Combination of extracorporeal membrane oxygenation and continuous renal replacement therapy in critically ill patients: a systematic review

Early Fluid Accumulation and Intensive Care Unit Mortality in Children Receiving Extracorporeal Membrane Oxygenation

Purpose of this study was to evaluate the impact of early fluid accumulation and renal dysfunction on mortality in children receiving extracorporeal membrane oxygenation (ECMO). Retrospective cohort study of neonatal and pediatric patients who received ECMO between January 2010 and December 2012 in a tertiary level multidisciplinary pediatric intensive care unit (ICU). Ninety-six patients were included, and forty-six (48%) of them received continuous renal replacement therapy (CRRT) during ECMO. Overall mortality was 38.5%. Proportion of patients with acute kidney injury (AKI) at ICU admission was 33% and increased to 47% at ECMO initiation. High-risk diagnoses, extracorporeal cardiopulmonary resuscitation (ECPR), and venoarterial (VA)-ECMO were more common among nonsurvivors. Nonsurvivors had significantly higher proportion of AKI at ICU admission (OR: 2.59, p = 0.04) and fluid accumulation on ECMO day 1 (9% vs. 1%, p = 0.05) compared with survivors. Multivariable logistic regression analysis (adjusted for a propensity score based on nonrenal factors associated with increased mortality) demonstrated that fluid accumulation on ECMO day 1 is significantly associated with increased ICU mortality (OR: 1.07, p = 0.04). Fluid accumulation within the first 24 hours after ECMO cannulation is significantly associated with increased ICU mortality in neonatal and pediatric patients. Prospective studies evaluating the impact of conservative fluid management and CRRT during the initial phase of ECMO may help further define this relationship.

Extracorporeal Membrane Oxygenation and Continuous Kidney Replacement Therapy: Technology and Outcomes - A Narrative Review

The number of patients using critical care is increasing as our populations live longer thanks to advances in medical therapies. This is reflected by an increase in both usage and number of critical care beds as compared with total hospital beds across the United States. As this aging population suffers more and more from multiorgan dysfunction, including but not limited to respiratory failure, cardiac failure, and acute kidney injury, technologies are used to facilitate recovery in those that would have assuredly passed away years ago. Some of these advancements include extracorporeal membrane oxygenation and continuous kidney replacement therapy. In this article, we review the literature regarding the history, technology, indications, and outcomes of synchronous extracorporeal membrane oxygenation and kidney replacement therapy.

Gender-related differences in treatment and outcome of extracorporeal cardiopulmonary resuscitation-patients

Extracorporeal cardiopulmonary resuscitation (eCPR) is a rapidly growing treatment strategy due to significant improvement in selected patients' survival rates. Gender-related differences might impact the outcome of therapeutic measures. Therefore, we sought to investigate patients with eCPR at our interdisciplinary extracorporeal membrane oxygenation center regarding sex-related differences with the view to potentially adjusting current selection criteria. From January 2016 to December 2019, 71 patients underwent eCPR at our institution. Data before eCPR and early outcome parameters were analyzed comparing male and female patients. The cohort analyzed consisted of 60 male (84%) and 11 female (15%) patients. Comparing both groups, male patients significantly more frequently suffered out-of-hospital cardiac arrest (68% male vs. 36% female, P = .04), whereas female patients were associated with more in-hospital cardiac arrest (32% male vs. 64% female, P = .04). Creatinine levels differed significantly (1.5 (1.1;2.1) mg/dL in male vs. 1.0 (0.7;1.5) mg/dL in female patients, P = .03). Also, several hepatic parameters showed a significant difference between the groups: aspartate aminotransferase 423 (249;804) U/L in male vs. 115 (61;408) U/L in female patients, P = .01; alanine aminotransferase 174 (102;446) U/L in male vs. 86 (36;118) U/L in female patients, P = .01). Renal failure requiring hemodialysis occurred more frequently in men than in women (P < .01). There is a significant effect of male sex regarding renal failure with subsequent continuous venovenous hemodialysis (CVVH) (R²  = 0.11, ANOVA P = .01, 95% CI = -0.79--0.079). However, in-hospital mortality was comparable between the groups (78% in male vs. 72% in female patients, P = .68). Our retrospective study showed several gender-related differences associated with different cardiac arrest scenarios. Male sex was associated with a significantly higher risk for renal failure requiring CVVH. Survival rates were comparable between the groups. Further investigations should include gender in the evaluation of risk stratification for eCPR-related complications to further improve selection criteria for this demanding therapy.

Renal replacement therapy in patients on extracorporeal membrane oxygenation support: Who and how

Patients undergoing extracorporeal membrane oxygenation (ECMO) support frequently develop renal failure requiring renal replacement therapy (RRT). RRT may be performed via a dialysis catheter based approach or via the ECMO circuit. We describe our experience with both techniques. A total of 68 patients undergoing ECMO support at our institution were retrospectively analyzed. Predictors of renal failure requiring RRT were determined. Patients undergoing RRT via a dialysis catheter were compared with those undergoing RRT via the ECMO circuit. 10 of the 68 patients required RRT support prior to ECMO. Of the remaining 58 patients, 25 (43%) required new RRT support on ECMO. Lower albumin levels and postcardiotomy shock were predictive of new renal failure requiring RRT on ECMO. RRT performed via the ECMO circuit demonstrated similar efficacy as via a dialysis catheter. Outcomes were much worse for patients requiring new RRT on ECMO support, with a doubling of the length of ECMO support and less that one-third the survival rate of patients not requiring RRT on ECMO support. New renal failure requiring RRT occurs in nearly one-half of patients on ECMO support, with poor outcomes. RRT may be performed via the ECMO circuit with similar efficacy as via a dialysis catheter.

Review of acute kidney injury and continuous renal replacement therapy in pediatric extracorporeal membrane oxygenation

Purpose

To review the relevant literature of acute kidney injury (AKI) and continuous renal replacement therapy (CRRT) as it relates to pediatric extracorporeal membrane oxygenation (ECMO).

Methods

Available online relevant literature.

Results

ECMO is a therapeutic modality utilized to support patients with refractory respiratory and/or cardiac failure. AKI and fluid overload (FO) are frequently observed in this patient population. There are multiple modalities that can be utilized for AKI and FO which include the following: diuretics, in-line hemofiltration, and CRRT. There are multiple considerations when using CRRT with ECMO including access, CRRT flows, hemolysis, anticoagulation, and CRRT termination.

Conclusion

While each ECMO center has its own set of equipment, experiences, and practices, it is imperative that the international ECMO community continues to work together to provide an evidence-based approach to address the morbidity and mortality associated with AKI and FO.

