 106.0 [90.8, 232.5] ng/L, P = 0.047), aldosterone (165.7 [94.0, 353.3] vs. 103.3 [84.3, 144.3] ng/L, P = 0.033), and renin (1.12 [0.74, 3.45] vs. 0.79 [0.52, 1.25] µg/L/h, P = 0.029), CONCLUSIONS: CVVHDF reduced the levels of catecholamines and RAAS substances and improved cardiovascular function. Continuous hemodiafiltration may represent a potential therapy in patients with severe EV-A71-HFMD complicated with cardiopulmonary failure.

ACUsmart Continuous Renal Replacement Therapy Platform: Multicenter Pilot Study for Technical and Clinical Assessment (A.M.P. Study).

BACKGROUND: ACUsmart (Medica S.P.A., Italy) is a new-generation, continuous renal replacement therapy (CRRT) machine for critically ill patients with acute kidney injury. We designed a multicenter international pilot study to provide a description of outlines of the ACUsmart system, evaluation aspects of functionality, usability, and feasibility, discriminating reasons of possible treatment's withdrawals or discontinuations and highlighting strong and weak points of the machine. METHODS: Data of 23 CRRT (and 11 plasma exchange) treatments were collected from 4 intensive care units. Parameters such as treatment duration, downtime, delivered dose, and number and type of alarms were recorded. The general perception of the machine was quantified through the administration of a survey to each component of the evaluating staff. RESULTS: A total treatment time of 447 h was carried with ACUsmart. Eleven continuous veno-venous hemofiltration, 4 continuous veno-venous hemodialysis , and 8 continuous veno-venous hemodiafiltration were performed. The average percentage of net treatment duration with respect to total treatment duration was 92.37%. The mean prescribed dose and delivered dose were 26.33 and 24.10 mL/kg/h, respectively. In general, the machine was rated by users involved as practical and easy to use, although few components need to be slightly improved. CONCLUSION: ACUsmart is a new multifunctional machine that meets most of the features required in a fourth-generation CRRT equipment.

Utility of transpulmonary thermodilution with Pulse Index Continuous Cardiac Output system for hemodynamic assessment in a hemodialysis patient with arteriovenous fistula and continuous renal replacement therapy: A case report.

Close hemodynamic monitoring is crucial for the patients to guide cardiovascular therapy for the optimal management. Transpulmonary thermodilution offers a less invasive hemodynamic monitoring with Pulse Index Continuous Cardiac Output system analysis. Intracardiac shunts have been associated with well-defined alterations in transpulmonary thermodilution-related hemodynamic parameters leading to inaccurate measurements and therefore are among the contraindications for transpulmonary thermodilution. However, data on the effects of arteriovenous fistulas as well as extracorporeal circuits on the thermodilution curves remain limited and inconclusive. Herein, we report generation of modified thermodilution curve forms leading to incorrect calculation of thermodilution-derived hemodynamic parameters by Pulse Index Continuous Cardiac Output system in a female patient in the presence of Continuous Veno-Venous Hemodiafiltration and a high flow arteriovenous fistula. Our findings revealed generation of modified thermodilution curves and unacceptably high extravascular lung water readings by Pulse Index Continuous Cardiac Output system. This seems consistent with early recirculation of cold indicator in case of a peripheral shunt emphasizing the potential impact of high flow arteriovenous fistula on reliability of transpulmonary thermodilution measurements in critically ill patients, limiting the use of Pulse Index Continuous Cardiac Output system in these conditions.

Blood purification on severe enterovirus 71-associated hand,foot and mouth disease in children / 中国小儿急救医学

