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Huang X, Gao Y, Chen X, Mei Y, Zhang H, Tian Y, Wu J. Optimizing the connection of CRRT and ECMO lines with additional pressure regulator on the therapeutic effect, filter life, and incidence of complications. Medicine (Baltimore) 2024; 103:e38580. [PMID: 38905421 PMCID: PMC11191920 DOI: 10.1097/md.0000000000038580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 05/23/2024] [Indexed: 06/23/2024] Open
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is used for severe cardiopulmonary failure, with veno-arterial ECMO for cardiogenic shock and veno-venous ECMO for acute respiratory failure. ECMO's application has expanded to ICUs, emergency departments, and operating rooms. ECMO patients are at high risk for complications, including acute kidney injury (AKI), often requiring renal replacement therapy (RRT), posing significant management challenges. METHODS From August 2015 to June 2022, 120 patients were cured with veno-venous ECMO (n = 60) or veno-arterial ECMO (VA-ECMO, n = 60) combined with CRRT in our hospital. In the control group (n = 60), the input end (arterial end) of CRRT was connected to the ECMO oxygenator. The reinfusion end (venous end) of CRRT was connected to the oxygenator of ECMO for CRRT + ECMO treatment. In the experimental group (n = 60), the input end (arterial end) of CRRT was connected to the oxygenator of ECMO, and an additional pressure regulating device was installed on the connection of the 2 lines. The observation indexes including clinical therapeutic effect, clinical therapeutic effect, the incidence of complications, and the incidence of complications were compared. RESULTS There was a notable decrease in serum creatinine, and the differences in blood urea nitrogen, procalcitonin, and C-reactive protein after operation were statistically significant (P < .05). The filter use time in the study group was notably longer (P < .01). There exhibited no remarkable difference in the incidences of bleeding, thrombosis, numbness of hands and feet, metabolic alkalosis, disseminated intravascular coagulation, organ dysfunction syndrome, hyperbilirubinemia, and infection. CONCLUSION This study demonstrates that additional pressure regulation devices are installed at the line connection between the CRRT input end and the CRRT return end to ensure that the flow rate of ECMO does not affect the CRRT treatment. ECMO and CRRT provide a safe pressure range so that the ECMO line can be safely connected to the CRRT machine at physiological pressure, reducing the occurrence of complications related to CRRT machine interruption and improving the efficiency of CRRT without affecting the efficiency of ECMO, ensuring patient safety.
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Affiliation(s)
- Xihua Huang
- The First Affiliated Hospital of Nanjing Medical University (Jiangsu Province Hospital), EICU (Emergency Intensive Care Unit), Nanjing, Jiangsu, China
| | - Yongxia Gao
- The First Affiliated Hospital of Nanjing Medical University (Jiangsu Province Hospital), EICU (Emergency Intensive Care Unit), Nanjing, Jiangsu, China
| | - Xufeng Chen
- The First Affiliated Hospital of Nanjing Medical University (Jiangsu Province Hospital), EICU (Emergency Intensive Care Unit), Nanjing, Jiangsu, China
| | - Yong Mei
- The First Affiliated Hospital of Nanjing Medical University (Jiangsu Province Hospital), EICU (Emergency Intensive Care Unit), Nanjing, Jiangsu, China
| | - Hui Zhang
- The First Affiliated Hospital of Nanjing Medical University (Jiangsu Province Hospital), EICU (Emergency Intensive Care Unit), Nanjing, Jiangsu, China
| | - Yali Tian
- The First Affiliated Hospital of Nanjing Medical University (Jiangsu Province Hospital), EICU (Emergency Intensive Care Unit), Nanjing, Jiangsu, China
| | - Juan Wu
- The First Affiliated Hospital of Nanjing Medical University (Jiangsu Province Hospital), EICU (Emergency Intensive Care Unit), Nanjing, Jiangsu, China
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Noel C, Green A, Florea I, Puri N, Dawson S, Gorski M, Rios R, Kouch M. A novel configuration for providing continuous renal replacement therapy via the ECMO circuit in VV ECMO without alarm adjustment. Perfusion 2024:2676591241263268. [PMID: 38896838 DOI: 10.1177/02676591241263268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024]
Abstract