The challenges of venoarterial extracorporeal membrane oxygenation for postcardiotomy cardiogenic shock

Postcardiotomy cardiogenic shock describes the syndrome of refractory cardiac performance following cardiac surgery. The use of venoarterial extracorporeal membrane oxygenation (VA-ECMO) for the management of postcardiotomy cardiogenic shock is controversial, and there are at least three scenarios where it may be necessary: first, pre-emptive postoperative VA-ECMO, where the decision for postoperative mechanical support is made prior to surgery, for example, in the context of poor pre-operative cardiac function; second, early yet unplanned post-cardiopulmonary bypass VA-ECMO following a long duration of cardiopulmonary bypass due to, for example, unexpected surgical complications; third, late rescue VA-ECMO following several attempts at weaning, either immediately following cardiopulmonary bypass or following transfer to the intensive care unit. The use of mechanical circulatory support for postcardiotomy cardiogenic shock is further complicated by the wide range of available devices, the availability of VA-ECMO in different centres, variations in experience and expertise as a function of local VA-ECMO workload, and regional variations in the diagnosis and management of postcardiotomy cardiogenic shock. Furthermore, survival appears to be low for such patients and it is not yet possible to predict who will survive. Many questions remain, however, such as those in relation to practices around patient selection, how best to study long-term outcomes, the ethics and efficacy of ECMO in such patients, and on all aspects of clinical decision-making. This review sets these clinical challenges in the context of the available evidence, including that from our centre.

Continuous Renal Replacement Therapy in Venovenous Extracorporeal Membrane Oxygenation: A Retrospective Study on Regional Citrate Anticoagulation

Systemic infusion of unfractionated heparin (UFH) is the standard anticoagulation technique for continuous renal replacement therapy (CRRT) during extracorporeal membrane oxygenation (ECMO), but often fails to avoid CRRT circuit clotting. The aim of this study was to assess, in patients undergoing CRRT during venovenous ECMO (vv-ECMO), the efficacy and safety of adding regional citrate anticoagulation (RCA) for CRRT circuit anticoagulation (RCA + UFH group) compared with the sole systemic heparin anticoagulation (UFH group). We performed a retrospective chart review (2009-2018) of patients treated with CRRT during ECMO. We evaluated filter life span, rate of CRRT circuit clotting, and coagulation parameters. The incidence of citrate anticoagulation-related complications was recorded. Forty-eight consecutive adult patients underwent CRRT during vv-ECMO in the study period. The incidence of CRRT circuit clotting was lower in the RCA + UFH group (11% vs. 38% in the UFH group, p < 0.001). Log-rank survival analysis demonstrated longer circuit lifetime for RCA + UFH group. No complication ascribable to citrate anticoagulation was recorded. Regional citrate anticoagulation resulted a feasible, safe, and effective technique as additional anticoagulation for CRRT circuits during ECMO. Compared with systemic heparinization only, this technique allowed to reduce the rate of CRRT circuit clotting.

Mid-term survival of patients with chronic kidney disease after extracorporeal membrane oxygenation

OBJECTIVES

Chronic kidney disease (CKD) impairs the elimination of fluids, electrolytes and metabolic wastes, which can affect the outcomes of extracorporeal membrane oxygenation (ECMO) treatment. This study aimed to elucidate the impact of CKD on in-hospital mortality and mid-term survival of adult patients who received ECMO treatment.

METHODS

Patients who received first-time ECMO treatment between 1 January 2003 and 31 December 2013 were included. Those with CKD were identified and matched to patients without CKD using a 1:2 ratio and were followed for 3 years. The study outcomes included in-hospital outcomes and the 3-year mortality rate. A subgroup analysis was conducted by comparing the dialytic patients with the non-dialytic CKD patients.

RESULTS

The study comprised 1008 CKD patients and 2016 non-CKD patients after propensity score matching. The CKD patients had higher in-hospital mortality rates [69.5% vs 62.2%; adjusted odds ratio 1.41; 95% confidence interval (CI) 1.15-1.72] than the non-CKD patients. The 3-year mortality rate was 80.4% in the CKD group and 68% in the non-CKD group (adjusted hazard ratio 1.17; 95% CI 1.06-1.28). The subgroup analysis showed that the 3-year mortality rates were 84.5% and 78.4% in the dialytic and non-dialytic patients, respectively. No difference in the 3-year mortality rate was noted between the 2 CKD subgroups (P = 0.111).

CONCLUSIONS

CKD was associated with increased risks of in-hospital and mid-term mortalities in patients who received ECMO treatment. Furthermore, no difference in survival was observed between the patients with end-stage renal disease and non-dialytic CKD patients.

2020 EACTS/ELSO/STS/AATS expert consensus on post-cardiotomy extracorporeal life support in adult patients

Post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase in its use, almost certainly due to improved technology, ease of management, growing familiarity with its capability and decreased costs. Trends in worldwide in-hospital survival, however, rather than improving, have shown a decline in some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal management. Nevertheless, PC-ECLS is proving to be a valuable resource for temporary cardiocirculatory and respiratory support in patients who would otherwise most likely die. Because a comprehensive review of PC-ECLS might be of use for the practitioner, and possibly improve patient management in this setting, the authors have attempted to create a concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management and avoidance of complications, appraisal of new approaches and ethics, education and training.

2020 EACTS/ELSO/STS/AATS Expert Consensus on Post-Cardiotomy Extracorporeal Life Support in Adult Patients

Post-cardiotomy extracorporeal life support (PC-ECLS) in adult patients has been used only rarely but recent data have shown a remarkable increase in its use, almost certainly due to improved technology, ease of management, growing familiarity with its capability and decreased costs. Trends in worldwide in-hospital survival, however, rather than improving, have shown a decline in some experiences, likely due to increased use in more complex, critically ill patients rather than to suboptimal management. Nevertheless, PC-ECLS is proving to be a valuable resource for temporary cardiocirculatory and respiratory support in patients who would otherwise most likely die. Because a comprehensive review of PC-ECLS might be of use for the practitioner, and possibly improve patient management in this setting, the authors have attempted to create a concise, comprehensive and relevant analysis of all aspects related to PC-ECLS, with a particular emphasis on indications, technique, management and avoidance of complications, appraisal of new approaches and ethics, education and training.

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.

Therapeutic Drug Monitoring Is a Feasible Tool to Personalize Drug Administration in Neonates Using New Techniques: An Overview on the Pharmacokinetics and Pharmacodynamics in Neonatal Age

Therapeutic drug monitoring (TDM) should be adopted in all neonatal intensive care units (NICUs), where the most preterm and fragile babies are hospitalized and treated with many drugs, considering that organs and metabolic pathways undergo deep and progressive maturation processes after birth. Different developmental changes are involved in interindividual variability in response to drugs. A crucial point of TDM is the choice of the bioanalytical method and of the sample to use. TDM in neonates is primarily used for antibiotics, antifungals, and antiepileptic drugs in clinical practice. TDM appears to be particularly promising in specific populations: neonates who undergo therapeutic hypothermia or extracorporeal life support, preterm infants, infants who need a tailored dose of anticancer drugs. This review provides an overview of the latest advances in this field, showing options for a personalized therapy in newborns and infants.

