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Lord S, Lee J. Critical Care in the Austere Environment. Crit Care Clin 2024; 40:451-462. [PMID: 38796220 DOI: 10.1016/j.ccc.2024.03.006] [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] [Indexed: 05/28/2024]
Abstract
Practice of critical care in austere settings involves navigating rapidly evolving environments, where physical resources, provider availability, and healthcare capacity are constrained. Austere Critical Care focuses on maintaining the highest standard of care possible for patients while also identifying resource limitations, responding to patient surges, and adhering to proper triage practices at the austere site. This includes transferring the patient when able and necessary. This article describes the current practice of critical care medicine in the austere environment, using recent natural disasters, pandemics, and conflicts as case studies.
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Affiliation(s)
- Spencer Lord
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA.
| | - Jarone Lee
- Department of Surgery, Division of Trauma, Emergency Surgery and Surgical Critical Care, Massachusetts General Hospital, Boston, MA, USA
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Lanker SL, Pino CJ, Humes HD, Chawla L, Johnston KA. In vivo Assessment of a Manual Single Lumen Alternating Micro-Batch Hemodiafiltration System. Blood Purif 2024; 53:650-656. [PMID: 38537620 DOI: 10.1159/000538358] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 03/11/2024] [Indexed: 08/09/2024]
Abstract
INTRODUCTION The manual single lumen alternating micro-batch hemodiafiltration (mSLAMB) system is a closed-loop dialysis system designed to provide kidney support in emergency situations (e.g., fluid overload, hyperkalemia, acidemia). If done repeatedly in small batches and at high flow rates, this system was found to achieve clearance levels comparable to traditional renal replacement therapy. METHODS Using a porcine model, uremic toxins and exogenous fluorescent tracer concentrations were successfully lowered within just 1 h of treatment. RESULTS With a maximal dialysate flow, mSLAMB can achieve decreases in serum potassium concentration of >0.5 mmol/L/h. With the mSLAMB hemodiafiltration system, micro-batch processing was also successful in removing up to 250 mL of ultrafiltrate in 8 cycles. CONCLUSION This process could create a better fluid balance allowing for administering therapeutic fluids such as sodium bicarbonate in the clinic. Electrolyte imbalance and volume overload remain severe life-threatening emergencies in low resource settings; therefore, mSLAMB should be explored further due to its modest vascular access requirements, low cost, and ability to be performed without electricity or batteries.
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Affiliation(s)
| | | | - H David Humes
- Innovative BioTherapies Inc, Ann Arbor, Michigan, USA
| | - Lakhmir Chawla
- Veterans Affairs Medical Center, San Diego, California, USA
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US Navy Ship-Based Disaster Response: Lessons Learned. CURRENT TRAUMA REPORTS 2022; 8:138-146. [PMID: 35529774 PMCID: PMC9061935 DOI: 10.1007/s40719-022-00227-3] [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] [Accepted: 04/06/2022] [Indexed: 11/12/2022]
Abstract
Purpose of Review The US Navy has a long history of responding to disasters around the globe. US Navy ships have unique characteristics and capabilities that determine their capacity for a disaster response. This paper discusses common considerations and lessons learned from three distinct disaster missions. Recent Findings The 2010 earthquake in Haiti had a robust response with multiple US Navy ship platforms. It was best assessed in three phases: an initial mass casualty response, a subacute response, and a humanitarian response. The 2017 response to Hurricane Maria had a significant focus on treating patients with acute needs secondary to chronic illnesses to decrease the burden on the local healthcare system. The COVID-19 response brought distinctive challenges as it was the first mission where hospital ships were utilized in an infectious disease deployment. Summary The first ships to respond to a disaster will need to focus on triage and acute traumatic injury. After this first phase, the ship’s medical assets will need to focus on providing care in a disrupted health care system which most often includes acute exacerbations of chronic disease. Surgeons must be ready to be flexible in their responsibilities, be competent with end-of-life care, and negotiate technical and cultural communication challenges.
