Reliable fluid-mechanical characterization of haemofilters: Addressing the deficiencies of current standards and practices.

Facile methods for accurate fluid-mechanical characterization of haemofilters (HF) are indispensable for haemofiltration process improvements, equipment design/optimization, and reliable module specifications. Currently employed methods, implemented through specific experimental in vitro protocols, are assessed herein in detail, considering the conditions prevailing during haemofiltration. Minimum number of key parameters required to fully describe the common countercurrent flow field, in the HF active section, include membrane permeance K and friction coefficients in lumen and shell side (ff and fs ). It is shown that the countercurrent flow mode itself is incapable of yielding these parameters, based on externally measured flow rates and pressures. Similarly, the relevant ISO protocol is deficient as it can only provide rough underpredictions of permeance K. The causes of such inherent deficiencies of current standards and practices are analyzed. In contrast, a recently developed methodology, accounting for the (heretofore ignored) pressure drop in module headers and combining a mechanistic theoretical model with experimental data from 2 special haemofilter operating modes, yields an accurate determination of the key parameters (K, ff , fs ). Additionally, it permits a full description of flow field for Newtonian liquids, for both constant and axially varying viscosity in fiber-lumen due to the transmembrane flux. Development of new reliable standards is suggested, facilitated by the insights gained in this work.

Targeted high volume hemofiltration could avoid extracorporeal membrane oxygenation in some patients with severe Hantavirus cardiopulmonary syndrome.

BACKGROUND: Hantavirus cardiopulmonary syndrome (HCPS) has a high lethality. Severe cases may be rescued by venoarterial extracorporeal membrane oxygenation (VA ECMO), alongside substantial complications. High volume hemofiltration (HVHF) is a depurative technique that provides homeostatic balance allowing hemodynamic stabilization in some critically ill patients. METHODS: We implemented HVHF before VA ECMO consideration in the last five severe HCPS patients requiring mechanical ventilation and vasoactive drugs admitted to our intensive care unit. Patients were considered HVHF-responders if VA ECMO was avoided and HVHF-nonresponders if VA ECMO support was needed despite HVHF. A targeted-HVHF strategy compounded by aggressive hyperoncotic albumin, sodium bicarbonate, and calcium supplementation plus ultrafiltration to avoid fluid overload was implemented on three patients. RESULTS: Patients had maximum serum lactate of 8.8 (8.7-12.8) mmol/L and a lowest cardiac index of 1.8 (1.8-1.9) L/min/m2 . The first two required VA ECMO. They were connected later to HVHF, displayed progressive tachycardia and declining stroke volume. The opposite was true for HVHF-responders who received targeted-HVHF. All patients survived, but one of the VA ECMO patients suffered a vascular complication. CONCLUSION: HVHF may contribute to support severe HCPS patients avoiding the need for VA ECMO in some. Early connection and targeted-HVHF may increase the chance of success.

Contemporary Management of Severe Acute Kidney Injury and Refractory Cardiorenal Syndrome: JACC Council Perspectives.

Acute kidney injury (AKI) and cardiorenal syndrome (CRS) are increasingly prevalent in hospitalized patients with cardiovascular disease and remain associated with poor short- and long-term outcomes. There are no specific therapies to reduce mortality related to either AKI or CRS, apart from supportive care and volume status management. Acute renal replacement therapies (RRTs), including ultrafiltration, intermittent hemodialysis, and continuous RRT are used to manage complications of medically refractory AKI and CRS and may restore normal electrolyte, acid-base, and fluid balance before renal recovery. Patients who require acute RRT have a significant risk of mortality and long-term dialysis dependence, emphasizing the importance of appropriate patient selection. Despite the growing use of RRT in the cardiac intensive care unit, there are few resources for the cardiovascular specialist that integrate the epidemiology, diagnostic workup, and medical management of AKI and CRS with an overview of indications, multidisciplinary team management, and transition off of RRT.

Use of Fluoride as a Marker Solute to Quantify the Current Effective Delivered Dose in Continuous Renal Replacement Therapy: An "in vitro" Study.