Post-operative renal failure management in mechanical circulatory support patients

Acute kidney injury (AKI) occurs commonly in patients requiring mechanical circulatory support (MCS) after cardiothoracic surgery. The prognostic implications of AKI in this patient group relate closely to the pathophysiology and risk factors associated with the underlying disease; pre-operative, intra-operative, and post-operative variables; hemodynamic factors; and type of support device used. General approaches to AKI management, including prevention strategies, medical management, and hemodynamic support, are also applicable in patients requiring MCS. Approaches to renal replacement therapy vary depend on patient factors, device-specific factors, and local preferences and experience. In this invited narrative review, we discuss the pathophysiology, risk factors, and prognostic implications of AKI in post-operative adult patients following institution of MCS. Management strategies for AKI are presented with a focus on those supported with either extracorporeal membrane oxygenation or a ventricular assist device.

Controversies in acute kidney injury: conclusions from a Kidney Disease: Improving Global Outcomes (KDIGO) Conference

In 2012, Kidney Disease: Improving Global Outcomes (KDIGO) published a guideline on the classification and management of acute kidney injury (AKI). The guideline was derived from evidence available through February 2011. Since then, new evidence has emerged that has important implications for clinical practice in diagnosing and managing AKI. In April of 2019, KDIGO held a controversies conference entitled Acute Kidney Injury with the following goals: determine best practices and areas of uncertainty in treating AKI; review key relevant literature published since the 2012 KDIGO AKI guideline; address ongoing controversial issues; identify new topics or issues to be revisited for the next iteration of the KDIGO AKI guideline; and outline research needed to improve AKI management. Here, we present the findings of this conference and describe key areas that future guidelines may address.

Kidney Replacement Therapy in COVID-19 Induced Kidney Failure and Septic Shock: A Pediatric Continuous Renal Replacement Therapy [PCRRT] Position on Emergency Preparedness With Resource Allocation

The recent worldwide pandemic of COVID-19 has had a detrimental worldwide impact on people of all ages. Although data from China and the United States indicate that pediatric cases often have a mild course and are less severe in comparison to adults, there have been several cases of kidney failure and multisystem inflammatory syndrome reported. As such, we believe that the world should be prepared if the severity of cases begins to further increase within the pediatric population. Therefore, we provide here a position paper centered on emergency preparation with resource allocation for critical COVID-19 cases within the pediatric population, specifically where renal conditions worsen due to the onset of AKI.

Fluid Balance and Recovery of Native Lung Function in Adult Patients Supported by Venovenous Extracorporeal Membrane Oxygenation and Continuous Renal Replacement Therapy

Fluid overload is associated with increased mortality in adult patients with acute respiratory distress syndrome. In patients requiring venovenous extracorporeal membrane oxygenation (VV-ECMO), the effects of fluid removal on survival and lung recovery remain undefined. We assessed the impact of early fluid removal in adult patients supported by VV-ECMO and concomitant continuous renal replacement therapy, in an 18-bed tertiary intensive care unit between 2010 and 2015. Twenty-four patients met inclusion criteria, of these 15 (63%) survived to hospital discharge. In our patient group, a more negative cumulative daily fluid balance was strongly associated with improved pulmonary compliance (2.72 ml/cmH2O per 1 L negative fluid balance; 95% confidence interval [CI]: 1.61-3.83; P < 0.001). In addition, a more negative mean daily fluid balance was associated with improved pulmonary compliance (4.37 ml/cmH2O per 1 L negative fluid balance; 95% CI: 2.62-6.13; P < 0.001). Survivors were younger and had lower mean daily fluid balance (-0.33 L [95% CI: -1.22 to -0.06] vs. -0.07 L [95% CI: -0.76 to 0.06]; P = 0.438) and lower cumulative fluid balance up to day 14 (-4.60 L [95% CI: -8.40 to -1.45] vs. -1.00 L [95% CI: -4.60 to 0.90]; P = 0.325), although the fluid balance effect alone did not reach statistical significance.

Hematologic concerns in extracorporeal membrane oxygenation

This ISTH "State of the Art" review aims to critically evaluate the hematologic considerations and complications in extracorporeal membrane oxygenation (ECMO). ECMO is experiencing a rapid increase in clinical use, but many questions remain unanswered. The existing literature does not address or explicitly state many pertinent details that may influence hematologic complications and, ultimately, patient outcomes. This review aims to broadly introduce modern ECMO practices, circuit designs, circuit materials, hematologic complications, transfusion-related considerations, age- and size-related differences, and considerations for choosing outcome measures. Relevant studies from the 2019 ISTH Congress in Melbourne, which further advanced our understanding of these processes, will also be highlighted.

The impact of CRRT modality in patients with AKI receiving ECMO: A nationwide registry study in Taiwan

PURPOSE

Patients receiving extracorporeal membrane oxygenation (ECMO) commonly develop acute kidney injury (AKI) and frequently require continuous renal replacement therapy (CRRT). The impact of different CRRT modalities on survival in patients receiving ECMO remains unclear.

MATERIALS AND METHODS

Using claims data from Taiwan's National Health Insurance Research Database, a total of 1077 patients who received ECMO and either continuous venovenous hemofiltration (CVVH) or continuous venovenous hemodialysis (CVVHD) for AKI were identified. Inverse probability of treatment weighting was applied using propensity scores to balance the baseline covariates of the two groups. The primary outcome was in-hospital morality.

RESULTS

We identified 1077 patients (mean age 57.9; 71.8% men). Postcardiotomy shock (49.2%) was the most frequently reported indication for ECMO. The CVVH group had a lower risk of in-hospital mortality (68.4% vs. 76.9%; odds ratio 0.65; 95% confidence interval [CI] 0.50-0.85) compared with the CVVHD group. The CVVH group also had a shorter mean ICU stay compared with the CVVHD group (mean difference -4.59 days, 95% CI -9.15 to -0.03 days).

CONCLUSION

Our results suggest that compared with CVVHD, CVVH may be associated with a lower risk of in-hospital mortality in patients with AKI who receive ECMO.

Renal function in children assisted with extracorporeal membrane oxygenation

Acute kidney injury is a frequent complication in patients requiring extracorporeal membrane oxygenation. A single-center retrospective analysis from a prospective observational database assessing the incidence of acute kidney injury in children undergoing extracorporeal membrane oxygenation, the use of continuous renal replacement therapy and its association with outcomes was performed. One hundred children were studied. Creatinine was normal in 33.3% of children at the beginning of extracorporeal membrane oxygenation, between 1.5 and 2 times its baseline levels in 18.4% of children (stage I acute kidney injury), between 2 and 3 times baseline levels (stage II) in 20.7%, and over 3 times baseline levels or requiring continuous renal replacement therapy (stage III) in 27.6% of the patients. Eighteen patients were on continuous renal replacement therapy before the beginning of extracorporeal membrane oxygenation, 81 required continuous renal replacement therapy during extracorporeal membrane oxygenation, and 38 after weaning from extracorporeal membrane oxygenation, but none of them did at discharge from the pediatric intensive care unit. Fifty-one children survived to pediatric intensive care unit discharge. Mortality was lower in children with normal kidney function or with stage I acute kidney injury at the beginning of extracorporeal membrane oxygenation than in those with stage II or III acute kidney injury (33.3% vs 58.3%, p = 0.021). Mortality in children requiring continuous renal replacement therapy during extracorporeal membrane oxygenation was 54.3% and 21.1% in the rest of patients (p < 0.01). We conclude that kidney function is significantly impaired in a high percentage of children undergoing extracorporeal membrane oxygenation and many of them are treated with continuous renal replacement therapy. Patients treated with continuous renal replacement therapy have a higher mortality than those with normal kidney function or stage I acute kidney injury at the beginning of extracorporeal membrane oxygenation. Most patients surviving to pediatric intensive care unit discharge recover normal renal function after weaning from extracorporeal membrane oxygenation.

