Continuous renal replacement therapy in patients following traumatic injury

Therapeutic plasma exchange is feasible and tolerable in severely injured patients with trauma-induced coagulopathy

Objectives

Trauma-induced coagulopathy (TIC) occurs in a subset of severely injured trauma patients. Despite having achieved surgical hemostasis, these individuals can have persistent bleeding, clotting, or both in conjunction with deranged coagulation parameters and typically require transfusion support with plasma, platelets, and/or cryoprecipitate. Due to the multifactorial nature of TIC, targeted interventions usually do not have significant clinical benefits. Therapeutic plasma exchange (TPE) is a non-specific modality of removing and replacing a patient's plasma in a euvolemic manner that can temporarily normalize coagulation parameters and remove deleterious substances, and may be beneficial in such patients with TIC.

Methods

In a prospective case series, TPE was performed in severely injured trauma patients diagnosed with TIC and transfusion requirement. These individuals all underwent a series of at least 3 TPE procedures performed once daily with plasma as the exclusive replacement fluid. Demographic, injury, laboratory, TPE, and outcome data were collected and analyzed.

Results

In total, 7 patients received 23 TPE procedures. All patients had marked improvements in routine coagulation parameters, platelet counts, a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS13) activities, inflammatory markers including interleukin-6 concentrations, and organ system injuries after completion of their TPE treatments. All-cause mortality rates at 1 day, 7 days, and 30 days were 0%, 0%, and 43%, respectively, and all patients for whom TPE was initiated within 24 hours after injury survived to the 30-day timepoint. Surgical, critical care, and apheresis nursing personnel who were surveyed were universally positive about the utilization of TPE in this patient population. These procedures were tolerated well with the most common adverse event being laboratory-diagnosed hypocalcemia.

Conclusion

TPE is feasible and tolerable in severely injured trauma patients with TIC. However, many questions remain regarding the application of TPE for these critically ill patients including identification of the optimal injured population, ideal time of treatment initiation, appropriate treatment intensity, and concurrent use of adjunctive treatments.

Level of evidence

Level V.

Development and Validation of a Renal Replacement after Trauma Scoring Tool

BACKGROUND

Stress on the healthcare system requires careful allocation of resources such as renal replacement therapy (RRT). The COVID-19 pandemic generated difficulty securing access to RRT for trauma patients. We sought to develop a renal replacement after trauma (RAT) scoring tool to help identify trauma patients who may require RRT during their hospitalization.

STUDY DESIGN

The 2017 to 2020 TQIP database was divided into a derivation (2017 to 2018 data) and validation (2019 to 2020 data) set. A 3-step methodology was used. Adult trauma patients admitted from the emergency department to the operating room or ICU were included. Patients with chronic kidney disease, transfers from another hospital, and emergency department death were excluded. Multiple logistic regression models were created to determine the risk for RRT in trauma patients. The weighted average and relative impact of each independent predictor was used to derive a RAT score, which was validated using area under receiver operating characteristic curve (AUROC).

RESULTS

From 398,873 patients in the derivation and 409,037 patients in the validation set, 11 independent predictors of RRT were included in the RAT score derived with scores ranging from 0 to 11. The AUROC for the derivation set was 0.85. The rate of RRT increased to 1.1%, 3.3%, and 20% at scores of 6, 8, and 10, respectively. The validation set AUROC was 0.83.

CONCLUSIONS

RAT is a novel and validated scoring tool to help predict the need for RRT in trauma patients. With future improvements including baseline renal function and other variables, the RAT tool may help prepare for the allocation of RRT machines/staff during times of limited resources.

