Training and Maintaining: Developing a Successful and Dynamic Continuous Renal Replacement Therapy Program

Anticoagulation Strategies for Continuous Renal Replacement Therapy in France: A Survey of Practices

INTRODUCTION

Anticoagulation for continuous renal replacement therapy (CRRT) can be performed using systemic anticoagulation or regional citrate anticoagulation (RCA). The 2012 Kidney Disease Improving Global Outcomes guidelines support the use of RCA as the first-line strategy in patients requiring CRRT, with and without bleeding risk. Implementing RCA in the intensive care unit (ICU) implies involving all medical and nursing staff. The primary objective of this study was to report and describe the various anticoagulation strategies for CRRT in French ICUs. The secondary objectives were to determine the rate of RCA use and to identify the factors limiting its implementation.

METHODS

An online questionnaire containing 40 questions was sent to attending physicians and fellows practicing in French ICUs between May and September 2021. The questionnaire was sent via several networks: mailing list from the French Society of Anesthesia and Intensive Care Medicine and mailing lists of RRT manufacturers.

RESULTS

A total of 597 responses were analyzed. RCA was used by most of the participants for patients with (81%) and without (80%) increased bleeding risk. The preferred CRRT modality of the participants while using RCA was continuous veno-venous hemodialysis (48%). The clinical situations frequently reported as an absolute contraindication to RCA were uncontrolled shock associated with liver failure and drug poisoning impairing citrate metabolism (62% and 52%, respectively). In case of a higher risk of citrate accumulation, most participants claimed to perform closer biological monitoring (57%) or to modify the CRRT protocol (61%). Among the participants who did not prescribe RCA as a first-line strategy, the main factors limiting its implementation were the lack of nurse (50%) or physician (34%) training.

CONCLUSION

RCA is the main anticoagulation strategy prescribed for CRRT in France. Providing medical and nursing staff easy access to training may facilitate the understanding and use of RCA as the first-line anticoagulation strategy for CRRT.

Kidney support for babies: building a comprehensive and integrated neonatal kidney support therapy program

Kidney support therapy (KST), previously referred to as Renal Replacement Therapy, is utilized to treat children and adults with severe acute kidney injury (AKI), fluid overload, inborn errors of metabolism, and kidney failure. Several forms of KST are available including peritoneal dialysis (PD), intermittent hemodialysis (iHD), and continuous kidney support therapy (CKST). Traditionally, extracorporeal KST (CKST and iHD) in neonates has had unique challenges related to small patient size, lack of neonatal-specific devices, and risk of hemodynamic instability due to large extracorporeal circuit volume relative to patient total blood volume. Thus, PD has been the most commonly used modality in infants, followed by CKST and iHD. In recent years, CKST machines designed for small children and novel filters with smaller extracorporeal circuit volumes have emerged and are being used in many centers to provide neonatal KST for toxin removal and to achieve fluid and electrolyte homeostasis, increasing the options available for this unique and vulnerable group. These new treatment options create a dramatic paradigm shift with recalibration of the benefit: risk equation. Renewed focus on the infrastructure required to deliver neonatal KST safely and effectively is essential, especially in programs/units that do not traditionally provide KST to neonates. Building and implementing a neonatal KST program requires an expert multidisciplinary team with strong institutional support. In this review, we first describe the available neonatal KST modalities including newer neonatal and infant-specific platforms. Then, we describe the steps needed to develop and sustain a neonatal KST team, including recommendations for provider and nursing staff training. Finally, we describe how quality improvement initiatives can be integrated into programs.

Optimizing continuous renal replacement therapy in the ICU: a team strategy

PURPOSE OF REVIEW

The consideration of acute kidney injury, its incidence and its impact on the outcome of patients has grown continuously in recent years, leading to an increase in the use of renal replacement therapy (RRT) techniques. However, the successful conduct of RRT depends on the effectiveness of the entire team, doctors and nurses. It is therefore important to know the essential elements to be implemented in the ICU to ensure optimal RRT.

RECENT FINDINGS

Recent studies show that the successful conduct of a RRT session requires a good knowledge of the principles of the technique, regular basic training, identification of experts, drafting clear and well followed protocols and good communication between the various stakeholders. In addition, the use of the latest advances, such as regional citrate anticoagulation, allows further optimization of therapy, only if, again, both physicians and nurses are properly trained and highly involved.

SUMMARY

We now have a better understanding of the measures to be deployed to optimize RRT. Organization, training, evaluation and protocols are the key points of the team's efficiency for a safe and effective implementation of RRT.

La formation des nouveaux professionnels arrivants en service de réanimation et en unités de soins continus par la simulation :« Gestion des situations critiques, un enjeu pour la sécurité du patient »

Les professionnels du service de réanimation du centre hospitalier Bretagne-Atlantique et de l’institut de formation des professionnels de santé de Vannes ont réalisé une formation relative à la gestion des situations critiques en réanimation et en unité de soins continus (USC). Cette formation a été construite suite aux constats suivants : 1) d’une part, les infirmières exerçant dans ces services ne bénéficient pas, en France, d’une spécialisation qualifiante ; 2) d’autre part, leur formation initiale ne leur permet pas d’être autonomes dans la gestion de l’imprévu dans ces services de haute technicité ; 3) pour autant, une expertise est nécessaire afin d’être performant dans la gestion des situations d’urgence mettant en jeu le pronostic vital du patient. Au regard de cette problématique, des événements critiques issus de la pratique professionnelle ont été scénarisés pour faire l’objet d’une formation en pratique simulée. Les infirmiers du territoire de santé affectés en réanimation et en USC ont ainsi pu expérimenter les situations à travers la simulation en santé. Cette méthode est particulièrement adaptée en matière de développement de compétences spécifiques dans ce contexte, car elle conjugue analyse de la pratique, réflexion sur l’action, apport de connaissances, mise en oeuvre de bonnes pratiques et coordination des actions. L’expérience de cette action de formation et son bilan sont présentés dans cet article.