BACKGROUND: The current effective delivered dose is a quality indicator for continuous renal replacement therapy. Its periodic assessment might enable physicians to deliver personalised treatments. Yet, its quantification as by extracorporeal urea clearance (Cl) is cumbersome and thus often neglected in routine practice. The aim of this in vitro study is to demonstrate the non-inferior effectiveness of assessing the current effective delivered dose using a simpler, cheaper and faster approach based on measurement of fluoride rather than urea extracorporeal Cl. METHODS: We compared urea and fluoride removal in 3 post-dilution continuous veno-venous haemofiltration (CVVH) and 3 continuous veno-venous haemodialysis (CVVHD) in vitro experimental models. Experiments ran for 180 min, using 3 L of human blood, heparin anticoagulation and a machine dose of 30 mL/kg/h. Urea and fluoride were measured in the inflow, outflow and effluent lines to compare sieving coefficients (SC), saturation coefficients (SA) and transmembrane Cls. RESULTS: In CVVH, the median SC values were 1.06 (1.02-1.07) and 1.02 (1.01-1.04) for fluoride and urea, respectively (discrepancy of 4.3%), while transmembrane convective Cls were 31.28 (30.01-31.31) mL/kg/h and 30.30 (29-31.85) mL/kg/h (discrepancy of 3.13%), respectively. In CVVHD, the median SA values were 1.01 (0.96-1.02) and 1 (0.95-1.01) for fluoride and urea, respectively (discrepancy of 1.6%), while transmembrane dialytic Cls were 30.26 (29.52-31.32) mL/kg/h and 31.16 (30-31.75) mL/kg/h (discrepancy of -2.97%), respectively. CONCLUSION: Fluoride transmembrane removal was close to that observed with urea, in terms of SC, SA and transmembrane Cl. Fluoride seems as much accurate as urea in assessing the current effective delivered dose during both CVVH and CVVHD and might therefore be adopted for dose measurement. Besides accuracy, fluoride bedside assessment could present many advantages over urea, particularly in terms of availability, costs, time requirement and rapidity of assessment.

Cytokine clearance with CytoSorb® during cardiac surgery: a pilot randomized controlled trial.

BACKGROUND: Cardiopulmonary bypass (CPB) is often associated with degrees of complex inflammatory response mediated by various cytokines. This response can, in severe cases, lead to systemic hypotension and organ dysfunction. Cytokine removal might therefore improve outcomes of patients undergoing cardiac surgery. CytoSorb® (Cytosorbents, NJ, USA) is a recent device designed to remove cytokine from the blood using haemoadsorption (HA). This trial aims to evaluate the potential of CytoSorb® to decrease peri-operative cytokine levels in cardiac surgery. METHODS: We have conducted a single-centre pilot randomized controlled trial in 30 patients undergoing elective cardiac surgery and deemed at risk of complications. Patients were randomly allocated to either standard of care (n = 15) or CytoSorb® HA (n = 15) during cardiopulmonary bypass (CPB). Our primary outcome was the difference between the two groups in cytokines levels (IL-1a, IL-1b, IL-2, IL-4, IL-5, IL-6, IL-10, TNF-α, IFN-γ, MCP-1) measured at anaesthesia induction, at the end of CPB, as well as 6 and 24 h post-CPB initiation. In a consecutive subgroup of patients (10 in HA group, 11 in control group), we performed cross-adsorber as well as serial measurements of coagulation factors' activity (antithrombin, von Willebrand factor, factor II, V, VIII, IX, XI, and XII). RESULTS: Both groups were similar in terms of baseline and peri-operative characteristics. CytoSorb® HA during CPB was not associated with an increased incidence of adverse event. The procedure did not result in significant coagulation factors' adsorption but only some signs of coagulation activation. However, the intervention was associated neither with a decrease in pro- or anti-inflammatory cytokine levels nor with any improvement in relevant clinical outcomes. CONCLUSIONS: CytoSorb® HA during CPB was not associated with a decrease in pro- or anti-inflammatory cytokines nor with an improvement in relevant clinical outcomes. The procedure was feasible and safe. Further studies should evaluate the efficacy of CytoSorb® HA in other clinical contexts. TRIAL REGISTRATION: ClinicalTrials.gov NCT02775123 . Registered 17 May 2016.

Early application of continuous high-volume haemofiltration can reduce sepsis and improve the prognosis of patients with severe burns.

