A technique for rapid exchange of continuous renal replacement therapy

Abstract

Re-initiation of continuous renal replacement therapy (CRRT) in neonates and young infants weighing less than 15 kg often necessitates a blood prime of the blood circuit path or a concurrent packed red blood cell (PRBC) transfusion to avoid causing hemodynamic instability due to acute hemodilution. The significant amount of time required for a routine CRRT circuit change can be associated with worsening electrolyte and acid-base abnormalities, fluid retention, greater hemodynamic instability and reducing effective hemofiltration time. In an attempt to limit the time without CRRT and to eliminate the requirement for additional blood exposure, a new technique, rapid exchange of continuous renal replacement therapy (RECRRT), was developed. Rapid exchange of continuous renal replacement therapy is a sequential technique that transfers citrated blood from one CRRT machine to another machine connected in series. The technique effectively negates the requirement for CRRT circuit path blood priming or PRBC transfusion. The amount of time without CRRT is markedly reduced by RECRRT to 2-3 min. The RECRRT technique has been utilized more than 30 times for at least 15 patients without an adverse event. RECRRT may benefit children who weigh less than 15 kg and in those patients who experience hemodynamic or clinical instability while CRRT is discontinued for only a brief period.

Continuous renal replacement therapy results in respiratory and hemodynamic beneficial effects in pediatric patients with severe systemic inflammatory response syndrome and multiorgan system dysfunction*

“…Hemodynamic instability (hypotension or poor perfusion) at the same time implementing a PFL was handled by one or a combination of the following steps: slow onset of CRRT blood flow; an increase in the patient's doses of vasoactive medications; addition of a new vasoactive medication; administration of more fluids; and significantly decreasing or aborting the PFL. As we commonly use polyacrylonitrile hemofilters for CRRT that are known to be associated with the bradykinin release syndrome (12,13), the PICU teams that cared for these patients were made aware of this syndrome and instructed to rapidly respond to any hypotensive episode that it might cause. In addition, contributing factors, such as acidemia, hypothermia, and angiotensin-converting enzyme inhibitors, were either immediately corrected or avoided.…”

Impact of Double-Machine Replacement Protocol at Start of Continuous Renal Replacement Therapy in Vasopressor-Dependent Patients: A Retrospective Cohort Study

“…Although our definition of pause time focused on the time for circuit replacement, the actual time of delivered therapy was decreased due to CRRT replacement. Previous studies have shown that patients often do not receive CRRT therapy for 30-60 min when the conventional replacement is performed unless another machine is primed in advance [27]. If a critical care phy-sician and nurses are not immediately available, the amount of time that the patient is off CRRT may be substantially longer.…”

Programs and processes for advancing pediatric acute kidney support therapy in hospitalized and critically ill children: a report from the 26th Acute Disease Quality Initiative (ADQI) consensus conference

“…The team must prepare for these issues proactively to prevent or minimize worsening hemodynamic instability. Various blood priming protocols exist to yield a more “physiologic” prime solution; safety, efficacy, and clinical consequences of these approaches need to be explored to determine which, if any, of them can be widely recommended and implemented [ 48 , 49 , 52 – 55 ]. In the meantime, the specific procedure for small children who may benefit from a blood prime initiation should be standardized for the individual program and not dictated by the rounding providers/team.…”