BACKGROUND It is common for patients on venovenous extracorporeal membrane oxygenation (VV ECMO) to require continuous renal replacement therapy (CRRT). This can be done using separate vascular access for the CRRT circuit, by placing the CRRT hemofilter within the ECMO circuit, or through a separate CRRT circuit connected to the ECMO circuit. When a CRRT circuit is connected to the ECMO circuit, the inflow and outflow CRRT limbs can both be placed pre-ECMO pump or the CRRT circuit can span the ECMO pump, with the CRRT inflow post-ECMO pump and the outflow pre-ECMO pump. Both configurations require the CRRT alarms to be inactivated due to high positive pressure experienced post-pump and low negative pressure pre-pump. We describe a novel technique that does not require separate venous access and still allows the CRRT alarms to be activated. TECHNIQUE The CRRT inflow line is connected to the post-oxygenator de-airing port. The CRRT outflow line is connected to the pre-pump side of the ECMO circuit. Pigtails allow for these connections and act as resistors negating the large range of pressures generated by the ECMO centrifugal pump. RESULTS We implemented this configuration in 11 patients with 100% success rate allowing for alarms to be maintained in all patients. The median number of interruptions per 100 CRRT days was 11.7. The median CRRT filter lifespan was 2.2 days, and the average blood flow was maintained at 311 mL/min. CONCLUSIONS This configuration allows for efficient use of CRRT in ECMO patients while maintaining the safety alarms on the CRRT machine.
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Affiliation(s)
- Christopher Noel
- Department of Medicine, Division of Critical Care Medicine, Cooper University Healthcare, Camden, NJ, USA
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Adam Green
- Department of Medicine, Division of Critical Care Medicine, Cooper University Healthcare, Camden, NJ, USA
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Ioana Florea
- Cooper Medical School of Rowan University, Camden, NJ, USA
- Department of Surgery, Cooper University Healthcare, Camden, NJ, USA
| | - Nitin Puri
- Department of Medicine, Division of Critical Care Medicine, Cooper University Healthcare, Camden, NJ, USA
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Solomon Dawson
- Cooper Medical School of Rowan University, Camden, NJ, USA
- Department of Medicine, Division of Nephrology, Cooper University Healthcare, Camden, NJ, USA
| | - Meghan Gorski
- Department of Medicine, Division of Critical Care Medicine, Cooper University Healthcare, Camden, NJ, USA
| | - Robert Rios
- Department of Surgery, Division of Cardiothoracic Surgery, Cooper University Healthcare, Camden, NJ, USA
| | - Michael Kouch
- Department of Medicine, Division of Critical Care Medicine, Cooper University Healthcare, Camden, NJ, USA
- Cooper Medical School of Rowan University, Camden, NJ, USA
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Raina R, Nair N, Pelletier J, Nied M, Whitham T, Doshi K, Beck T, Dantes G, Sethi SK, Kim YH, Bunchman T, Alhasan K, Lima L, Guzzo I, Fuhrman D, Paden M. Concurrent use of continuous kidney replacement therapy during extracorporeal membrane oxygenation: what pediatric nephrologists need to know-PCRRT-ICONIC practice points. Pediatr Nephrol 2024:10.1007/s00467-024-06311-x. [PMID: 38386072 DOI: 10.1007/s00467-024-06311-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Revised: 01/15/2024] [Accepted: 01/27/2024] [Indexed: 02/23/2024]
Abstract
Extracorporeal membrane oxygenation (ECMO) provides temporary cardiorespiratory support for neonatal, pediatric, and adult patients when traditional management has failed. This lifesaving therapy has intrinsic risks, including the development of a robust inflammatory response, acute kidney injury (AKI), fluid overload (FO), and blood loss via consumption and coagulopathy. Continuous kidney replacement therapy (CKRT) has been proposed to reduce these side effects by mitigating the host inflammatory response and controlling FO, improving outcomes in patients requiring ECMO. The Pediatric Continuous Renal Replacement Therapy (PCRRT) Workgroup and the International Collaboration of Nephrologists and Intensivists for Critical Care Children (ICONIC) met to highlight current practice standards for ECMO use within the pediatric population. This review discusses ECMO modalities, the pathophysiology of inflammation during an ECMO run, its adverse effects, various anticoagulation strategies, and the technical aspects and outcomes of implementing CKRT during ECMO in neonatal and pediatric populations. Consensus practice points and guidelines are summarized. ECMO should be utilized in patients with severe acute respiratory failure despite the use of conventional treatment modalities. The Extracorporeal Life Support Organization (ELSO) offers guidelines for ECMO initiation and management while maintaining a clinical registry of over 195,000 patients to assess outcomes and complications. Monitoring and preventing fluid overload during ECMO and CKRT are imperative to reduce mortality risk. Clinical evidence, resources, and experience of the nephrologist and healthcare team should guide the selection of ECMO circuit.
