Background Extracorporeal blood-purification techniques are frequently needed in the pediatric intensive care unit (PICU), yet data on their clinical application are lacking. This study aims to review the indications, rate of application, clinical characteristics, complications, and outcomes of patients undergoing extracorporeal blood purification (i.e., by continuous renal replacement therapy [CRRT] or therapeutic plasma exchange [TPE]) in our PICU, including before the coronavirus disease 2019 (COVID-19) pandemic in 2019 and during the pandemic from 2020 to 2022. Methods: This study included children admitted for extracorporeal blood-purification therapy in the PICU. The indications for TPE were analyzed and compared to the American Society for Apheresis categories. Results: In 82 children, 380 TPE sessions and 37 CRRT sessions were carried out children, with 65 patients (79%) receiving TPE, 17 (20.7%) receiving CRRT, and four (4.8%) receiving both therapies. The most common indications for TPE were neurological diseases (39/82, 47.5%), followed by hematological diseases (18/82, 21.9%). CRRT was mainly performed for patients suffering from acute kidney injury. Patients with neurological diseases received the greatest number of TPE sessions (295, 77.6%). Also, the year 2022 contained the greatest number of patients receiving extracorporeal blood-purification therapy (either CRRT or TPE). Conclusions: The use of extracorporeal blood-purification techniques increased from 2019 through 2022 due to mainly autoimmune dysregulation among affected patients. TPE can be safely used in an experienced PICU. No serious adverse events were observed in the patients that received TPE, and overall survival over the 4 years was 86.5%.
Background Polytrauma from road accidents is a common cause of hospital admissions and deaths, frequently leading to acute kidney injury (AKI) and impacting patient outcomes. Methods: This retrospective, single-center study included polytrauma victims with an Injury Severity Score (ISS) >25 at a tertiary healthcare center in Dubai. Results: The incidence of AKI in polytrauma victims is 30.5%, associated with higher Carlson comorbidity index (P=0.021) and ISS (P=0.001). Logistic regression shows a significant relationship between ISS and AKI (odds ratio [OR], 1.191; 95% confidence interval [CI], 1.150–1.233; P<0.05). The main causes of trauma-induced AKI are hemorrhagic shock (P=0.001), need for massive transfusion (P<0.001), rhabdomyolysis (P=0.001), and abdominal compartment syndrome (ACS; P<0.001). On multivariate logistic regression AKI can be predicated by higher ISS (OR, 1.08; 95% CI, 1.00–1.17; P=0.05) and low mixed venous oxygen saturation (OR, 1.13; 95% CI, 1.05–1.22; P<0.001). The development of AKI after polytrauma increases length of stay (LOS)-hospital (P=0.006), LOS-intensive care unit (ICU; P=0.003), need for mechanical ventilation (MV) (P<0.001), ventilator days (P=0.001), and mortality (P<0.001). Conclusions: After polytrauma, the occurrence of AKI leads to prolonged hospital and ICU stays, increased need for mechanical ventilation, more ventilator days, and a higher mortality rate. AKI could significantly impact their prognosis.
Background The transition of dialysis modalities from continuous renal replacement therapy (CRRT) to intermittent hemodialysis (iHD) is frequently conducted during the recovery phase of critically ill patients with acute kidney injury. Herein, we addressed the occurrence of intradialytic hypotension (IDH) after this transition, and its association with the mortality risk. Methods: A total of 541 patients with acute kidney injury who attempted to transition from CRRT to iHD at Seoul National University Hospital, Korea from 2010 to 2020 were retrospectively collected. IDH was defined as a discontinuation of dialysis because of hemodynamic instability plus a nadir systolic blood pressure <90 mm Hg or a decrease in systolic blood pressure ≥30 mm Hg during the first session of iHD. Odds ratios (ORs) of outcomes, such as in-hospital mortality and weaning from RRT, were measured using a logistic regression model after adjusting for multiple variables. Results: IDH occurred in 197 patients (36%), and their mortality rate (44%) was higher than that of those without IDH (19%; OR, 2.64; 95% confidence interval [CI], 1.70–4.08). For patients exhibiting IDH, the iHD sessions delayed successful weaning from RRT (OR, 0.62; 95% CI, 0.43–0.90) compared with sessions on those without IDH. Factors such as low blood pressure, high pulse rate, low urine output, use of mechanical ventilations and vasopressors, and hypoalbuminemia were associated with IDH risk. Conclusions: IDH occurrence following the transition from CRRT to iHD is associated with high mortality and delayed weaning from RRT.
