Risk Factors for the Mortality of Patients With Coronavirus Disease 2019 Requiring Extracorporeal Membrane Oxygenation in a Non-Centralized Setting: A Nationwide Study

BACKGROUND

Limited data are available on the mortality rates of patients receiving extracorporeal membrane oxygenation (ECMO) support for coronavirus disease 2019 (COVID-19). We aimed to analyze the relationship between COVID-19 and clinical outcomes for patients receiving ECMO.

METHODS

We retrospectively investigated patients with COVID-19 pneumonia requiring ECMO in 19 hospitals across Korea from January 1, 2020 to August 31, 2021. The primary outcome was the 90-day mortality after ECMO initiation. We performed multivariate analysis using a logistic regression model to estimate the odds ratio (OR) of 90-day mortality. Survival differences were analyzed using the Kaplan-Meier (KM) method.

RESULTS

Of 127 patients with COVID-19 pneumonia who received ECMO, 70 patients (55.1%) died within 90 days of ECMO initiation. The median age was 64 years, and 63% of patients were male. The incidence of ECMO was increased with age but was decreased after 70 years of age. However, the survival rate was decreased linearly with age. In multivariate analysis, age (OR, 1.048; 95% confidence interval [CI], 1.010-1.089; P = 0.014) and receipt of continuous renal replacement therapy (CRRT) (OR, 3.069; 95% CI, 1.312-7.180; P = 0.010) were significantly associated with an increased risk of 90-day mortality. KM curves showed significant differences in survival between groups according to age (65 years) (log-rank P = 0.021) and receipt of CRRT (log-rank P = 0.004).

CONCLUSION

Older age and receipt of CRRT were associated with higher mortality rates among patients with COVID-19 who received ECMO.

[Therapeutic Plasma Exchange in a Patient with Chronic Hemodialysis and a New Diagnosis of Myasthenia Gravis]

Case ReportC.S.T. (♂, 71 years old) is a patient with multiple and severe comorbidities, undergoing thrice-weekly chronic hemodialysis since 2008 due to the progression of post-lithiasic uropathy. Over the past 2 months, the patient had been experiencing progressive ptosis of the eyelids, muscle weakness, and ultimately dysphagia and dysarthria that emerged in the last few days. Urgently admitted to the Neurology department, electromyography (EMG) was performed, leading to a diagnosis of predominant cranial myasthenia gravis (with borderline anti-acetylcholine receptor antibody serology). Prompt treatment with pyridostigmine and steroids was initiated. Considering the high risk of acute myasthenic decompensation, therapeutic plasma exchange (TPE) with centrifugation technique was promptly undertaken after femoral CVC placement. TPE sessions were alternated with hemodialysis. The patient's condition complicated after the third TPE session, with septic shock caused by Methicillin-Sensitive Staphylococcus Aureus (MSSA). The patient was transferred to the Intensive Care Unit (ICU). Due to hemodynamic instability, continuous veno-venous hemodiafiltration (CVVHDF) with citrate anticoagulation was administered for 72 hours. After resolving the septic condition, intermittent treatment with Acetate-Free Biofiltration (AFB) technique was resumed. The patient completed the remaining three TPE sessions and, once the acute condition was resolved, was transferred back to Neurology. Here, the patient continued the treatment and underwent a rehabilitation program, showing significant motor and functional recovery until discharge. Conclusions. The multidisciplinary interaction among Nephrologists, Neurologists, Anesthesiologists, and experts from the Immunohematology and Transfusion Medicine Service enabled the management and treatment of a rare condition (MG) in a high-risk chronic hemodialysis patient.