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Affiliation(s)
- Rupesh Raina
- Department of Nephrology, Akron Children's Hospital, Akron, OH, USA.
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA.
| | - Nikhil Nair
- Case Western University School of Medicine, Cleveland, OH, USA
| | - Jonathan Pelletier
- Division of Critical Care Medicine, Department of Pediatrics, Akron Children's Hospital, Akron, OH, USA
- Department of Pediatrics, College of Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Matthew Nied
- Department of Internal Medicine, Case Western Reserve / University Hospitals, Cleveland, OH, USA
| | - Tarik Whitham
- Department of Pediatrics, College of Medicine, Northeast Ohio Medical University, Rootstown, OH, USA
| | - Kush Doshi
- Akron Nephrology Associates/Cleveland Clinic Akron General Medical Center, Akron, OH, USA
| | - Tara Beck
- Department of Pediatrics, University of Pittsburgh Medical Center Children's Hospital, Pittsburgh, PA, USA
| | - Goeto Dantes
- Department of Surgery, Emory University, Atlanta, GA, USA
| | - Sidharth Kumar Sethi
- Pediatric Nephrology, Kidney Institute, Medanta, The Medicity, Gurgaon, Haryana, India
| | - Yap Hui Kim
- Department of Pediatrics, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Timothy Bunchman
- Department of Pediatric Nephrology, Children's Hospital of Richmond, Richmond, VA, USA
| | - Kahild Alhasan
- Pediatric Nephrology, King Saud University, Riyadh, Saudi Arabia
| | - Lisa Lima
- Department of Pediatric Critical Care, Emory University, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Isabella Guzzo
- Division of Nephrology and Dialysis, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Dana Fuhrman
- Department of Pediatrics, University of Pittsburgh Medical Center Children's Hospital, Pittsburgh, PA, USA
| | - Matthew Paden
- Department of Pediatric Critical Care, Emory University, Children's Healthcare of Atlanta, Atlanta, GA, USA
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Wu J, Huang X, Mei Y, Lv J, Li W, Hu D, Zhang G, Zhang H, Gao Y, Zhang H, Chen X, Sun F. Impact of connecting methods of continuous renal replacement therapy device on patients underwent extracorporeal membrane oxygenation: A retrospectively observational study. Aust Crit Care 2023; 36:695-701. [PMID: 36610945 DOI: 10.1016/j.aucc.2022.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 11/02/2022] [Accepted: 11/03/2022] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVE The objective of this study was to compare the safety and efficiency of different extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT) connection methods. BACKGROUND The number of patients receiving ECMO is increasing, and the fields of application are getting wider. However, patients receiving ECMO are prone to acute kidney injury and fluid overload requiring CRRT. There are few comparative studies of two different systems of connecting CRRT device and ECMO from safety and efficacy perspective. METHODS This retrospective observational study included patients receiving ECMO in the extracorporeal life support centre of the First Affiliated Hospital of Nanjing Medical University from June, 2015, to December, 2020. Patients were divided into the parallel system group and integrated system group according to the connecting method between ECMO circuit and CRRT line. The outcomes were discharge survival rate, CRRT therapeutic dose completion rate, CRRT catheterisation time, CRRT initiating time, local bleeding at the CRRT catheter site, mean filter life, ECMO circuit thrombosis, ECMO air leakage, or blood leakage due to CRRT. RESULTS Thirty patients in the parallel system group and 70 patients in the integrated system group were finally included. The discharge survival rate and CRRT therapeutic dose completion rate were not significantly different between the two groups. The parallel system group had significant longer CRRT initiating time (49.0 ± 12.1 min vs. 14.6 ± 2.1 min, P < 0.001) and shorter filter life (11.5 ± 3.2 h vs. 47.3 ± 14.0 h, P < 0.001) than the integrated system group. The occurrence rate of local bleeding was 93.3% in the parallel system group, and there is no bleeding case in the integrated system group. There was no case of ECMO circuit thrombosis from CRRT as well as ECMO air or blood leakage caused by CRRT in either group. ECMO therapy can be adapted by adjusting the position of the CRRT outlet in the integrated system. CONCLUSIONS Connecting CRRT and ECMO as an integrated system might accelerate CRRT initiation, avoid local bleeding, and prolong filter life compared to the parallel system. The chance of developing CRRT-related ECMO circuit leak and thrombosis is manageable.