Extracorporeal removal of organophosphate from blood has been proposed, but the efficacy of hemodialysis and hemoperfusion has not been established. We report a case of organophosphate poisoning in which continuous renal replacement therapy (CRRT) was applied with conventional indications and was found to increase plasma cholinesterase levels by hemodiafiltration. A 73-year-old male was found unconscious at home and was brought to the emergency department by ambulance. An empty bottle of Supracide insecticide, of which the active ingredient is methidathion, was found beside him. CRRT was initiated because he showed signs of oliguria and acidosis with an unstable hemodynamic condition. Although his condition improved temporarily after CRRT initiation, it subsequently deteriorated, and he died despite maximal supportive effort. His prefilter plasma cholinesterase levels remained at <200 U/L for 3 days, while his postfilter levels were 358 U/L 1 hour after CRRT initiation and they were 689 U/L 18 hours later. Our case suggests that CRRT might play a role in treating organophosphate poisoning by possibly eliminating organophosphate.
Background Fluid overload prior to continuous renal replacement therapy (CRRT) is an important prognostic factor. Thus, precise evaluation of fluid status is necessary to treat such patients. In this study, we investigated whether fluid assessment using bioelectrical impedance analysis (BIA) can predict outcomes in critically ill patients requiring CRRT. Methods: A prospective observational study was performed in patients who were admitted to the intensive care unit and who required CRRT. BIA was conducted before CRRT; then, the ratio of extracellular water to total body water (ECW/TBW) was derived to estimate volume status. Results: A total of 31 patients treated with CRRT were included. There were 18 men (58.1%), and the median age was 67 years (interquartile range, 51 to 78 years). Fourteen patients (45.2%) died within 28 days after CRRT initiation. Patients were divided into 16 with ECW/TBW ≥0.41 and 15 with ECW/TBW <0.41. Survival rate within 28 days was different between the two groups (P = 0.044). Cox regression analysis revealed a relationship between ECW/TBW ≥0.41 and 28-day mortality, but it was not statistically significant (hazard ratio, 3.0; 95% confidence interval, 0.9 to 9.8; P = 0.061). Lastly, the area under the curve of ECW/TBW for 28-day mortality was analyzed. The area under the curve of ECW/TBW was 0.73 (95% confidence interval, 0.54 to 0.92), and this was significant (P = 0.037). Conclusions: Fluid status can be assessed using BIA in critically ill patients requiring CRRT, and BIA can predict mortality. Further large trials are needed to confirm the usefulness of BIA in critically ill patients.
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A 49-year-old man with end-stage renal disease was admitted to the hospital with a severe headache and vomiting. On neurological examination the Glasgow Coma Scale (GCS) score was 15 and his brain CT showed acute subdural hematoma over the right cerebral convexity with approximately 11-mm thickness and 9-mm midline shift. We chose a conservative treatment of scheduled neurological examination, anticonvulsant medication, serial brain CT scanning, and scheduled hemodialysis (three times per week) without using heparin. Ten days after admission, he complained of severe headache and a brain CT showed an increased amount of hemorrhage and midline shift. Emergency burr hole trephination and removal of the hematoma were performed, after which symptoms improved. However, nine days after the operation a sudden onset of general tonic-clonic seizure developed and a brain CT demonstrated an increased amount of subdural hematoma. Under the impression of persistent increased intracranial pressure, the patient was transferred to the intensive care unit (ICU) in order to control intracranial pressure. Management at the ICU consisted of regular intravenous mannitol infusion assisted with continuous renal replacement therapy. He stayed in the ICU for four days. Twenty days after the operation he was discharged without specific neurological deficits.