Proceedings of the 2022 UAB CRRT Academy: Non-Invasive Hemodynamic Monitoring to Guide Fluid Removal with CRRT and Proliferation of Extracorporeal Blood Purification Devices

In 2022, we celebrated the 15th anniversary of the University of Alabama at Birmingham (UAB) Continuous Renal Replacement Therapy (CRRT) Academy, a 2-day conference attended yearly by an international audience of over 100 nephrology, critical care, and multidisciplinary trainees and practitioners. This year, we introduce the proceedings of the UAB CRRT Academy, a yearly review of select emerging topics in the field of critical care nephrology that feature prominently in the conference. First, we review the rapidly evolving field of non-invasive hemodynamic monitoring and its potential to guide fluid removal by renal replacement therapy (RRT). We begin by summarizing the accumulating data associating fluid overload with harm in critical illness and the potential for harm from end-organ hypoperfusion caused by excessive fluid removal with RRT, underscoring the importance of accurate, dynamic assessment of volume status. We describe four applications of point-of-care ultrasound used to identify patients in need of urgent fluid removal or likely to tolerate fluid removal: lung ultrasound, inferior vena cava ultrasound, venous excess ultrasonography, and Doppler of the left ventricular outflow track to estimate stroke volume. We briefly introduce other minimally invasive hemodynamic monitoring technologies before concluding that additional prospective data are urgently needed to adapt these technologies to the specific task of fluid removal by RRT and to learn how best to integrate them into practical fluid-management strategies. Second, we focus on the growth of novel extracorporeal blood purification devices, starting with brief reviews of the inflammatory underpinnings of multiorgan dysfunction and the specific applications of pathogen, endotoxin, and/or cytokine removal and immunomodulation. Finally, we review a series of specific adsorptive technologies, several of which have seen substantial clinical use during the COVID-19 pandemic, describing their mechanisms of target removal, the limited existing data supporting their efficacy, ongoing and future studies, and the need for additional prospective trials.

Managing the kidney - The role of continuous renal replacement therapy in neonatal and pediatric ECMO

Extracorporeal membrane oxygenation (ECMO) represents a lifesaving therapy utilized in in the most critically ill neonates and children with reversible cardiopulmonary failure. As a result of the severity of their critical illness these patients are among the highest risk populations for developing acute kidney injury (AKI) and disorders of fluid balance including the pathologic state of fluid overload (FO). In multiple studies AKI has been shown to occur commonly in 60-80% children treated with ECMO and is associated with adverse outcomes. In early studies evaluating ECMO in neonatal respiratory populations, the importance of fluid balance and the development of FO was recognized as an important contributor to adverse outcomes. Multiple single center studies and multicenter work have confirmed that FO occurs commonly across ECMO populations and is consistently associated with adverse outcomes. As a result of the high rates of AKI and the high rates of FO, continuous renal replacement therapy (CRRT) is increasingly utilized in neonatal and pediatric ECMO. In this state-of-the-art review, we cover the definitions, pathophysiology, incidence, and impact of AKI and FO in neonates and children supported with ECMO and summarize and appraise the evidence regarding the use of CRRT concurrently with ECMO. This review will cover the appropriate timing of this initiation, the options for providing CRRT with ECMO, overview of CRRT prescription, and the long-term implications of kidney support therapy in this population.

[Acute kidney injury in severely burned patient: prevention and treatment]

Acute Kidney Injury (AKI) is associated with a great increase in morbidity and mortality in severely burned patients and occurs as a complication in more than 25% of these cases. The onset of ARF may be early or late. Early AKI depends mainly on reduced cardiac output resulting from fluid loss, rhabdomyolysis, or hemolysis. Late AKI, instead, is usually a consequence of sepsis and is often associated with multiorgan failure (MOF). The first sign of AKI is the contraction of diuresis despite adequate volemic filling, which is followed by elevation of serum urea and creatinine. Fluid therapy is the main treatment in the burned victim: in the first few hours after injury, it aims to avoid hypovolemic shock and the possible related MOF, while later it becomes the cornerstone of treatment, besides antibiotic therapy in the case of sepsis onset. Particular care must also be taken in the choice of administered drugs in order to avoid possible nephrotoxic damage in addition to burning injury. Hemodialytic renal replacement therapy is used both for water balance management in patients requiring massive fluid infusions and for blood purification purposes to control the metabolic state, acid-base balance, and electrolytes abnormality. Our team has been collaborating for over 25 years in the management of severely burned patients admitted to the Centro Grandi Ustionati at the Bufalini Hospital in Cesena.