Aquapheresis (AQ) in Tandem with Extracorporeal Membrane Oxygenation (ECMO) in Pediatric Patients

Children with cardiopulmonary failure requiring extracorporeal membrane oxygenation (ECMO) are at risk for fluid overload (FO) despite the normal estimated glomerular filtration rate (eGFR). It has been shown that survival in the intensive care unit (ICU) is inversely proportional to FO. Therefore, fluid removal, or prevention of FO, in these critical cases has the potential to improve survival. Aquapheresis (AQ), a procedure used for fluid removal, with success in patients with heart failure has also been used in children with acute oliguric kidney injury (AKI), to prevent and treat FO. The purpose of this article was to describe the use of Aquadex FlexFlow^® for AQ in pediatric patients on ECMO, as a means to provide a simplified and safe form of fluid removal with minimal impact on ECMO therapy. The principal variables collected include patients' demographics, urine output, serum creatinine, withdrawal and infusion pressures, ultrafiltration (UF) rates, and ECMO flow ranges, along with length of stay in pediatric ICU and survival. Patient survival was 100% with preserved eGFR. The ECMO flows were not affected by AQ. Urine output decreased somewhat during therapy, with little AQ machine pressure variations. Range of UF tolerated without hemodynamic abnormalities was 1.24-6.2 mL/kg/h, allowing the patients to maintain their pre-AQ body weight, while receiving intravenous (IV) nutrition and medications. This article describes the use of AQ in tandem with ECMO in a user-friendly and safe way to provide UF in children requiring cardiopulmonary support, with minimal flow and hemodynamic disturbance.

Analysis of survival after initiation of continuous renal replacement therapy in patients with extracorporeal membrane oxygenation

Background

No study has specifically investigated the duration of continuous renal replacement therapy (CRRT) in patients who experienced acute kidney injury during extracorporeal membrane oxygenation (ECMO) support. However, there are concerns that prolonged CRRT may be futile.

Methods

We conducted a retrospective population-based cohort study using Taiwan National Health Insurance Research Database data collected between January 1, 2007 and December 31, 2013. Patients who received ECMO and CRRT during the study period were included. We divided patients into three groups based on the duration of CRRT received: ≤ 3 days, 4–6 days, and ≥ 7 days. The outcomes were all-cause mortality, end-stage renal disease, ventilator dependency, and readmission rate.

Results

There were 247, 134 and 187 patients who survived the hospitalization in the CRRT for ≤3 days, 4–6 days and > 7 days respectively. Survival after discharge did not differ significantly between CRRT for 4–6 days vs. ≤ 3 days (adjusted hazard ratio [aHR] 1.16, 95% confidence interval [CI] 0.85–1.57), between CRRT for > 7 days vs. ≤ 3 days (aHR 1.001, 95% CI 0.73–1.38) and between CRRT for > 7 days vs. 4–6 days (aHR 0.87, 95% CI 0.62–1.22). The patients who received CRRT for ≥7 days had a higher risk of ESRD than did those who received CRRT for ≤3 days (adjusted hazard ratio [aHR] 3.46, 95% confidence interval [CI] 1.47–8.14) and for 4–6 days (aHR 3.10, 95% CI 1.03–9.29). The incidence of ventilator dependence was higher in the patients with CRRT ≥7 days than in those with ≤3 days (aHR 2.45, 95% CI 1.32–4.54). The CRRT ≥7 days group also exhibited a higher readmission rate than did the 4–6 days and ≤ 3 days groups (aHR 1.43, 95% CI 1.04–1.96 and aHR 1.67, 95% CI 1.13–2.47, respectively).

Conclusions

Our study found similar long-term survival but increased ESRD and ventilator dependency among ECMO patients who underwent CRRT for ≥7 days. These results offer reason to be concerned that this aggressive life support may maintain patient survival but do so at the cost of long-term disabilities and a lower quality of life.

Electronic supplementary material

The online version of this article (10.1186/s12882-019-1516-6) contains supplementary material, which is available to authorized users.

Complications of veno-arterial extracorporeal membrane oxygenation for refractory cardiogenic shock or cardiac arrest

Background:

The frequency of using veno-arterial extracorporeal membrane oxygenation increased, especially in patients with refractory cardiogenic shock or cardiac arrest. However, data of complications of veno-arterial extracorporeal membrane oxygenation are lacking. This study sought to investigate the incidence of veno-arterial extracorporeal membrane oxygenation complications for acute myocardial infarction patients with refractory cardiogenic shock or cardiac arrest and its relationship with patient survival.

Methods:

This study included 151 consecutive patients who underwent veno-arterial extracorporeal membrane oxygenation between 2006 and 2018 at a single referral center. We divided the patients into those who survived for 30 days after veno-arterial extracorporeal membrane oxygenation ( n = 57, 38%; group 1) and those who died within 30 days after veno-arterial extracorporeal membrane oxygenation support ( n = 94, 62%; group 2). The major adverse clinical events associated with veno-arterial extracorporeal membrane oxygenation were defined as first occurrence of infection, major bleeding, and stroke.

Results:

Adverse clinical events associated with veno-arterial extracorporeal membrane oxygenation occurred in 34 (59.6%) and 56 (59.6%) patients in groups 1 and 2, respectively. Group 2 had more patients who underwent new renal replacement therapy (21.1% vs 37.2%, p = 0.037). After multivariable analysis, cardiac arrest was independently associated with 30-day mortality (odds ratio = 3.6; 95% confidence interval = 1.7–7.63; p = 0.001). After excluding patients who died within 48 h after undergoing veno-arterial extracorporeal membrane oxygenation, new renal replacement therapy (odds ratio = 4.47; 95% confidence interval = 1.58–12.61; p = 0.005) and major adverse clinical events (odds ratio = 2.66; 95% confidence interval = 1.01–7.03; p = 0.049) were independently associated with 30-day mortality.

Conclusion:

Although veno-arterial extracorporeal membrane oxygenation can improve the survival, it is associated with morbidity. Therefore, risk–benefit analysis for veno-arterial extracorporeal membrane oxygenation and prevention of complications are important to improve prognosis.