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Sekkarie M, Hiracham P, Soudan K, Rifai AO. Hemodialysis Machines Capable of Performing Isolated Ultrafiltration in the Absence of Adequate Water Supply Are Needed During Disasters. Kidney Int Rep 2021; 6:1480-1481. [PMID: 34013130 PMCID: PMC8116769 DOI: 10.1016/j.ekir.2021.03.875] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Accepted: 03/08/2021] [Indexed: 11/24/2022] Open
Affiliation(s)
- Mohamed Sekkarie
- Nephrology and Hypertension Associates, Bluefield, West Virginia, USA
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Abstract
Disasters occur regularly, and frequently large numbers of patients treated with maintenance dialysis or with the recent onset of acute kidney injury are put at risk owing to the lack of access to dialysis care precipitating also a kidney failure disaster. The absence of necessary dialysis treatments can result in excessive emergency department visits, hospitalizations, morbidity, or an early death. Those with kidney failure are often evaluated in disaster medical locations or hospitals without nephrologists in attendance. Here we offer guidance for medical personnel evaluating such patients so that dialysis-dependent individuals can be properly assessed and managed with the need for urgent dialysis recognized. A disaster dialysis triage system is proposed. (Disaster Med Public Health Preparedness. 2019;13:782-790).
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Glaser J, Zeman J, Noble S, Fernandez N. CAVH in the Combat Environment: A Case Report and Lessons Learned in Southern Afghanistan. Mil Med 2019; 183:e167-e171. [PMID: 29401336 DOI: 10.1093/milmed/usx017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Accepted: 10/20/2017] [Indexed: 11/15/2022] Open
Abstract
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.
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Affiliation(s)
- Jacob Glaser
- Naval Medical Research Unit San Antonio, Combat Casualty Care Directorate, 3650 Chambers Pass JBSA Fort Sam Houston, San Antonio, TX 78234
| | - Joseph Zeman
- Department of Pulmonary Critical Care, Walter Reed National Military Medical Center, 8901 Wisconsin Avenue, Bethesda, MD 20889
| | - Stephen Noble
- Department of Cardiothoracic Surgery, Naval Medical Center Portsmouth, 620 John Paul Jones Circle, Portsmouth, VA 23708
| | - Nathanial Fernandez
- Department of Vascular Surgery, Naval Medical Center San Diego, 34800 Bob Wilson Dr, San Diego, CA 92134
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Gorbatkin C, Bass J, Finkelstein FO, Gorbatkin SM. Peritoneal Dialysis in Austere Environments: An Emergent Approach to Renal Failure Management. West J Emerg Med 2018; 19:548-556. [PMID: 29760854 PMCID: PMC5942023 DOI: 10.5811/westjem.2018.3.36762] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Revised: 02/16/2018] [Accepted: 03/09/2018] [Indexed: 12/26/2022] Open
Abstract
Peritoneal dialysis (PD) is a means of renal replacement therapy (RRT) that can be performed in remote settings with limited resources, including regions that lack electrical power. PD is a mainstay of end-stage renal disease (ESRD) therapy worldwide, and the ease of initiation and maintenance has enabled it to flourish in both resource-limited and resource-abundant settings. In natural disaster scenarios, military conflicts, and other austere areas, PD may be the only available life-saving measure for acute kidney injury (AKI) or ESRD. PD in austere environments is not without challenges, including catheter placement, availability of dialysate, and medical complications related to the procedure itself. However, when hemodialysis is unavailable, PD can be performed using generally available medical supplies including sterile tubing and intravenous fluids. Amidst the ever-increasing global burden of ESRD and AKI, the ability to perform PD is essential for many medical facilities.