BACKGROUND: In the early stage of severe burn, patients often exhibit a high level of inflammatory mediators in blood and are likely to develop sepsis. High-volume haemofiltration (HVHF) can eliminate these inflammatory mediators. We hypothesised that early application of HVHF may be beneficial in reducing sepsis and improving the prognosis of patients with severe burns. METHODS: Adults patients with burns ≥ 50% total burn surface area (TBSA) and in whom the sum of deep partial and full-thickness burn areas was ≥ 30% were enrolled in this randomised prospective study, and they were divided into control (41 cases) and HVHF (41 cases) groups. Patients in the control group received standard management for major burns, whereas the HVHF group additionally received HVHF treatment (65 ml/kg/h for 3 consecutive days) within 3 days after burn. The incidence of sepsis and mortality, some laboratory data, levels of inflammatory cytokines in the blood, HLA-DR expression on CD14+ peripheral blood monocytes, the proportion of CD25+Foxp3+ in CD4+ T lymphocytes, and the counts of CD3+, CD4+ and CD8+ T lymphocytes were recorded within 28 days post-burn. RESULTS: The incidence of sepsis, septic shock and duration of vasopressor treatment were decreased significantly in the HVHF group. In addition, in the subgroup of patients with burns ≥ 80% TBSA, the 90-day mortality showed significant decreases in the HVHF group. The ratio of arterial oxygen partial pressure to the fraction of inspiration oxygen was improved after HVHF treatment. In the patients who received HVHF treatment, the blood levels of inflammatory cytokines, including tumour necrosis factor-α, interleukin (IL)-1ß, IL-6 and IL-8, as well as the blood level of procalcitonin were found to be lower than in the control group. Moreover, higher HLA-DR expression on CD14+ monocytes and a lower proportion of CD25+Foxp3+ in CD4+ T lymphocytes were observed in the patients in the HVHF group. CONCLUSIONS: Early application of HVHF benefits patients with severe burns, especially for those with a greater burn area (≥ 80% TBSA), decreasing the incidence of sepsis and mortality. This effect may be attributed to its early clearance of inflammatory mediators and the recovery of the patient's immune status. TRIAL REGISTRATION: Chinese Clinical Trial Register, ChiCTR-TRC-12002616 . Registered on 24 October 2012.

Guía de práctica clínica para la adecuación de hemodiálisis: guía en versión extensa / Clinical practice guide for the adequacy of hemodialysis: guide in extended version

Este documento abarca la adecuación de hemodiálisis.

High-volume hemofiltration in adult burn patients with septic shock and acute kidney injury: a multicenter randomized controlled trial.

BACKGROUND: Sepsis and septic shock occur commonly in severe burns. Acute kidney injury (AKI) is also common and often results as a consequence of sepsis. Mortality is unacceptably high in burn patients who develop AKI requiring renal replacement therapy and is presumed to be even higher when combined with septic shock. We hypothesized that high-volume hemofiltration (HVHF) as a blood purification technique would be beneficial in this population. METHODS: We conducted a multicenter, prospective, randomized, controlled clinical trial to evaluate the impact of HVHF on the hemodynamic profile of burn patients with septic shock and AKI involving seven burn centers in the United States. Subjects randomized to the HVHF were prescribed a dose of 70 ml/kg/hour for 48 hours while control subjects were managed in standard fashion in accordance with local practices. RESULTS: During a 4-year period, a total of nine subjects were enrolled for the intervention during the ramp-in phase and 28 subjects were randomized, 14 each into the control and HVHF arms respectively. The study was terminated due to slow enrollment. Ramp-in subjects were included along with those randomized in the final analysis. Our primary endpoint, the vasopressor dependency index, decreased significantly at 48 hours compared to baseline in the HVHF group (p = 0.007) while it remained no different in the control arm. At 14 days, the multiple organ dysfunction syndrome score decreased significantly in the HVHF group when compared to the day of treatment initiation (p = 0.02). No changes in inflammatory markers were detected during the 48-hour intervention period. No significant difference in survival was detected. No differences in adverse events were noted between the groups. CONCLUSIONS: HVHF was effective in reversing shock and improving organ function in burn patients with septic shock and AKI, and appears safe. Whether reversal of shock in these patients can improve survival is yet to be determined. TRIAL REGISTRATION: Clinicaltrials.gov NCT01213914 . Registered 30 September 2010.

Evidence of altered haemostasis in an ovine model of venovenous extracorporeal membrane oxygenation support.