CAVH in the Combat Environment: A Case Report and Lessons Learned in Southern Afghanistan

Background

Acute kidney injury is a common complication of both civilian and military trauma. The lack of dedicated resources restrict dialysis in the forward setting. We report a case of a combat polytrauma and renal failure, using continuous arteriovenous hemofiltration to clear uremia and remove volume, allowing for ventilator liberation and safe disposition.

Materials and Methods

The patient presented with traumatic lower extremity injuries and abdominal wounds and developed acute post-traumatic renal failure. Using available supplies, the patient was cannulated for continuous arteriovenous hemofiltration. Aggressive fluid and electrolyte management accomplished specific goals of ventilator liberation and clearance of uremia.

Results

Over 48 h, blood urea nitrogen was reduced from 101 mg/dL to 63 mg/dL. Creatinine was reduced from 8.2 mg/dL to 4.7 mg/dL. Acute respiratory distress syndrome was improved reducing P:F (PaO2:FiO2) ratio from 142 to 210. The patient was extubated and transferred safely.

Conclusions

The ability to perform acute dialysis can be lifesaving. Although resource constrained, we created a dialysis system in the forward environment with a filter and universally available equipment. This represents the first described use of continuous arteriovenous hemofiltration at the NATO Role 3 hospital in Afghanistan. This technique represents another potential tool for deployed trauma teams to improve care.

Massive Air Embolism Caused by a Central Venous Catheter During Extracorporeal Membrane Oxygenation

Extracorporeal membrane oxygenation (ECMO) has become an integral treatment option for patients as a bridge to transplant, management of post cardiotomy cardiogenic shock, and for rescue after cardiopulmonary arrest. Significant strides in ECMO technology and management cannot, however, replace the importance of maintaining and following a comprehensive safety checklist. We herein report a case of massive air entrainment from an inadvertently disconnected port of a central venous catheter (CVC) in the neck which culminated in an airlock of the ECMO circuit. Ascertaining the relative position of the tip of the CVC with respect to the venous cannula on chest X-ray, tightly securing all its ports, and appraising and educating the health-care team can prevent this rare but devastating complication of fatal air embolism.

The Effect of Simultaneous Renal Replacement Therapy on Extracorporeal Membrane Oxygenation Support for Postcardiotomy Patients with Cardiogenic Shock: A Pilot Randomized Controlled Trial

OBJECTIVE

The objectives of this study were to determine the feasibility and safety of simultaneous renal replacement therapy (RRT) during extracorporeal membrane oxygenation (ECMO) support for postcardiotomy patients with cardiogenic shock and whether simultaneous RRT with ECMO would improve survival and reduce morbidity. The authors hypothesized that simultaneous RRT could facilitate effective fluid management and rapid metabolic control in postcardiotomy patients with cardiogenic shock who were undergoing ECMO support.

DESIGN

A parallel, open-label, single-center pilot randomized trial.

SETTING

University-affiliated cardiac surgery intensive care unit.

PARTICIPANTS

The study comprised 41 postcardiotomy patients with cardiogenic shock who received ECMO support.

INTERVENTIONS

Participants were enrolled and randomly assigned via a 1:1 allocation to a simultaneous RRT arm versus a standard care arm. The patients in the simultaneous RRT arm received RRT within 12 hours of the start of ECMO regardless of the conventional RRT indication. Simultaneous RRT was delivered with the RRT machine connected to the ECMO circuit. The patients in the standard care arm did not receive RRT at the start of ECMO unless the conventional RRT indications were fulfilled.

MEASUREMENTS AND MAIN RESULTS

All 41 patients enrolled were followed-up for 30 days and the results analyzed. The primary feasibility outcome was the time from randomization to simultaneous RRT of <12 hours in the simultaneous RRT arm. All participants in simultaneous RRT arm fulfilled with a median time from randomization to simultaneous RRT of 4.4 (2.7-5.6) hours. The 30-day all-cause mortality was 61.9% in the simultaneous RRT arm and 75.0% in the standard care arm (p = 0.51). The lactate clearance was higher in the simultaneous RRT arm (0.56 ± 0.4 v 0.28 ± 0.4 mmol/L/h; p = 0.04). There was lower cumulative fluid balance in the simultaneous RRT arm on ECMO day 3 (-1,510 [-3560 to 1,162] v -332 [-2,027 to 2,181]; p = 0.38) and ECMO day 5 (-2,671 [-5,197 to 3,334] v -1,509 [-3,595 to 1,162]; p = 0.41) without significance. There were no significant differences in adverse events reported and no hemodynamic instability owing to simultaneous RRT delivery.

CONCLUSIONS

This pilot study suggests the feasibility and safety of simultaneous RRT during ECMO support for postcardiotomy patients with cardiogenic shock, providing an efficient means for controlling fluid status and metabolics. A large trial based on this pilot study is required to confirm the clinical benefits.

Effect of Extracorporeal Membrane Oxygenation on the New Vancomycin Dosing Regimen in Critically Ill Patients Receiving Continuous Venovenous Hemofiltration

BACKGROUND

The optimal dosing regimen of vancomycin for critically ill patients receiving continuous venovenous hemofiltration (CVVH) remains controversial, not to mention those with concurrent use of extracorporeal membrane oxygenation (ECMO). We aimed to determine if a new dosing regimen can achieve the target vancomycin trough concentration (Ctrough) of 10-20 mcg/mL in patients receiving CVVH with or without ECMO.

METHODS

We conducted a retrospective study by enrolling patients who received vancomycin while undergoing CVVH. The vancomycin dosing regimen was 15-20 mg/kg as the loading dose and 7.5 mg/kg every 12 hours as the maintenance doses. Serum concentration was determined after at least 4 doses of vancomycin were given.

RESULTS

A total of 38 patients were enrolled, of which 21 were also on ECMO. The ultrafiltration rate of CVVH was 30.6 ± 5.5 mL·kg·h with the Ctrough of 14.7 ± 3.5 mcg/mL. Ctrough was within the target range in 82% of patients. All CVVH-only patients achieved the target concentration, whereas only 76.2% of those with concurrent ECMO did (P = 0.031).

CONCLUSIONS

All patients receiving CVVH achieved the target Ctrough with this new dosing regimen, but those with concurrent ECMO did not. Ctrough must be more closely monitored in patients using ECMO simultaneously.

Co-initiation of continuous renal replacement therapy, peritoneal dialysis, and extracorporeal membrane oxygenation in neonatal life-threatening hyaline membrane disease: A case report

RATIONALE

Extracorporeal membrane oxygenation (ECMO) is a well-known technique to provide cardio-pulmonary support. Although continuous renal replacement therapy (CRRT) is frequently indicated, the need for faster fluid removal as the primary indication for ECMO is uncommon. Experiences on concomitant applications of ECMO, peritoneal dialysis (PD) and CRRT in neonates are relatively limited.

PATIENT CONCERNS

We report a 2-day-old male neonate with life-threatening hyaline membrane disease (HMD), accompained by severe systemic fluid retention, sepsis and abdominal compartment syndrome.