Brain death results in adverse pathophysiologic effects in many brain-dead donors with cardiovascular instability. We experienced a brain-dead donor with continuous renal replacement therapy (CRRT) who was in a severe metabolic, electrolyte derangement and poor pulmonary function. The thirty-nine-year-old male patient with subarachnoid hemorrhage and intraventricular hemorrhage was admitted into the intensive care unit (ICU). After sudden cardiac arrest, he went into a coma state and was referred to as a potential organ donor. When he was transferred, his vital sign was unstable even under the high dose of inotropics and vasopressors. Even with aggressive treatment, the level of blood sugar was 454 mg/dl, serum K+ 7.1 mEq/L, lactate 5.33 mmol/L and PaO2/FiO2 60.3. We decided to start CRRT with the mode of continuous venovenous hemodiafiltration (CVVHDF).
After 12 hours of CRRT, vital sign was maintained well without vasopressors, and blood sugar, serum potassium and lactate levels returned to 195 of PaO2/FiO2. Therefore, he was able to donate his two kidneys and his liver.
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BACKGROUND Initiation of renal replacement therapy (RRT) in critically ill septic shock patients with acute kidney injury is highly subjective and may influence outcome. The aim of this study is to evaluate the relationship between initiation of RRT and 28 day mortality in patients with severe sepsis and septic shock (SSSS). METHODS All patients diagnosed with SSSS and treated at the medical intensive care unit (ICU) in university-affiliated hospital from January 2005 to December 2006 were reviewed.
Initiation of RRT was stratified into "early" and "late" by RIFLE (Risk, Injury, Failure, Loss, and End-stage) criteria and blood urea nitrogen (BUN) at the time RRT began. The primary outcome was death after 28 days from any cause. RESULTS Of the 326 patients diagnosed with SSSS and admitted into the medical ICU during the study period, 78 patients received RRT. Mean age was 61.5 +/- 14.7 years old and 54 patients were male (69.2%). The initiation of RRT was categorized into early (Risk, and Injury) and late (Failure) by RIFLE criteria and also categorized into early (BUN < 75 mg/dl) and late (BUN > or = 75 mg/dl). When the relationship between RIFLE criteria and 28 day mortality was compared, no significant difference was shown (70.8% vs. 73.3%, p = 0.81). The initiation of RRT by BUN also showed no significant difference in 28 day mortality (77.3% vs. 69.6%, p = 0.50). CONCLUSIONS Initiation of RRT, stratified into "early" and "late" by RIFLE and BUN, showed no significant difference in 28 day mortality regarding patient with SSSS.
BACKGROUND The objective of this study is to analyze the factors associated with mortality and complication in children requiring continuous renal replacement therapy (CRRT) in a pediatric intensive care unit. METHODS We retrospectively analyzed 96 patients who required CRRT at a pediatric intensive care unit in Seoul National University Hospital between April 2005 and April 2011. We evaluated the clinical features, diagnosis, mortality risk factors and complications related to CRRT. RESULTS Univariate and multivariate analyses were performed to analyze the mortality risk factors of patients requiring CRRT. The overall mortality was 56.3%, the median age was 8 years, and the ages ranged from 4 days to 22 years. The median weight of the patients was 7.9 kg, and the weights ranged from 3.6-72.9 kg. 16 patients were diagnosed with primary renal disease, and the remainder with other underlying diseases. Mortality was higher in children who received stem cell transplantation and in children with a diagnosis of imunologic disease and neurologic disease. The Pediatric Risk of Mortality (PRISM) III score at initiating CRRT was 17.8 +/- 8.9 and the degree of fluid overload at CRRT (FO%) was 12.9 +/- 16.0. The PRISM III score at the start of CRRT and low uric acid level were the factors associated with an increased risk of mortality. Of the 96 children, 13 (13.53%) presented problems of venous catheterization. Hypotension during connection to CRRT was detected in 28 patients (29.2%). Clinically significant hemorrhage occurred in 10 patients (10.4%). CONCLUSIONS Children who require CRRT have a high mortality rate. The higher score of PRISM III at the starting time of CRRT and the lower uric acid level are the factors associated with a higher mortality. The most frequent complication of CRRT was hypotension on connection to CRRT.
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