Planned Extracorporeal Life Support Employment during Liver Transplantation: The Potential of ECMO and CRRT as Preventive Therapies-Case Reports and Literature Review

Liver Transplantation (LT) has become the gold standard treatment for End-Stage Liver Disease (ESLD). One of the main strategies to manage life-threatening complications, such as cardio-respiratory failure, is Extracorporeal Membrane Oxygenation (ECMO) in the peri-transplantation period, with different configurations of the technique and in combination with other extracorporeal care devices such as Continuous Renal Replacement Therapy (CRRT). This retrospective study includes three clinical cases of planned ECMO support strategies in LT and evaluates their application compared with current literature exploring PubMed/Medline. The three LT supported with ECMO and CRRT were performed at IRCCS Polyclinic S. Orsola-Malpighi, Bologna. All three cases of patients with compromised organ function analysed produced positive outcomes. The planned use of ECMO and CRRT support in peri-transplantation has allowed the patients to overcome contraindications and successfully undergo LT. In recent years, only a few reports have documented successful LT outcomes performed with intraoperative ECMO in critically ESLD patients. However, the management of LT with ECMO and/or CRRT assistance is an emerging challenge, with the need for more published evidence on this topic to guide treatment choices in patients with severe, acute and reversible respiratory and cardiovascular failure after LT.

Nursing competence in continuous renal replacement therapy: development and validation of a measurement tool

BACKGROUND

Acute Renal Failure is an essential condition frequently encountered in intensive care units and requires targeted treatment. The critical care nursing team must be adequately trained to manage patients undergoing Continuous Renal Replacement Therapy.

OBJECTIVES

To develop and validate the Continuous Renal Replacement Therapy - Measurement Competency Tool, aimed at measuring nursing competence in managing patients undergoing renal replacement techniques.

METHODS

A cross-sectional tool validation study with a test-retest.A total of 30 critical care nurses participated in this study. The study examined content and face validity. Test-retest reliability with Pearson's r correlation and internal consistency reliability was assessed using Cronbach's α. Current guidelines for Continuous Renal Replacement Therapy techniques were used to develop an instrument to measure nursing competence through an online survey. A pool of 10 experts evaluated this tool.

RESULTS

The Continuous Renal Replacement Therapy - Measurement Competency Tool achieved good content and face validity (S-CVI= 0.97; I-CVI=87%-100%), and good internal consistency reliability (Cronbach's α= 0.799). Pilot testing and test-retesting was conducted with 30 critical care nurses. The intraclass correlation for the test-retest analysis indicates excellent test-retest reliability, confirming the stability of the tool.

ConclUSION

The tool assesses nursing competence concerning Continuous Renal Replacement Therapy techniques in the intensive care unit, which proved to be valid and reliable. This new tool will make it possible to measure the competence of nurses with respect to Continuous Renal Replacement Therapy techniques.

Meropenem pharmacokinetics in critically ill patients with or without burn treated with or without continuous veno-venous hemofiltration

Introduction

Severe burn injury involves widespread skin and tissue damage leading to systemic inflammation, hypermetabolism and multi‐organ failure. The hypermetabolic phase of burn injury has been associated with increased systemic antibiotic clearance; however, critical illness in the absence of burn may also induce similar physiologic changes. Continuous renal replacement therapy (CRRT) is often implemented in critically ill patients and may also affect antibiotic clearance. Although the pharmacokinetics (PK) of meropenem has been described in both the burn and non‐burn critically ill populations, direct comparative data is lacking.

Methods

For this study, we evaluated PK parameters of meropenem from 23 critically ill patients, burn or non‐burn, treated with or without continuous veno‐venous haemofiltration (CVVH) to determine the contribution of burn and CVVH to the variability of therapeutic meropenem levels.