DIAGNOSIS

Hyaline membrane disease (HMD), neonatal respiratory distress syndrome, sepsis, capillary leakage syndrome, and abdominal compartment syndrome.

INTERVENTION

Veno-arterial ECMO, CRRT, and PD were synchronously initiated for the sake of faster fluid removal possible.

OUTCOMES

The infant was successfully weaned from ECMO circuit and fluid overload was greatly improved four days after extracorporeal life support (ECLS), without major complications.

LESSONS

Initiation of CRRT and PD during ECMO therapy is effective and safe to release fluid overload in neonates, and severe complications are absent. When a neonate requires dialysis of urgency, ECMO offers assured vascular access to hemodialysis, allowing faster fluid removal.

Neonatal Cardiac ECMO in 2019 and Beyond

Worldwide, the use of Extracorporeal Membrane Oxygenation (ECMO) for cardiac failure has been steadily increasing in the neonatal population and has become a widely accepted modality. Especially in centers caring for children with (congenital) heart disease, ECMO is now an essential part of care available for those with severe heart failure as a bridge to recovery, long term mechanical support, or transplantation. Short-term outcomes depend very much on indication. Hospital survival is ~40% for all neonatal cardiac ECMO patients combined. ECMO is being used for pre- and/or post-operative stabilization in neonates with congenital heart disease and in neonates with medical heart disease such as myocarditis, cardiomyopathy or refractory arrhythmias. ECMO use during resuscitation (ECPR) or for sepsis is summarized elsewhere in this special edition of Frontiers in Pediatrics. In this review article, we will discuss the indications for neonatal cardiac ECMO, the difficult process of patients' selection and identifying the right timing to initiate ECMO, as well as outline pros and cons for peripheral vs. central cannulation. We will present predictors of mortality and, very importantly, predictors of survival: what can be done to improve the outcomes for your patients. Furthermore, an overview of current insights regarding supportive care in neonatal cardiac ECMO is given. Additionally, we will address issues specific to neonates with single ventricle physiology on ECMO, for example cannulation strategies and the influence of shunt type (Blalock-Taussig shunt vs. "right ventricle to pulmonary artery" shunt). We will not only focus on short term outcomes, such as hospital survival, but also on the importance of long-term neuro-developmental outcomes, and we will end this review with suggestions for future research.

Using additional pressure control lines when connecting a continuous renal replacement therapy device to an extracorporeal membrane oxygenation circuit

Background

The introduction of a continuous renal replacement therapy (CRRT) device into the extracorporeal membrane oxygenation (ECMO) circuit is widely used. However, excessive pressure transmitted to the CRRT device is a major disadvantage. We investigated the effects of using additional pressure control lines on the pressure and the lifespan of the CRRT circuit connected to the ECMO.

Methods

This is an observational study using prospectively collected data from consecutive patients receiving CRRT connected into the ECMO circuit at a university-affiliated, tertiary hospital from January 2013 to December 2016. The CRRT circuit was connected into the ECMO circuit through the Luer Lock connection without an additional pressure control line in 16 patients (9%, no line group), an additional pressure control line on the inlet line in 36 patients (23%, single line group), and additional pressure control lines on both the inlet and outlet lines in 118 patients (77%, double line group). The outcome measures of interest were compared among the three groups.

Results

The median access pressure was higher in the no line group compared to the groups. However, median filter pressure, effluent pressure, and return pressure were higher in the double line group compared to the other groups. There were no significant differences in platelets, lactate dehydrogenase, and plasma hemoglobin among the 3 groups over the time period studied. Median lifespan of the CRRT circuits in the double line group was 45.0 (29.0–63.7) hours, which was higher compared to 21.8 (11.6–31.8) hours in the no line group and 23.0 (15.0–34.6) hours in the single line group, respectively. In addition, in-hospital mortality was lower in the double line group (48.3%) compared to the no line group (68.8%) and the single line group (75.0%).

Conclusions

Additional tubing can be considered a simple and safe method for pressure control and lengthening circuit survival when connecting the CRRT device to the ECMO circuit.

Oxidative Stress and Neonatal Respiratory Extracorporeal Membrane Oxygenation

Oxidative stress is a frequent condition in critically ill patients, especially if exposed to extracorporeal circulation, and it is associated with worse outcomes and increased mortality. The inflammation triggered by the contact of blood with a non-endogenous surface, the use of high volumes of packed red blood cells and platelets transfusion, the risk of hyperoxia and the impairment of antioxidation systems contribute to the increase of reactive oxygen species and the imbalance of the redox system. This is responsible for the increased production of superoxide anion, hydrogen peroxide, hydroxyl radicals, and peroxynitrite resulting in increased lipid peroxidation, protein oxidation, and DNA damage. The understanding of the pathophysiologic mechanisms leading to redox imbalance would pave the way for the future development of preventive approaches. This review provides an overview of the clinical impact of the oxidative stress during neonatal extracorporeal support and concludes with a brief perspective on the current antioxidant strategies, with the aim to focus on the potential oxidative stress-mediated cell damage that has been implicated in both short and long-term outcomes.

Outcomes of extracorporeal membrane oxygenation in adult patients with hypoxemic respiratory failure refractory to mechanical ventilation

Introduction

Extracorporeal membrane oxygenation (ECMO) is a mode of extracorporeal life support that has been used to support cardiopulmonary disease refractory to conventional therapy. The experience with the use of ECMO in acute hypoxemic respiratory failure is still limited. The aim of this study was to report clinical outcomes in adult patients with acute hypoxemic respiratory failure refractory to mechanical ventilation treated with ECMO.

Methods

Between July 2011 and October 2017, 18 adult patients with hypoxemic respiratory failure refractory to mechanical ventilation were admitted to the Intensive Care Unit of an acute care tertiary hospital in Barcelona, Spain. These patients were treated with ECMO as salvage respiratory therapy. Outcomes included clinical data, ventilatory and blood gas characteristics, survival, and complications.

Results

Fifteen patients (83.3%) were previously treated in prone position. The indication of VV-ECMO was established at an early stage after a mean (SD) of 3.8 (2.5) days on mechanical ventilation. The mean duration of ECMO was 10.4 days, and 16 patients (88.9%) required venous cannulation, mostly femoral-internal jugular. The mean length of ICU stay was 27 days and the mean hospital stay was 42.1 days. The ICU survival rate was 55.5% (n = 10) and the hospital survival rate was 50% (n = 9).

Conclusions

This clinical study in a small series of ICU patients treated with ECMO confirms the usefulness of this technique as a ventilatory support in patients with refractory hypoxemic respiratory failure. However, the indication of this procedure is also committed to an ethical reflection considering the possible futility of the measure on a case-by-case basis and associated complications.