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Affiliation(s)
- Chad Gorbatkin
- Madigan Army Medical Center, Department of Emergency Medicine, Tacoma, Washington
| | - John Bass
- Madigan Army Medical Center, Department of Emergency Medicine, Tacoma, Washington
| | | | - Steven M. Gorbatkin
- Atlanta VA Medical Center, Emory University, Department of Nephrology, Atlanta, Georgia
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Al-Makki A, Rifai AO, Murad L, Zanabli AR, Kayal A, Soudan K, Kherallah M, Alsaghir F, Sekkarie M. The syrian national kidney foundation: Response for the need of kidney patients during the crisis. Avicenna J Med 2014; 4:54-7. [PMID: 24982825 PMCID: PMC4065460 DOI: 10.4103/2231-0770.133331] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Akram Al-Makki
- Indiana University Health Arnett, Lafayette, Indiana, USA E-mail:
| | - A Oussama Rifai
- Hypertension Kidney and Dialysis Specialists, Panama City, Florida, USA
| | - Lina Murad
- Metropolitan Access Center, Colmar Manor, Maryland, USA
| | - Abdul R Zanabli
- Charleston Nephrology, Hypertension, and Transplant, S Charleston, West Virginia, USA
| | - Anas Kayal
- Ruston Nephrology Associates, Ruston, Louisiana, USA
| | - Khaldoun Soudan
- Freedman Clinic of Internal Medicine, Alexandria, Louisiana, USA
| | | | | | - Mohamed Sekkarie
- Nephrology and Hypertension Associates, Bluefield, West Virginia, USA
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Kumar V, Ramachandran R, Rathi M, Kohli HS, Sakhuja V, Jha V. Peritoneal dialysis: the great savior during disasters. Perit Dial Int 2014; 33:327-9. [PMID: 23660608 DOI: 10.3747/pdi.2012.00156] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Vivek Kumar
- Department of Nephrology Postgraduate Institute of Medical Education and Research Chandigarh, India
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Disaster nephrology: crush injury and beyond. Kidney Int 2013; 85:1049-57. [PMID: 24107850 DOI: 10.1038/ki.2013.392] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2013] [Revised: 07/20/2013] [Accepted: 07/25/2013] [Indexed: 01/09/2023]
Abstract
Disasters result in a substantial number of renal challenges, either by the creation of crush injury in victims trapped in collapsed buildings or by the destruction of existing dialysis facilities, leaving chronic dialysis patients without access to their dialysis units, medications, or medical care. Over the past two decades, lessons have been learned from the response to a number of major natural disasters that have impacted significantly on crush-related acute kidney injury and chronic dialysis patients. In this paper we review the pathophysiology and treatment of the crush syndrome, as summarized in recent clinical recommendations for the management of crush syndrome. The importance of early fluid resuscitation in preventing acute kidney injury is stressed, logistic difficulties in disaster conditions are described, and the need for an implementation of a renal disaster relief preparedness program is underlined. The role of the Renal Disaster Relief Task Force in providing emergency disaster relief and the logistical support required is outlined. In addition, the importance of detailed education of chronic dialysis patients and renal unit staff in the advance planning for such disasters and the impact of displacement by disasters of chronic dialysis patients are discussed.
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Raman G, Perkins RM, Jaar BG. Acute kidney injury and ESRD management in austere environments. Adv Chronic Kidney Dis 2012; 19:149-57. [PMID: 22578674 DOI: 10.1053/j.ackd.2012.03.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2012] [Revised: 03/22/2012] [Accepted: 03/23/2012] [Indexed: 11/11/2022]
Abstract
Current knowledge about managing acute kidney injury in disaster situations stems mostly from lessons learned while taking care of crush syndrome patients during major earthquakes. More recently, there has been a greater focus on emergency preparedness for ESRD management. Natural or man-made disasters create an "austere environment," wherein resources to administer standard of care are limited. Advance planning and timely coordinated intervention during disasters are paramount to administer effective therapies and save lives. This article reviews the presentation and management of disaster victims with acute kidney injury and those requiring renal replacement therapies. Major contributions of some key national and international organizations in the field of disaster nephrology are highlighted. The article intends to increase awareness about nephrology care of disaster victims, among nephrology and non-nephrology providers alike.
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