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) is a life-saving modality used in the management of cardiopulmonary failure that is refractory to conventional medical and surgical therapies. The major problems clinicians face are bleeding and clotting, which can occur simultaneously. To discern the impact of pulmonary injury and ECMO on the host's haemostatic response, we developed an ovine model of smoke-induced acute lung injury (S-ALI) and ECMO. The aims of this study were to determine if the ECMO circuit itself altered haemostasis and if this was augmented in a host with pulmonary injury. METHODS: Twenty-seven South African meat merino/Border Leicester Cross ewes underwent instrumentation. Animals received either sham injury (n = 12) or S-ALI (n = 15). Control animal groups consisted of healthy controls (ventilation only for 24 h) (n = 4), ECMO controls (ECMO only for 24 h) (n = 8) and S-ALI controls (S-ALI but no ECMO for 24 h) (n = 7). The test group comprised S-ALI sheep placed on ECMO (S-ALI + ECMO for 24 h) (n = 8). Serial blood samples were taken for rotational thromboelastometry, platelet aggregometry and routine coagulation laboratory tests. Animals were continuously monitored for haemodynamic, fluid and electrolyte balances and temperature. Pressure-controlled intermittent mandatory ventilation was used, and mean arterial pressure was augmented by protocolised use of pressors, inotropes and balanced fluid resuscitation to maintain mean arterial pressure >65 mmHg. RESULTS: Rotational thromboelastometry, platelet aggregometry and routine coagulation laboratory tests demonstrated that S-ALI and ECMO independently induced changes to platelet function, delayed clot formation and reduced clot firmness. This effect was augmented with the combination of S-ALI and ECMO, with evidence of increased collagen-induced platelet aggregation as well as changes in factor VIII (FVIII), factor XII and fibrinogen levels. CONCLUSIONS: The introduction of an ECMO circuit itself increases collagen-induced platelet aggregation, decreases FVIII and von Willebrand factor, and induces a transient decrease in fibrinogen levels and function in the first 24 h. These changes to haemostasis are amplified when a host with a pre-existing pulmonary injury is placed on ECMO. Because patients are often on ECMO for extended periods, longer-duration studies are required to characterise ECMO-induced haemostatic changes over the long term. The utility of point-of-care tests for guiding haemostatic management during ECMO also warrants further exploration.

Hemoadsorption by CytoSorb in septic patients: a case series.

BACKGROUND: Septic shock, defined as life-threatening organ dysfunction caused by a dysregulated host response to infection, is a highly lethal condition that causes substantial morbidity and mortality among critically ill patients. One of the hallmarks of sepsis is the excessive release of cytokines and other inflammatory mediators causing refractory hypotension, tissue damage, metabolic acidosis and ultimately multiple organ failure. In this context, cytokine reduction by hemoadsorption represents a new concept for blood purification, developed to attenuate the overwhelming systemic levels of pro-inflammatory and anti-inflammatory mediators released in the early phase of sepsis. METHODS: In the present case series, we evaluated the impact of a new hemoadsorption device (CytoSorb) used as adjunctive therapy, on hemodynamics and clinically relevant outcome parameters in 26 critically ill patients with septic shock and in need of renal replacement therapy. RESULTS: We found that treatment of these patients with septic shock was associated with hemodynamic stabilization and a reduction in blood lactate levels. Actual mortality in the overall patient population was lower than mortality predicted by acute physiology and chronic health evaluation II (APACHE II). These effects seem to be more pronounced in patients in whom therapy started within 24 h of sepsis diagnosis, whereas a delay in the start of therapy was associated with a poor response to therapy in terms of reduction of catecholamine demand and survival. Moreover, from our patient population, medical patients seemed to benefit more than post-surgical patients in terms of survival. Treatment using the CytoSorb device was safe and well-tolerated with no device-related adverse events during or after the treatment sessions. CONCLUSION: Hemoadsorption using CytoSorb resulted in rapid hemodynamic stabilization and increased survival, particularly in patients in whom therapy was started early. Given the positive clinical experience of this case series, randomized controlled trials are urgently needed to define the potential benefits of this new treatment option.

Non-antibiotic treatments for bacterial diseases in an era of progressive antibiotic resistance.

The emergence of multi-drug resistant (MDR) microbial pathogens threatens the very foundation upon which standard antibacterial chemotherapy is based. We must consider non-antibiotic solutions to manage invasive bacterial infections. Transition from antibiotics to non-traditional treatments poses real clinical challenges that will not be easy to solve. Antibiotics will continue to reliably treat some infections (e.g., group A streptococci and Treponema pallidum) but will likely need adjuvant therapies or will need to be replaced for many bacterial infections in the future.