Pharmacokinetics and Extracorporeal Membrane Oxygenation in Adults: A Literature Review

Extracorporeal membrane oxygenation is a rapidly emerging treatment for respiratory or cardiac failure and is used as a bridge to recovery, transplant, or destination therapy. Adult patients receiving extracorporeal membrane oxygenation also receive significant amounts of pharmacotherapy. Although the body of literature on extra-corporeal membrane oxygenation in general is extensive, only a few publications focus on pharmacokinetic changes related to extracorporeal membrane oxygenation in adults. Understanding pharmacokinetics in adult patients receiving extracorporeal membrane oxygenation is important to correctly select and dose medications in this patient population. This article reviews published studies of the effects of extracorporeal membrane oxygenation on pharmacokinetics in adults.

Management of Fluid Overload in the Pediatric ICU

The implications and management of fluid overload in pediatric critical care remain areas of ongoing controversy. Consensus definitions and methods of quantitating fluid overload continue to evolve, paralleling our growing understanding of fluid dynamics in critically ill patients. Fluid overload has been associated with adverse outcomes in some patient populations; guidelines for fluid management therapies are sparse and have little supporting data. Conflicting data for efficacy of therapies such as diuretic medications and renal replacement therapy are likely reflective of an incomplete understanding of the dynamic relationship between critical illness and fluid overload. Although some guidance regarding diuresis, continuous renal replacement therapy, and fluid balance goals is elucidated in the following chapters, it is important to recognize that further research into these management strategies is required before standardized approaches to management can be established.

Impact of an inline extracorporeal membrane oxygenation hemofilter system in neonatal acute kidney injury

Extracorporeal membrane oxygenation (ECMO) is considered a recognized lifesaving support for patients with cardiorespiratory failure. Acute kidney injury (AKI) and fluid overload are significant morbidity factors resulting in serious complications. The inline hemofilter system (IHS) and the continuous renal replacement therapy (CRRT) machine are different methods of renal replacement therapy for patients with ECMO. IHS is the alternate, safe dialysis modality of choice because it is user-friendly, inexpensive, and efficiently removes fluid overload and renal diffusive clearance. We report on a 20-day-old male neonate with multiple congenital cardiac defects who needed venoarterial ECMO and had AKI necessitating renal replacement therapy using IHS. The patient had stable electrolyte parameters, good ultrafiltration, and efficient diffusive clearance. He was decannulated from ECMO therapy after 9 days without any related complications. Therefore, neonatal IHS is a safe and efficient alternative approach to AKI.

Combination of extracorporeal membrane oxygenation and inline hemofiltration for the acute hyperkalemic cardiac arrest in a patient with Duchenne muscular dystrophy following orthopedic surgery -a case report

Background

Duchenne muscular dystrophy (DMD) is the most common childhood muscular dystrophy that anesthesiologists can encounter in the operation room, and patients with DMD are susceptible to complications such as rhabdomyolysis, hyperkalemic cardiac arrest, and hyperthermia during the perioperative period. Acute onset of hyperkalemic cardiac arrest is a crisis because of the difficulty in achieving satisfactory resuscitation owing to the sustained hyperkalemia accompanied by rhabdomyolysis.

Case

We here report a case of a 13-year-old boy who had multiple leg fractures and other trauma after a car accident and who had suffered from acute hyperkalemic cardiac arrest. He was refractory to cardiopulmonary resuscitation and showed sustained hyperkalemia. With extracorporeal membrane oxygenation and in-line hemofiltration, he recovered from repeated cardiac arrest and hyperkalemia.

Conclusions

Combining ECMO and in-line hemofiltration might be a safe and effective technique for refractory hyperkalemic cardiac arrest and rhabdomyolysis in patients with DMD.

Venoarterial Extracorporeal Membrane Oxygenation in Cardiogenic Shock

Venoarterial extracorporeal membrane oxygenation has emerged as a viable treatment for patients in cardiogenic shock with biventricular failure and pulmonary dysfunction. Advances in pump and oxygenator technology, cannulation strategies, patient selection and management, and durable mechanical circulatory support have contributed to expanded utilization of this technology. However, challenges remain that require investigation to improve outcomes.

Impact of connecting continuous renal replacement therapy to the extracorporeal membrane oxygenation circuit

PURPOSE

Continuous veno-venous haemofiltration (CVVH) directly connected to extracorporeal membrane oxygenation (ECMO) may ensure better blood flow and allow prolonged circuit life. The objective of this study was to assess circuit life of CVVH connected to ECMO and to a dialysis catheter.

MATERIALS AND METHODS

In this prospective observational study, patients receiving CVVH via ECMO were compared to time-matched patients receiving CVVH via a conventional dialysis catheter. CVVH circuit life and the safety and efficacy of the two CVVH procedures were analysed. Time to event was estimated using Kaplan-Meier analysis and compared using the log-rank test.

RESULTS

Seventeen patients were included in each group, with 43 sessions in the ECMO group and 56 sessions in the DC group. Median CVVH circuit life was 48 [21-72] vs 20 [6-39] hours in the ECMO and DC groups, respectively (relative risk of termination of the session: 2.4, 95% CI [1.41-3.9], log rank P=0.0009). CVVH blood flow was higher in the ECMO group. Despite higher anticoagulant doses in the catheter group, the circuit clotting rate was lower in the ECMO group. Effluent volume was slightly higher in the ECMO group (39ml/kg/h [33-47] vs 34ml/kg/h [32-39]), but with no biological impact. CVVH via ECMO was well tolerated with no major drawbacks.

CONCLUSIONS

In patients requiring ECMO, CVVH connected to ECMO instead of DC could be proposed as an alternative approach, allowing more stable blood flow and prolonged CVVH circuit life.

An overview of medical ECMO for neonates

Extracorporeal membrane oxygenation (ECMO), a life-saving therapy for respiratory and cardiac failure, was first used in neonates in the 1970s. The indications and criteria for ECMO have changed over the years, but it continues to be an important option for those who have failed other medical therapies. Since the Extracorporeal Life Support Organization (ELSO) Registry was established in 1989, more than 29,900 neonates have been placed on ECMO for respiratory failure, with 84% surviving their ECMO course, and 73% surviving to discharge or transfer. In this chapter, we will review the basics of ECMO, patient characteristics and criteria, patient management, ECMO complications, special uses of neonatal ECMO, and patient outcomes.

Does acute kidney injury affect survival in adults with acute respiratory distress syndrome requiring extracorporeal membrane oxygenation?

INTRODUCTION

Patients who develop severe acute respiratory distress syndrome (ARDS) despite full medical management may require veno-venous extracorporeal membrane oxygenation (VV ECMO) to support respiratory function. Survival outcomes remain unclear in those who develop acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT) during VV ECMO for isolated severe respiratory failure in adult populations.

METHODS

A retrospective chart review (2010-2016) of patients who underwent VV ECMO for ARDS was conducted with university institutional review board (IRB) approval. Patients supported by veno-arterial ECMO were excluded. AKI was defined by acute renal failure receiving CRRT and the outcomes of patients on VV ECMO were compared between the AKI and non-AKI groups.