Objective To assess the clinical benefits of continuous blood purification(CBP) in severe enterovirus 71(EV71)-associated hand,foot and mouth disease (HFMD) in children.Methods We retro-spectively analyzed the medical records of pediatric patients with EV71-associated HFMD admitted to PICU in Shanghai Children's Hospital from January 2012 to December 2016.Severity of EV71-associated HFMD was graded in the accordance with the expert consensus on severe EV71-infected HFMD.According to the severity,the patients with stage 2 HFMD were treated with standard management,and the patients with stage 3-4 HFMD were treated with continuous veno-venous hemodiafiltration(CVVHDF) as an adjuvant therapy. Patient demographics,clinical characteristics,cardiovascular function indexes,outcome and complications of CVVHDF were collected and analyzed.Results A total of 76 patients with severe EV71-associated HFMD were enrolled in this study.Among them,there were 21 patients with stage 3-4 HFMD,and 17 cases were treated with CVVHDF as an adjuvant therapy with a survival rate of 82.4 %(14/17).The median time of CVVHDF treatment was 48(36,64)h.The plasma levels of angiotensin Ⅱ[185.9(125.2,800.0) ng/L vs. 106.0(90.8,232.5) ng/L],aldosterone[165.7(94.0,353.3) ng/L vs. 103.3(84.3,144.3)ng/L],rennin [1.12(0.74,3.45) μg/(L·h) vs. 0.79(0.52,1.25) μg/(L·h) ],adrenaline[169.8(145.5,244.6) ng/L vs. 148.0(109.0,208.1) ng/L],dopamine[152.7(97.0,191.1) ng/L vs. 96.0(68.0,160.9) ng/L], and lactate[3.50(2.75,3.90) mmol/L vs. 1.30(0.95,1.90) mmol/L] were significantly decreased after CVVHDF treatment(all P<0.05,respectively).The fever,heart rate,systolic blood pressure,left ventricular ejection fraction and cardiac index of the patients were significantly improved after treatment(all P<0.05, respectively).Conclusion CBP is an important rescue therapy for patients with severe EV71-infected HFMD, which results in rapidly improving fever,cardiovascular function and stabling the levels of vasoactive mediators.

Dabigatran overdose: a case report of acute hepatitis. Extracorporeal treatment.

Dabigatran is an oral, direct thrombin inhibitor approved by international regulatory agencies for stroke prevention in patients with paroxysmal or persistent non-rheumatic atrial fibrillation (AF). The benefits of dabigatran are widely described, but its use in the geriatric population is not without risk. Chronic kidney disease is a common comorbidity with AF, and thus frequent checks of renal function in elderly patients are recommended. We report a case of dabigatran intoxication in an elderly man affected by heart failure and worsening renal function, who developed acute hepatitis and coma, which was successfully treated with continuous veno-venous hemodiafiltration. Although extracorporeal therapy has been suggested as a strategy for clearing dabigatran during acute bleeding, this approach may be useful in other dabigatran-related, life-threatening conditions, such as that described in this report.

Comparison of therapeutic effects between different blood purification therapies for treatment of patients with multiple organ dysfunction syndrome / 中国中西医结合急救杂志

Objective To compare the clinical therapeutic effects of continuous veno-venous hemofiltration (CVVH) and continuous veno-venous hemodiafiltration (CVVHDF) for treatment of patients with multiple organ dysfunction syndrome (MODS).Methods A prospective observation was conducted, seventy patients with MODS admitted to the Department of Critical Care Medicine of the Affiliated Hospital of Zunyi Medical College from September 2013 to December 2016 were enrolled, and they were divided into a CVVH group and a CVVHDF group according to different treatment, 35 cases in each group. In the CVVH group, the ultrafiltration fluid flow rate was set at 1800 mL/h, while in the CVVHDF group, the flow rate was set at 2000 mL/h for both substitution fluid and dialysate, and the blood flow of the two groups was 150-180 mL/min. The changes of creatinine (SCr), urea nitrogen (BUN), pH value, HCO3-, helper T cell (Th1, Th2) and Th1/Th2 ratio were compared between the two groups before and after treatment for 24, 48 and 72 hours.Results With the extension of time, SCr, BUN were reduced in both groups after treatment compared to those before treatment, 72 hoursafter treatment they reached the lowest value, and the degree of change in CVVHDF group was more significant than that in CVVH group [SCr (μmol/L): 150.62±32.09 vs. 180.41±30.52, BUN (mmol/L): 7.31±2.19 vs. 9.06±2.36. allP 0.05). With the extension of therapeutic time, Th1, Th1/Th2 in two groups were gradually elevated after treatment, and 72 hours after treatment they reached the peak values; Th2 showed a trend of gradual decrease and after 72 hours of treatment it reached the lowest value, and the changes in CVVHDF group were more significant than those in CVVH group [Th1 (×10-2): 1.51±0.12 vs. 1.21±0.11, Th2 (×10-2): 1.64±0.65 vs. 1.70±0.18, Th1/Th2: 0.91±0.14 vs. 0.71±0.15, allP < 0.05].Conclusion Both CVVH and CVVHDF can effectively remove inflammatory mediators and metabolic products, adjust the balance of acid and base, regulate immune system in the body of patients with MODS, and the CVVHDF is more effective than CVVH.

Nomenclature for renal replacement therapy and blood purification techniques in critically ill patients: practical applications.