KDOQI clinical practice guideline for hemodialysis adequacy: 2015 update

The National Kidney Foundation's Kidney Disease Outcomes Quality Initiative (KDOQI) has provided evidence-based guidelines for all stages of chronic kidney disease (CKD) and related complications since 1997. The 2015 update of the KDOQI Clinical Practice Guideline for Hemodialysis Adequacy is intended to assist practitioners caring for patients in preparation for and during hemodialysis. The literature reviewed for this update includes clinical trials and observational studies published between 2000 and March 2014. New topics include high-frequency hemodialysis and risks; prescription flexibility in initiation timing, frequency, duration, and ultrafiltration rate; and more emphasis on volume and blood pressure control. Appraisal of the quality of the evidence and the strength of recommendations followed the Grading of Recommendation Assessment, Development, and Evaluation (GRADE) approach. Limitations of the evidence are discussed and specific suggestions are provided for future research.(AU)

Nursing essential principles: continuous renal replacement therapy.

AIMS: This article aims to guide critical care nurses with the care and management of patients on continuous renal replacement therapy (CRRT). BACKGROUND: CRRT, a highly specialized therapy involving complex nursing care, is used widely in the intensive care unit to treat patients with acute kidney injury. METHODS: A literature search was conducted using CINAHL, Medline from PubMed and BNI using the search terms CRRT or continuous veno-venous haemofiltration and nursing or nurses from 2000 onwards and limited to the English language. The appraised evidence and expert opinion is used in this article. RESULTS: Four essential nursing principles for CRRT are reviewed (1) the importance of continuous assessment of the indications to influence the appropriate mode; (2) ensuring good vascular access; (3) the avoidance of unnecessary interruptions and (4) the prevention of complications. CONCLUSION: The identified four essential nursing principles provide guidance on this complex aspects of nursing practice. Specific nursing research to guide the care and management of this therapy is limited so should be explored in the future. RELEVANCE TO CLINICAL PRACTICE: Critical care nurses caring for and managing patients on CRRT require an understanding of how to deliver safe CRRT.

High cut-off hemofiltration versus standard hemofiltration: a pilot assessment of effects on indices of apoptosis.

OBJECTIVES: To measure plasma pro-apoptotic and pro-necrotic activity in severe acute kidney injury (AKI) patients within a randomized controlled trial of continuous veno-venous hemofiltration with high cut-off filters (CVVH-HCO) versus standard filters (CVVH-Std). METHODS: We measured pro-apoptotic and pro-necrotic plasma activity by trypan blue exclusion cell viability assay, detection of DNA fragmentation, and by determination of caspase-3 activity and annexin V-based apoptosis and necrosis detection assay. RESULTS: Compared to no apoptosis or necrosis after incubation with healthy plasma, 14-18% of cells showed apoptosis and 4-8% showed necrosis after incubation with plasma from AKI patients. When comparing different measures of pro-apoptotic or pro-necrotic activity, CVVH-HCO and CVVH-Std showed no differential effects on such activity, which remained high over the first 3 days of treatment. However, using annexin V-FITC, there was a significant drop in pro-apoptotic activity across the filter for the CVVH-HCO group (p = 0.043) but not for the CVVH-Std group (p = 0.327) and a significant difference between the two groups (CVVH-HCO vs. CVVH-Std p = 0.006). CONCLUSIONS: Patients with severe AKI have increased pro-apoptotic and pro-necrotic activity. Although on single-pass effect assessment, CVVH-HCO was superior to CVVH-Std in decreasing annexin V-FITC-assessed pro-apoptotic activity, there was no overall attenuation of such activity during the first 3 days of treatment.

Effects of the volume of processed plasma on the outcome, arterial pressure and blood procalcitonin levels in patients with severe sepsis and septic shock treated with coupled plasma filtration and adsorption.

AIMS: To understand how coupled plasma filtration and adsorption (CPFA) could influence the time course of the advanced stages of sepsis, mean arterial pressure (MAP) and norepinephrine dosage. METHODS: Patients with severe sepsis and septic shock with ≥2 organ failures not responding to volume resuscitation and vasopressor infusion were treated with CPFA within 8 h of admission to the intensive care unit. RESULTS: Thirty-nine patients were treated (median age: 63 years, median SAPS II score: 45) and 28 survived advanced sepsis. In the latter, the median MAP increased and the norepinephrine dosage decreased significantly after CPFA, whereas in the nonsurvivors these values did not change significantly. The volume of treated plasma was significantly higher in survivors than nonsurvivors. CONCLUSION: These results suggest a possible existence of a dose-response effect for CPFA. Future studies are therefore recommended to evaluate the efficacy of this treatment and to determine its best timing and intensity.