RESULTS

We identified 54 ARDS patients supported by VV ECMO (mean ECMO days 12 ± 6.7) with 16 (30%) in the AKI group and 38 (70%) in the non-AKI group. No patient had previous renal failure and the serum creatinine was not significantly different between the two groups at the time of ECMO initiation. The AKI group showed a greater incidence of complications during ECMO, including liver failure (38% vs. 5%, p=0.002) and hemorrhage (94% vs. 45%, p=0.0008). ECMO survival of the AKI group (56% [9/16]) was inferior to the non-AKI group (87% [33/38], p=0.014).

CONCLUSIONS

Our study demonstrated that VV ECMO successfully manages patients with severe isolated lung injury. However, once patients develop AKI during VV ECMO, they are likely to further develop multi-organ dysfunction, including hepatic and hematological complications, leading to inferior survival.

Adjunctive Therapies During Extracorporeal Membrane Oxygenation to Enhance Multiple Organ Support in Critically Ill Children

Since the advent of extracorporeal membrane oxygenation (ECMO) over 40 years ago, there has been increasing interest in the use of the extracorporeal circuit as a platform for providing multiple organ support. In this review, we will examine the evidence for the use of continuous renal replacement therapy, therapeutic plasma exchange, leukopheresis, adsorptive therapies, and extracorporeal liver support in conjunction with ECMO.

Extracorporeal membrane oxygenation combined with continuous renal replacement therapy in cutaneous burn and inhalation injury caused by hydrofluoric acid and nitric acid

RATIONALE

Hydrofluoric acid (HF) is a highly corrosive agent and can cause corrosive burns. HF can penetrate deeply into tissues through intact skin and the lipid barrier, leading to painful liquefactive necrosis, and inducing hypocalcemia and hypomagnesemia. In this study, we hypothesize that continuous renal replacement therapy (CRRT) may be beneficial in addressing hemodynamic instability in cases of HF poisoning.

PATIENT CONCERNS

A 25-year-old man fell into an electroplating pool containing 10% HF and 50% nitric acid.

DIAGNOSES

He had severe cutaneous injuries involving approximately 60% of his total body surface area including the head, face, neck, right upper arm, right hand, trunk, perineum, and both lower limbs and feet. Examination at admission showed the following electrolyte concentrations: ionic calcium 0.192 mmol/L, total calcium 0.72 mmol/L, magnesium 0.4 mmol/L, potassium 5.49 mmol/L, and sodium 136.8 mmol/L.

INTERVENTIONS

An initial 20 mL intravenous bolus of 10% calcium gluconate was followed by a continuous infusion at 6 g/h plus continuous intravenous drip 25% magnesium sulfate at 1.5 g/h. Continuous cardiac monitoring was performed in the intensive care unit. Extracorporeal membrane oxygenation (ECMO) was used to improve oxygenation function at 38 hours post exposure. Antibiotic therapy using imipenem/cilastin plus vancomycin was required.

OUTCOMES

After treatment for 12 hours, electrolyte concentrations returned to normal. On day 11, the hemodynamic parameters were stable and oxygenation function had improved. On day 26, the patient was weaned off CRRT. One month later, the patient twice received skin grafting, then was discharged from the hospital without pulmonary, cardiac, or neurological complications 3 months later.

LESSONS

The present case study demonstrates that CRRT may be an effective and potentially lifesaving therapy after severe exposure to HF. Prolonged hemodialysis is recommended to remove delayed release fluoride ions to avoid delayed systemic injury. When conventional therapy can not improve oxygenation and/or carbon dioxide retention, ECMO should be performed as soon as possible.

Implementing a practice change: early initiation of continuous renal replacement therapy during neonatal extracorporeal life support standardizes care and improves short-term outcomes

PURPOSE

We hypothesized that a standardized approach to early continuous renal replacement therapy (CRRT) during neonatal extracorporeal life support (ECLS) results in greater homogeneity of CRRT initiation times with improvements in fluid balance and outcomes.

METHODS

Retrospective analysis of data (2007-2015) obtained from neonates treated prior to (E1; n = 32) and after (E2; n = 31) a 2011 practice change: CRRT initiation within 48 h of ECLS.

RESULTS

Birthweight, gestational age, ECLS mode, and age at ECLS initiation were similar to each epoch. Survival [E1: median 75%, E2: 71%] and length of ECLS [E1: median 221 h, E2: 180 h] were comparable. During E2, 100% of infants received CRRT (vs. E1: 37%; p < 0.001) and 97% of infants initiated CRRT within 48 h of ECLS (vs. E1: 13%; p < 0.001). Control charts demonstrate reduced practice variation. Elapsed time from ECLS to CRRT differed between Epochs [E1: median 105 h, E2: 9 h; p < 0.001] as did weight at CRRT initiation [E1: 4.13 kg (29% above baseline), E2: 3.19 kg (0%); p < 0.001]. Significant differences in weight change were noted on days 6 and 7 (E1: 14%, E2: 2%; raw data comparison yielded p < 0.05) and curves were different (p < 0.05).

CONCLUSIONS

We successfully implemented a practice change, initiating CRRT within 48 h of ECLS cannulation, leading to decreased practice variation and improved short-term outcomes including decreased weight gain at CRRT initiation and faster return to baseline weight during the first 7 days of ECLS. We did not demonstrate changes in duration of ECLS, invasive ventilation, or survival.

3-month prognostic impact of severe acute renal failure under veno-venous ECMO support: Importance of time of onset

PURPOSE

Veno-venous ECMO is increasingly used for the management of refractory ARDS. In this context, acute kidney injury (AKI) is a major and frequent complication, often associated with poor outcome. We aimed to identify characteristics associated with severe renal failure (Kidney Disease Improving Global Outcome (KDIGO) 3) and its impact on 3-month outcome.

METHODS

Between May 2009 and April 2016, 60 adult patients requiring VV-ECMO in our University Hospital were prospectively included.

RESULTS

AKI occurrence was frequent (75%; n=45), 51% of patients (n=31) developed KDIGO 3 - predominantly prior to ECMO insertion - and renal replacement therapy was required in 43% (n=26) of cases. KDIGO 3 was associated with a lower mechanical ventilation weaning rate (24% vs 68% for patients with no AKI or other stages of AKI; p<0.001) and a higher 90-day mortality rate (72% vs 32%, p=0.002). Multivariate logistic regression suggested that KDIGO 3 occurrence prior to ECMO insertion, as well as PaCO2>57mmHg and mSOFA>12 were independent risks factors for 90-day mortality.

CONCLUSION

KDIGO 3 AKI occurrence is correlated with the severity of patients' clinical condition prior to ECMO insertion and is negatively associated with 90-day survival.

Continuous Renal Replacement Therapy: Case Vignettes

The most common indication for continuous renal replacement therapy (CRRT) in critically ill patients is acute kidney injury with hemodynamic instability. Typically, the patient has metabolic disturbances and potential or actual fluid overload that require intervention. Certain critical care diagnoses and/or conditions or therapies present unique CRRT management approaches. Case vignettes are used to present the unique management of CRRT in critically ill patients with rhabdomyolysis, heart failure, and respiratory failure requiring extracorporeal membrane oxygenation.