Primary injuries and secondary organ failures in trauma patients with acute kidney injury treated with continuous renal replacement therapy

Background. Acute kidney injury (AKI) treated with continuous renal replacement therapy (CRRT) is a severe complication in trauma patients. The aim of the study was to assess primary traumatic injuries and secondary organ failures in severe posttraumatic AKI. Methods. Retrospective review of adult trauma patients admitted to the trauma centre at Oslo University Hospital Ullevål. Injury severity score (ISS) was used to assess the severity of primary injuries, and sequential organ failure assessment (SOFA) score was utilized to measure secondary organ failures. Results. Forty-two (8%) of 506 trauma patients admitted to intensive care unit developed AKI treated with CRRT, whereof 40 (95%) suffered blunt trauma mechanisms. Patients had extensive primary organ injuries with median (interquartile range) ISS 36 (27-49). The majority of the patients had respiratory (93% intubated) and cardiovascular (67% with inotropic and/or vasoactive medication) failure within 24 hours after admission. AKI was often part of multiple organ failure, most frequently respiratory and cardiovascular failure, affecting 33 (75%) and 30 (71%) of the patients, respectively. Conclusion. Trauma patients with AKI undergoing CRRT often had severe primary injuries due to blunt trauma. Most of them suffered from secondary multiple organ failure concomitant to AKI.

Practical considerations for the dosing and adjustment of continuous renal replacement therapy in the intensive care unit

Familiarity with the initiation, dosing, adjustment, and termination of continuous renal replacement therapy (CRRT) is a core skill for contemporary intensivists. Guidelines for how to administer CRRT in the intensive care unit are not well documented. The purpose of this review is to discuss the modalities, terminology, and components of CRRT, with an emphasis on the practical aspects of dosing, adjustments, and termination. Management of electrolyte and acid-base derangements commonly encountered with acute renal failure is emphasized. Knowledge regarding the practical aspects of managing CRRT in the intensive care unit is a prerequisite for achieving desired physiological end points.

Variability in Uremic Control during Continuous Venovenous Hemodiafiltration in Trauma Patients

Introduction. Acute kidney injury (AKI) necessitating continuous renal replacement therapy (CRRT) is a severe complication in trauma patients (TP). We wanted to assess daily duration of CRRT and its impact on uremic control in TP. Material and Methods. We retrospectively reviewed adult TP, with or without rhabdomyolysis, with AKI undergoing CRRT. Data on daily CRRT duration and causes for temporary stops were collected from the first five CRRT days. Uremic control was assessed by daily changes in serum urea (Δurea) and creatinine (Δcreatinine) concentrations. Results. Thirty-six TP were included with a total of 150 CRRT days, 17 (43%) with rhabdomyolysis. The median (interquartile range (IQR)) time per day with CRRT was 19 (15–21) hours. There was a significant correlation between daily CRRT duration and Δurea (r = 0.60, P≤0.001) and Δcreatinine (r = 0.43; P = 0.012). CRRT pauses were caused by filter clotting (54%), therapeutic interventions (25%), catheter related problems (10%), filter timeout (6%), and diagnostic procedures (6%). Rhabdomyolysis did not affect the CRRT data. Conclusions. TP undergoing CRRT had short daily CRRT duration causing reduced uremic control. Clinicians should modify their daily clinical practice to improve technical skills and achieve sufficient dialysis dose.

Montelukast abrogates rhabdomyolysis-induced acute renal failure via rectifying detrimental changes in antioxidant profile and systemic cytokines and apoptotic factors production

In addition to antiasthmatic effect, the cysteinyl leukotriene receptor 1 (CysLT₁) antagonist montelukast shows renoprotective effect during ischemia/reperfusion and cyclosporine-induced renal damage. Here, we proposed that montelukast protects against rhabdomyolysis-induced acute renal failure. Compared with saline-treated rats, at 48 h following the induction of rhabdomyolysis using intramuscular glycerol (10 ml 50% glycerol/kg), significant elevations in serum levels of urea, creatinine, phosphate and acute renal tubular necrosis were observed. This was associated with elevations in serum Fas, interleukin-10, tumor necrotic factor-alpha, and transforming growth factor-beta1 and renal malondialdehyde and nitrite and detrimental reductions in renal catalase and superoxide dismutase activities. The effects of rhabdomyolysis on renal functional, biochemical and structural integrity and the associated changes in cytokines and Fas levels were abolished upon concurrent administration of montelukast (10 mg/kg i.p.) for 3 days (1 day before and 2 days after induction of rhabdomyolysis). Alternatively, administration of the anti-oxidant, α-tocopherol (400 mg/kg i.m.) for 3 days, succeeded in alleviating renal oxidative stress, but had no significant effect on the circulating levels of most cytokines and partially restored kidney functional and structural damage. Serum level of interleukin-6 was not altered by rhabdomyolysis but showed significant elevations in rats treated with montelukast or α-tocopherol. Collectively, motelukast abrogated functional and structural renal damage induced by rhabdomyolysis via ameliorating renal oxidative stress and modulation of systemic cytokines and apoptotic factors production. The results of this work are expected to open new avenues for early prevention of rhabdomyolysis-induced acute renal failure using selective CysLT₁ antagonists such as montelukast.