The hemodynamic effects during sustained low-efficiency dialysis versus continuous veno-venous hemofiltration for uremic patients with brain hemorrhage: a crossover study.

OBJECT: Hemodynamic instability occurs frequently during dialysis treatment and remains a significant cause of patient morbidity and mortality, especially in patients with brain hemorrhage. This study aims to compare the effects of hemodynamic parameters and intracranial pressure (ICP) between sustained low-efficiency dialysis (SLED) and continuous veno-venous hemofiltration (CVVH) in dialysis patients with brain hemorrhage. METHODS: End-stage renal disease (ESRD) patients with brain hemorrhage undergoing ICP monitoring were enrolled. Patients were randomized to receive CVVH or SLED on the 1st day and were changed to the other modality on the 2nd day. The ultrafiltration rate was set at between 1.0 kg/8 hrs and 1.5 kg/8 hrs according to the patient's fluid status. The primary study end point was the change in hemodynamics and ICP during the dialytic periods. The secondary end point was the difference between cardiovascular peptides and oxidative and inflammatory assays. RESULTS: Ten patients (6 women; mean age 59.9 ± 3.6 years) were analyzed. The stroke volume variation was higher with SLED than CVVH (generalized estimating equations method, p = 0.031). The ICP level increased after both SLED and CVVH (time effect, p = 0.003) without significant difference between modalities. The dialysis dose quantification after 8-hour dialysis was higher in SLED than CVVH (equivalent urea clearance by convection, 62.7 ± 4.4 vs 50.2 ± 3.9 ml/min; p = 0.002). Additionally, the endothelin-1 level increased after CVVH treatment (p = 0.019) but not SLED therapy. CONCLUSIONS: With this controlled crossover study, the authors provide the pilot evidence that both SLED and CVVH display identical acute hemodynamic effects and increased ICP after dialysis in brain hemorrhage patients. CLINICAL TRIAL REGISTRATION NO.: NCT01781585 (ClinicalTrials.gov).

Pediatric sepsis: challenges and adjunctive therapies.

Sepsis remains an important challenge in pediatric critical care medicine. This review provides an appraisal of adjunctive therapies for sepsis and highlights opportunities for meeting selected challenges in the field. Future clinical studies should address long-term and functional outcomes as well as acute outcomes. Potential adjunctive therapies such as corticosteroids, hemofiltration, hemoadsorption, and plasmapheresis may have important roles, but still require formal and more rigorous testing by way of clinical trials. Finally, the design of future clinical trials should consider novel approaches for stratifying outcome risks as a means of improving the risk-to-benefit ratio of experimental therapies.

Detección de riesgos para la seguridad del paciente en la implementación de técnicas continuas de depuración extracorpórea / Detection of risks for the safety of the patients in the implementation of continuous techniques of extracorporeal depuration (CTED)

IntroducciónLas técnicas de depuración extracorpórea (TCDE) gestionan elevados volúmenes de intercambio de fluidos y precisa control exhaustivo de su seguridad.ObjetivoDetectar riesgos en TCDE y determinar su frecuencia por paciente.Material y métodoEstudio observacional retrospectivo. Criterios de inclusión: pacientes ingresados desde enero a diciembre de 2009 con TCDE en la Unidad de Cuidados Intensivos (UCI) Polivalente del Hospital 12 de Octubre. Identificamos previamente diez riesgos detectables en historias clínicas. Analizamos variables demográficas y del tratamiento. Las variables cuantitativas se expresan como media±desviación estándar y cualitativas, como frecuencias absolutas y relativas. Análisis: SPSS 15.0®.ResultadosSe incluyó a 54 pacientes (11,7%) con media de edad de 59,78±14,8 años; 42 (77,8%) eran varones. En el 81,4% la indicación fue fracaso renal agudo. Se trató al 80,3% con hemodiafiltración. La media de TCDE fue de 112,9±139,9 h, con una mediana [intervalo intercuartílico] de 2 [0-31] filtros por paciente. La frecuencia de riesgo/paciente fue: el 100% de los pacientes sin monitorización de Mg y P, y el 3,7% (n=2) urea; en 16 (29,6%) se produjo coagulación del circuito antes de 24 h y en 25 (46,3%) no se pudo devolver sangre; en 14 (29,3%) faltaba siempre pauta escrita en la orden de tratamiento; en gráfica del paciente no se reflejó las dosis en 2 (3,7%); en 3 pacientes (5,6%) con coagulopatía se pautó anticoagulante en el circuito; en 1 (1,9%) se evidenció sangrado y en 10 (18,5%), hipotermia leve (35-32°C).ConclusionesSe precisa monitorización protocolizada de Mg y P. Se debe pautar la terapia en el tratamiento médico. Se precisa optimizar la técnica para prolongar su duración y evitar pérdidas hemáticas (AU)

