When the earth trembles in the Americas: the experience of Haiti and Chile 2010.

The response of the nephrological community to the Haiti and Chile earthquakes which occurred in the first months of 2010 is described. In Haiti, renal support was organized by the Renal Disaster Relief Task Force (RDRTF) of the International Society of Nephrology (ISN) in close collaboration with Médecins Sans Frontières (MSF), and covered both patients with acute kidney injury (AKI) and patients with chronic kidney disease (CKD). The majority of AKI patients (19/27) suffered from crush syndrome and recovered their kidney function. The remaining 8 patients with AKI showed acute-to-chronic renal failure with very low recovery rates. The intervention of the RDRTF-ISN involved 25 volunteers of 9 nationalities, lasted exactly 2 months, and was characterized by major organizational difficulties and problems to create awareness among other rescue teams regarding the availability of dialysis possibilities. Part of the Haitian patients with AKI reached the Dominican Republic (DR) and received their therapy there. The nephrological community in the DR was able to cope with this extra patient load. In both Haiti and the DR, dialysis treatment was able to be prevented in at least 40 patients by screening and adequate fluid administration. Since laboratory facilities were destroyed in Port-au-Prince and were thus lacking during the first weeks of the intervention, the use from the very beginning on of a point-of-care device (i-STAT®) was very efficient for the detection of aberrant kidney function and electrolyte parameters. In Chile, nephrological problems were essentially related to difficulties delivering dialysis treatment to CKD patients, due to the damage to several units. This necessitated the reallocation of patients and the adaptation of their schedules. The problems could be handled by the local nephrologists. These observations illustrate that local and international preparedness might be life-saving if renal problems occur in earthquake circumstances.

Volume management by renal replacement therapy in acute kidney injury.

Management of fluid balance is one of the basic but vital tasks in the care of critically ill patients. Hypovolemia results in a decrease in cardiac output and tissue perfusion and may lead to progressive multiple organ dysfunction, including the development of acute renal injury (AKI). However, in an effort to reverse pre-renal oliguria, it is not uncommon for patients with established oliguric acute renal failure, particularly when associated with sepsis, to receive excessive fluid resuscitation, leading to fluid overload. In patients with established oliguria, renal replacement therapy may be required to treat hypervolemia. Safe prescription of fluid loss during RRT requires intimate knowledge of the patient's underlying condition, understanding of the process of ultrafiltration and close monitoring of the patient's cardiovascular response to fluid removal. To preserve tissue perfusion in patients with AKI, it is important that RRT be prescribed in a way that optimizes fluid balance by removing fluid without compromising the effective circulating fluid volume. In patients who are clinically fluid overloaded, it is equally important that the amount of fluid removed be as exact as possible. Fluid balance errors can occur as a result of inappropriate prescription, operator error or machine error. Some CRRT machines have potential for significant fluid errors if alarms can be overridden. Threshold values for fluid balance error have been developed which can be used to predict the severity of harm. It is important that RRT education programs emphasize the risk associated with fluid balance errors and with overriding machine alarms.

Patient and kidney survival by dialysis modality in critically ill patients with acute kidney injury.

Using a large, international cohort, we sought to determine the effect of initial technique of renal replacement therapy (RRT) on the outcome of acute renal failure (ARF) in the intensive care unit (ICU). We enrolled 1218 patients treated with continuous RRT (CRRT) or intermittent RRT (IRRT) for ARF in 54 ICUs in 23 countries. We obtained demographic, biochemical and clinical data and followed patients to either death or hospital discharge. Information was analyzed to assess the independent impact of treatment choice on survival and renal recovery. Patients treated first with CRRT (N=1006, 82.6%) required vasopressor drugs and mechanical ventilation more frequently compared to those receiving IRRT (N=212, 17.4%), (p<0.0001). Unadjusted hospital survival was lower (35.8% vs. 51.9%, p<0.0001). However, unadjusted dialysis-independence at hospital discharge was higher after CRRT (85.5% vs. 66.2%, p<0.0001). Multivariable logistic regression showed that choice of CRRT was not an independent predictor of hospital survival or dialysis-free hospital survival. However, the choice of CRRT was a predictor of dialysis independence at hospital discharge among survivors (OR: 3.333, 95% CI: 1.845 - 6.024, p<0.0001). Further adjustment using a propensity score did not significantly change these results. We conclude that worldwide, the choice of CRRT as initial therapy is not a predictor of hospital survival or dialysis-free hospital survival but is an independent predictor of renal recovery among survivors.

Use of the subcutaneous route of administration of morphine in the intensive care unit.

Subcutaneous morphine was administered to 13 consecutive patients admitted to an intensive care unit. Intermittent injections via a butterfly needle and via continuous infusion were used in 11 and 2 cases, respectively. The mean daily dose of morphine and mean duration of treatment were 108 +/- 128mg and 5 +/- 4 days, respectively. Only 3 episodes of local irritation were detected in 60 patient days. We conclude that the subcutaneous route is safe and effective for patients receiving morphine in the intensive care unit setting, and it allows for continuation of treatment when patients are discharged to the general hospital wards.

When the earth trembles in the Americas: The experience of Haiti and Chile 2010

Ce document décrit les caractéristiques, les problèmes, les réussites et les leçons de l'intervention en Haïti suite au séisme de janvier 2010 du Renal Disaster Relief Task Force (RDRTF) de la Société Internationale de Néphrologie (ISN), ainsi que les conséquences néphrologiques du tremblement de terre chilien. Le RDRTF-ISN offre un soutien néphrologique en cas de grandes catastrophes, telles que les forts tremblements de terre pour lesquels un grand nombre de patients développent des lésions rénales aiguës (Acute Kidney Injury - AKI). Toutes les interventions sont intégrées dans les activités médicales de Médecins Sans Frontières (MSF - Médecins sans frontières). En Haïti la réponse a couvert tant les patients souffrant de lésions rénales aiguës que ceux atteints de maladies rénales chroniques. Au Chili les problèmes néphrologiques étaient essentiellement liés aux difficultés d'assurer la dialyse aux patients souffrant de conditions chroniques à cause de la destruction de plusieurs unités de dialyse.