A portable continuous blood purification machine for emergency rescue in disasters

BACKGROUND

Continuous renal replacement therapy plays an important role in emergency rescue. Currently, no continuous renal replacement therapy machine can be used under unstable conditions as the fluid flow of these machines is controlled electronically. A novel machine that can provide emergency continuous renal replacement therapy in disaster rescue is therefore needed.

METHODS

Based on a volumetric metering method, a prototype portable continuous blood purifier based on a volumetric metering method was developed. Basic performance tests, special environmental tests, animal experiments and clinical use of the novel machine were completed to test and verify its performance under unstable conditions.

RESULTS

All tests completed showed that the machine met the requirements of the national industry standards with a size reduced to approximately one half of the Baxter Aquarius machine. The clearance of harmful substances by the machine described here was equal to that of the Baxter Aquarius machine and was adequate for clinical purposes.

CONCLUSIONS

The novel prototype performed well in all situations tested and can aid rescue work on disaster sites.

Acute kidney injury with renal replacement therapy in trauma patients

BACKGROUND

Acute kidney injury (AKI) with renal replacement therapy (RRT) is rare in trauma patients. The primary aim of the study was to assess incidence, mortality and chronic RRT dependency in this patient group.

METHODS

Adult trauma patients with AKI receiving RRT at a regional trauma referral center over a 12-year period were retrospectively reviewed.

RESULTS

Population-based incidence of post-traumatic AKI with RRT was 1.8 persons per million inhabitants per year (p.p.m./year) [95% confidence the interval (CI) 1.5-2.1 p.p.m./year]. In trauma patients admitted to hospital, incidence was 0.5 per thousand (95% CI 0.3-0.7 per thousand) of those treated in intensive care unit (ICU), it was 8.3% (95% CI 5.9-10.8%). The median age was 46 years. Odds ratio (OR) for post-traumatic AKI requiring RRT was higher in males than in females in general population (OR 5.6, 95% CI 2.2-14.0), and in trauma patients admitted to hospital (OR 4.4, 95% CI 1.9-10.3) and ICU (OR 4.5, 95% CI 1.9-10.7). The in-hospital mortality rate was 24% (95% CI 11-37%), 3-month mortality 36% (95% CI 21-51%) and 1-year mortality 40% (95% CI 25-55%). Age was a risk factor for death after 1 year, with 57% (95% CI 7-109%) increased risk for each 10 years added. None of the survivors was dialysis-dependent 3 months or 1 year after trauma.

CONCLUSION

AKI in trauma patients requiring RRT was rare in this single-center study. More males than females were affected. Mortality was modest, and renal recovery was excellent as none of the survivors became dependent on chronic RRT.

Critical care organ support: a focus on extracorporeal systems

PURPOSE OF REVIEW

An extensive search of the literature published in the past 2 years related to critical care organ support was undertaken. This review is limited to those that focus on extracorporeal life support modalities for adults.

RECENT FINDINGS

Traditional indications for extracorporeal life support such as oxygenation, carbon dioxide exchange and support of perfusion have expanded to include solute and toxin clearance for kidney, liver and potentially neurological failure. Enhanced understanding of cell-mediated mechanisms of injury may explain multiple-organ dysfunction following single-organ damage. Extracorporeal life support systems can be used safely in patients with traumatic brain, chest, and abdominal injury. 'Emergency perfusion and resuscitation' following traumatic exsanguination is entering clinical trials.

SUMMARY

Multiple-organ dysfunction followed by traumatic injury can be treated with multiple-organ support. A total extracorporeal organ support system may be used in the future as a portable, bedside organ support device.