IntroductionContinuous techniques of extracorporeal depuration (CTED) manage high volumes of fluid exchange and extensive control of its safety is required.ObjectiveTo detect the risks of CTED and to determine its frequency per patient.Material and methodsAn observational, retrospective study was performed. Inclusion criteria were patients admitted from January 2009 to December 2009, with CTED in the Polyvalent Intensive Care Unit (ICU) of the Hospital 12 de Octubre. We previously identified 10 risks that were detectable in the clinical records. We analyzed demographic and treatment variables. The quantitative variables were expressed as mean±SD and the qualitative ones as absolute and relative frequencies. Analysis: SPSS 15.0®.ResultsA total of 54 patients (11.7%), with ages 59.78±14.8, 42 men (77.8%) were included. In 81.4%, the indication was acute kidney failure; 80.3% were treated with hemodiafiltration. Mean hours of CTED were 112.9±139.9 and the medium of 2 filters per patient (recommended intakes 0-31). Risk/patient rate was: 100% of patients without monitoring of the Mg and P, and 3.7% (n=2) urea; in 16 (29.6%), there was coagulation of the circuit prior to 24hours and in 25 (46.3%) the blood could not be returned; in 14 (29.3%), written regime was always lacking on the order for treatment. The dose was not reflected on the patient's chart in 2 (3.7%); in 3 patients (5.6%) with coagulation disorder, anticoagulants were prescribed in the circuit. In 1 (1.9%) bleeding was observed and in 10 (18.5%) there was mild hypothermia (35-32°C).ConclusionsA standardized monitoring of the Mg and P is required. The therapy should be prescribed in the medical treatment. The technique needs to be improved in order to prolong its duration and avoid blood losses (AU)

[Detection of risks for the safety of the patients in the implementation of continuous techniques of extracorporeal depuration (CTED)]. / Detección de riesgos para la seguridad del paciente en la implementación de técnicas continuas de depuración extracorpórea.

INTRODUCTION: Continuous techniques of extracorporeal depuration (CTED) manage high volumes of fluid exchange and extensive control of its safety is required. OBJECTIVE: To detect the risks of CTED and to determine its frequency per patient. MATERIAL AND METHODS: An observational, retrospective study was performed. Inclusion criteria were patients admitted from January 2009 to December 2009, with CTED in the Polyvalent Intensive Care Unit (ICU) of the Hospital 12 de Octubre. We previously identified 10 risks that were detectable in the clinical records. We analyzed demographic and treatment variables. The quantitative variables were expressed as mean±SD and the qualitative ones as absolute and relative frequencies. ANALYSIS: SPSS 15.0(®). RESULTS: A total of 54 patients (11.7%), with ages 59.78±14.8, 42 men (77.8%) were included. In 81.4%, the indication was acute kidney failure; 80.3% were treated with hemodiafiltration. Mean hours of CTED were 112.9±139.9 and the medium of 2 filters per patient (recommended intakes 0-31). Risk/patient rate was: 100% of patients without monitoring of the Mg and P, and 3.7% (n=2) urea; in 16 (29.6%), there was coagulation of the circuit prior to 24 hours and in 25 (46.3%) the blood could not be returned; in 14 (29.3%), written regime was always lacking on the order for treatment. The dose was not reflected on the patient's chart in 2 (3.7%); in 3 patients (5.6%) with coagulation disorder, anticoagulants were prescribed in the circuit. In 1 (1.9%) bleeding was observed and in 10 (18.5%) there was mild hypothermia (35-32°C). CONCLUSIONS: A standardized monitoring of the Mg and P is required. The therapy should be prescribed in the medical treatment. The technique needs to be improved in order to prolong its duration and avoid blood losses.