Results

A two‐compartment model best described the data and revealed creatinine clearance (CrCl) and total burn surface area (TBSA) as significant covariates on clearance (CL) and peripheral volume of distribution (Vp), respectively. Of interest, non‐burn patients on CVVH displayed an overall lower inherent CL as compared to burn patients on CVVH (6.43 vs. 12.85 L/h). Probability of target attainment (PTA) simulations revealed augmented renal clearance (ARC) may necessitate dose adjustments, but TBSA and CVVH would not.

Conclusions

We recommend a standard dose of 1000 mg every 8 hours; however, if ARC is suspected, or the severity of illness requires a more stringent therapeutic target, we recommend a loading dose of 1000–2000 mg infused over 30 minutes to 1 hour followed by continuous infusion (3000–6000 mg over 24 hours), or intermittent infusion of 2000 mg every 8 hours.

Caspofungin Population Pharmacokinetics in Critically Ill Patients Undergoing Continuous Veno-Venous Haemofiltration or Haemodiafiltration

BACKGROUND AND OBJECTIVE

Sepsis and continuous renal replacement therapy (CRRT) can both significantly affect antifungal pharmacokinetics. This study aimed to describe the pharmacokinetics of caspofungin in critically ill patients during different CRRT modes.

METHODS

Patients receiving caspofungin and undergoing continuous veno-venous haemofiltration (CVVH) or haemodiafiltration (CVVHDF) were eligible to take part in the study. Blood samples were collected at seven sampling times during a dosing interval. Demographics and clinical data were recorded. Population pharmacokinetic analysis and Monte-Carlo simulation were undertaken using Pmetrics.

RESULTS

Twelve pharmacokinetic profiles from nine patients were analysed. The caspofungin CRRT clearance (CL) was 0.048 ± 0.12 L/h for CVVH and 0.042 ± 0.042 L/h for CVVHDF. A two-compartment linear model best described the data. Patient weight was the only covariate affecting drug CL and central volume. The mean (standard deviation) parameter estimates were 0.64 ± 0.12 L/h for CL, 9.35 ± 3.56 L for central volume, 0.25 ± 0.19 per h for the rate constant for drug distribution from central to peripheral compartments and 0.19 ± 0.10 per h from peripheral to central compartments. Based on simulation results, a caspofungin 100 mg loading dose followed by a 50 mg maintenance dose for patients with a total body weight of ≤80 kg best achieved the pharmacokinetic/PD targets whilst a 70 mg maintenance dose was required for patients with a weight of >80 kg.

CONCLUSION

No caspofungin dosing adjustment is necessary for patients undergoing either form of CRRT. However, higher than recommended loading doses of caspofungin are required to achieve pharmacokinetic/pharmacodynamic targets in critically ill patients. Registration: ClinicalTrials.gov Identifier NCT01403220.

Influence of Daily Fluid Balance prior to Continuous Renal Replacement Therapy on Outcomes in Critically Ill Patients

Positive fluid balance is a risk factor for mortality in critically ill patients, especially those requiring continuous renal replacement therapy (CRRT). However, the association between daily fluid balance and various organ impairments remains unclear. This study investigated the impacts of daily fluid balance prior to CRRT on organ dysfunction, as well as mortality in critically ill patients. We identified daily fluid balance between intensive care unit (ICU) admission and CRRT initiation. According to daily fluid balance, the time to CRRT initiation and the rate of organ failure based on the sequential organ failure assessment (SOFA) score were assessed. We recruited 100 patients who experienced CRRT for acute kidney injury. CRRT was initiated within 2 [0, 4] days. The time to CRRT initiation was shortened in proportion to daily fluid balance, even after the adjustment for the renal SOFA score at ICU admission (HR 1.14, P = 0.007). Based on the SOFA score, positive daily fluid balance was associated with respiratory, cardiovascular, nervous, and coagulation failure, independent of each initial SOFA score at ICU admission (HR 1.36, 1.26, 1.24 and 2.26, all P < 0.05). Ultimately, we found that positive fluid balance was related with an increase in the rate of 28-day mortality (HR 1.14, P = 0.012). Positive daily fluid balance may accelerate the requirement for CRRT, moreover, it can be associated with an increased risk of multiple organ failure in critically ill patients.