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Affiliation(s)
- Juan Wu
- Emergency Department, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Xihua Huang
- Emergency Department, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Yong Mei
- Emergency Department, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Jinru Lv
- Emergency Department, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Wei Li
- Emergency Department, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Deliang Hu
- Emergency Department, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Gang Zhang
- Emergency Department, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Huazhong Zhang
- Emergency Department, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Yongxia Gao
- Emergency Department, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Hui Zhang
- Emergency Department, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Xufeng Chen
- Emergency Department, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China
| | - Feng Sun
- Emergency Department, The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu 210029, China.
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Arnold F, Wobser R, Kalbhenn J, Westermann L. Integration of sustained low-efficiency dialysis into extracorporeal membrane oxygenation circuit in critically ill COVID-19 patients - a feasibility study. Artif Organs 2022; 46:1847-1855. [PMID: 35490349 PMCID: PMC9347788 DOI: 10.1111/aor.14277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Revised: 03/29/2022] [Accepted: 04/11/2022] [Indexed: 11/29/2022]
Abstract
Background Severe COVID‐19 can necessitate multiple organ support including veno‐venous extracorporeal membrane oxygenation (vvECMO) and renal replacement therapy. The therapy can be complicated by venous thromboembolism due to COVID‐19‐related hypercoagulability, thus restricting vascular access beyond the vvECMO cannula. Although continuous renal replacement therapy can be performed via a vvECMO circuit, studies addressing sustained low‐efficiency dialysis (SLED) integration into vvECMO circuits are scarce. Here we address the lack of evidence by evaluating feasibility of SLED integration into vvECMO circuits. Methods Retrospective cohort study on nine critically ill COVID‐19 patients, treated with integrated ECMO‐SLED on a single intensive care unit at a tertiary healthcare facility between December 2020 and November 2021. The SLED circuits were established between the accessory arterial oxygenator outlets of a double‐oxygenator vvECMO setup. Data on filter survival, quality of dialysis, and volume management were collected and compared with an internal control group receiving single SLED. Results This study demonstrates general feasibility of SLED integration into existing vvECMO circuits. Filter lifespans of ECMO‐SLED compared with single SLED are significantly prolonged (median 18.3 h vs. 10.3 h, p < 0.01). ECMO‐SLED treatment is furthermore able to sufficiently normalize creatinine, blood urea nitrogen, and serum sodium, and allows for adequate ultrafiltration rates. Conclusions We can show that ECMO‐SLED is practical, safe, results in adequate dialysis quality and enables sufficient electrolyte and volume management. Our data indicate that SLED devices can serve as potential alternative to continuous‐veno‐venous‐hemodialysis for integration in vvECMO circuits.
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Affiliation(s)
- Frederic Arnold
- Department of Medicine IV, Medical Center, Faculty of Medicine University of Freiburg, Freiburg, Germany.,Institute for Microbiology and Hygiene, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Berta-Ottenstein-Programme for Clinician Scientists, Faculty of Medicine, University of Freiburg, Germany
| | - Rika Wobser
- Department of Medicine IV, Medical Center, Faculty of Medicine University of Freiburg, Freiburg, Germany
| | - Johannes Kalbhenn
- Anesthesiology and Critical Care, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Lukas Westermann
- Department of Medicine IV, Medical Center, Faculty of Medicine University of Freiburg, Freiburg, Germany
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Zeidman AD. Extracorporeal Membrane Oxygenation and Continuous Kidney Replacement Therapy: Technology and Outcomes - A Narrative Review. Adv Chronic Kidney Dis 2021; 28:29-36. [PMID: 34389134 DOI: 10.1053/j.ackd.2021.04.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 03/31/2021] [Accepted: 04/14/2021] [Indexed: 11/11/2022]
Abstract
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.
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