This article reports the conclusions of the second part of a consensus expert conference on the nomenclature of renal replacement therapy (RRT) techniques currently utilized to manage acute kidney injury and other organ dysfunction syndromes in critically ill patients. A multidisciplinary approach was taken to achieve harmonization of definitions, components, techniques, and operations of the extracorporeal therapies. The article describes the RRT techniques in detail with the relevant technology, procedures, and phases of treatment and key aspects of volume management/fluid balance in critically ill patients. In addition, the article describes recent developments in other extracorporeal therapies, including therapeutic plasma exchange, multiple organ support therapy, liver support, lung support, and blood purification in sepsis. This is a consensus report on nomenclature harmonization in extracorporeal blood purification therapies, such as hemofiltration, plasma exchange, multiple organ support therapies, and blood purification in sepsis.

Plasma exchange combined continuous veno-venous hemo diafiltration in the treatment of critical hemolytic uremic syndrome / 中国小儿急救医学

Objective To investigta e the efficayc of bedside plasma exchange( PE) combined con-tinuous veno-venous hemodiafiltration ( CVVHDF ) in childer n with critical hemo lty ic uremic syndrome ( HUS) .Method s Eight patients with HUS from Pediatric Intensive Care Unit of Shanghai Ch ildren′s Hos-pitalw ere included in the present stuyd .The seveir ty of children was gar ded accordni g to peid atric critiac l ill-ness soc re and pediatric riks ofs core mortalityⅢ.Four of them received continuuo s blood purification treat-me nt.Meanwhile,the clinical manifestation and outcom e of HUS weer analyzed.Results Eight children with HUS weer ni itially trae ted with diuretic and blood transfusion for 12-24 hours.Four ac ses who deteriora-ted aggressively were ep rofr med PE and CVVHDF.Plasauto iQ21 and Prisma flex wereu sed with Pir sma TPE 2000 membrna e plasma separator and AN69 M60 membrane filter respectively.All the 4 patients with critical HUS survived after bedside continuous blood purification treatment.Clinical symptoms and serum bio-chemistry were improved sing ificantly as follows.The average levels of serum creatinine and lactate dehydro-genase decreased obviously(318μmol/L vs.162μmol/L;1 963 U/L vs.407 U/L,respectively).In addi-tion,platelet count increased significantly(40 ×109/L vs.97 ×109/L) .Eventually,symptoms disappeared in these 4 patients.Conclusion The combined therapy of PE and CVVHDF in HUS could stabilize fluid acid-base equilibrium,prevent hemolysis and improve the renal function.

Combined use of non-biological artificial liver treatments for patients with acute liver failure complicated by multiple organ dysfunction syndrome.

BACKGROUND: Acute liver failure (ALF) caused by viral and non-viral hepatitis is often accompanied with severe metabolic disorders, the accumulation of toxic substances and continuous release and accumulation of a large number of endogenous toxins and inflammatory mediators. The present study aimed to investigate the effects of various combined non-biological artificial liver treatments for patients with acute liver failure (ALF) complicated by multiple organ dysfunction syndrome (MODS). METHODS: Thirty-one patients with mid- or late-stage liver failure complicated by MODS (score 4) were randomly divided into three treatment groups: plasmapheresis (PE) combined with hemoperfusion (HP) and continuous venovenous hemodiafiltration (CVVHDF), PE+CVVHDF, and HP+CVVHDF, respectively. Heart rate (HR) before and after treatment, mean arterial pressure (MAP), respiratory index (PaO2/FiO2), hepatic function, platelet count, and blood coagulation were determined. RESULTS: Significant improvement was observed in HR, MAP, PaO2/FiO2, total bilirubin (TBIL) and alanine aminotransferase (ALT) levels after treatment (P<0.05). TBIL and ALT decreased more significantly after treatment in the PE+CVVHDF and PE+HP+CVVHDF groups (P<0.01). Prothrombin time (PT) and albumin were significantly improved only in the PE+CVVHDF and PE+HP+CVVHDF groups (P<0.05). TBIL decreased more significantly in the PE+HP+CVVHDF group than in the HP+CVVHDF and PE+CVVHDF groups (P<0.05). The survival rate of the patients was 58.1% (18/31), viral survival rate 36.4% (4/11), and non-viral survival rate 70% (14/20). CONCLUSION: Liver function was relatively improved after treatment, but PE+HP+CVVHDF was more efficient for the removal of toxic metabolites, especially bilirubin. The survival rate was significantly higher in the patients with non-viral liver failure than in those with viral liver failure.

Atenolol and amlodipine combination overdose managed with continuous venovenous hemodiafiltration: A case report.

We present a patient of who ingested large dose of of atenolol and amlodipine and was treated successfully with continuous venovenous hemodiafiltration. Early recognition of indications for renal support and early initiation of the same is the key to successful management.