Circuit Start during Continuous Renal Replacement Therapy in Vasopressor-Dependent Patients: The Impact of a Slow Blood Flow Protocol

Kim, In Byung; Fealy, Nigel; Baldwin, Ian; Bellomo, Rinaldo

doi:10.1159/000323035

Cited by 9 publications

(9 citation statements)

References 24 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Patients at higher risk of complications, given hemodynamic instability at baseline, are more likely to be selected for treatment with CRRT (or SLED). Hypotension at CRRT initiation has been reported in 18.8–25.0% of patients [ 8 , 54 ]. Kim et al [ 54 ] also assessed hypotension in relation to CRRT initiation and found that it affected 7.8% of circuit starts.…”

Section: Discussionmentioning

confidence: 99%

“…Hypotension at CRRT initiation has been reported in 18.8–25.0% of patients [ 8 , 54 ]. Kim et al [ 54 ] also assessed hypotension in relation to CRRT initiation and found that it affected 7.8% of circuit starts. Eastwood et al [ 18 ] compared CRRT routine and slow blood flow rates at initiation and reported no hypotensive events in either arm.…”

Section: Discussionmentioning

confidence: 99%

See 1 more Smart Citation

Interventions to prevent hemodynamic instability during renal replacement therapy in critically ill patients: a systematic review

et al. 2018

View full text Add to dashboard Cite

BackgroundHemodynamic instability related to renal replacement therapy (HIRRT) may increase the risk of death and limit renal recovery. Studies in end-stage renal disease populations on maintenance hemodialysis suggest that some renal replacement therapy (RRT)-related interventions (e.g., cool dialysate) may reduce the occurrence of HIRRT, but less is known about interventions to prevent HIRRT in critically ill patients receiving RRT for acute kidney injury (AKI). We sought to evaluate the effectiveness of RRT-related interventions for reducing HIRRT in such patients across RRT modalities.MethodsA systematic review of publications was undertaken using MEDLINE, MEDLINE in Process, EMBASE, and Cochrane’s Central Registry for Randomized Controlled Trials (RCTs). Studies that assessed any intervention’s effect on HIRRT (the primary outcome) in critically ill patients with AKI were included. HIRRT was variably defined according to each study’s definition. Two reviewers independently screened abstracts, identified articles for inclusion, extracted data, and evaluated study quality using validated assessment tools.ResultsFive RCTs and four observational studies were included (n = 9; 623 patients in total). Studies were small, and the quality was mostly low. Interventions included dialysate sodium modeling (n = 3), ultrafiltration profiling (n = 2), blood volume (n = 2) and temperature control (n = 3), duration of RRT (n = 1), and slow blood flow rate at initiation (n = 1). Some studies applied more than one strategy simultaneously (n = 5). Interventions shown to reduce HIRRT from three studies (two RCTs and one observational study) included higher dialysate sodium concentration, lower dialysate temperature, variable ultrafiltration rates, or a combination of strategies. Interventions not found to have an effect included blood volume and temperature control, extended duration of intermittent RRT, and slower blood flow rates during continuous RRT initiation. How HIRRT was defined and its frequency of occurrence varied widely across studies, including those involving the same RRT modality. Pooled analysis was not possible due to study heterogeneity.ConclusionsSmall clinical studies suggest that higher dialysate sodium, lower temperature, individualized ultrafiltration rates, or a combination of these strategies may reduce the risk of HIRRT. Overall, for all RRT modalities, there is a paucity of high-quality data regarding interventions to reduce the occurrence of HIRRT in critically ill patients.Electronic supplementary materialThe online version of this article (10.1186/s13054-018-1965-5) contains supplementary material, which is available to authorized users.

show abstract

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Interventions to prevent hemodynamic instability during renal replacement therapy in critically ill patients: a systematic review

et al. 2018

View full text Add to dashboard Cite

show abstract

“…Nevertheless, that same group [ 2 ] published a retrospective study to analyze the impact of the slow blood flow protocol in vasopressor-dependent patients. They studied 205 circuit connections and a decrease in MAP > 20% was only observed in 16 out of 205 connections (7.8%) and CRRT did not have to be discontinued because of hypotension in any patient.…”

Section: Discussionmentioning

confidence: 99%

“…Continuous renal replacement therapy (CRRT) is most commonly used in this setting, since it is better tolerated than intermittent therapy from a hemodynamic point of view. Nevertheless, hypotension during and after the connection to CRRT is very common [ 2 , 3 ]. In adult patients, hemodynamic instability during CRRT is associated with changes in circulating blood volume, blood flow rate variability, and electrolyte disturbances [ 4 , 5 ].…”

Section: Introductionmentioning

confidence: 99%

Hemodynamic impact of the connection to continuous renal replacement therapy in critically ill children

et al. 2018

View full text Add to dashboard Cite

BackgroundContinuous renal replacement therapy (CRRT) is the treatment of choice for critically ill children with acute kidney injury. Hypotension after starting CRRT is frequent but very few studies have analyzed its incidence and clinical relevance.MethodsA prospective, observational study was performed including critically ill children treated with CRRT between 2010 and 2014. Hemodynamic data and connection characteristics were collected before, during, and 60 min after CRRT circuit connection. Hypotension with the connection was defined as a decrease in > 20% of the mean arterial pressure from baseline or when intravenous fluid resuscitation or an increase in vasopressors was required.ResultsOne hundred sixty-one connections in 36 children (median age 18.8 months) were analyzed. Twenty-eight patients (77.8%) were in the postoperative period of cardiac surgery, 94% had mechanical ventilation, and 86.1% had vasopressors. The heparinized circuit priming solution was discarded in 8.7% and infused to the patient in 18% of the connections. The circuit was re-primed in the remaining 73.3% using albumin (79.3%), red blood cells (4.5%), or another crystalloid solution without heparin (16.2%). Hypotension occurred in 49.7% of the connections a median of 5 min after the beginning of the therapy. Fluid resuscitation was required in 38.5% and the dose of vasopressors was increased in 12.4% of the connections. There was no relationship between hypotension and age or weight. Re-priming the circuit with albumin reduced the incidence of hypotension from 71.4 to 44.6% (p = 0.004).ConclusionsHypotension after the connection to CRRT is very frequent in critically ill children. Re-priming the circuit with albumin could improve hemodynamics during connection.

show abstract

“…Recently, we performed a retrospective observational study to evaluate the impact of a CRRT start safety protocol in critically ill vasopressor-dependent AKI patients [10]. We found that less than 2% of circuit starts (n = 500) were associated with hypotension (defined as a decrease of 20% from baseline mean arterial pressure (MAP) and that even in high-risk patients (noradrenaline rate greater than 50 µg/min) only a minority had experienced hypotension (defined as a MAP <50 mm Hg).…”

Section: Introductionmentioning

confidence: 99%

Haemodynamic Impact of a Slower Pump Speed at Start of Continuous Renal Replacement Therapy in Critically Ill Adults with Acute Kidney Injury: A Prospective Before-and-After Study

et al. 2011

Self Cite

View full text Add to dashboard Cite

Background and Objective: Patients are at risk of haemodynamic instability when starting continuous renal replacement therapy (CRRT). Methods: We compared data for ‘routine-protocol’ pump speed increases of 50 ml/min over 1–4 min with ‘slower’ increases of 20–50 ml/min over 3–10 min to achieve an operating blood flow of 200 ml/min. Results: We studied 21 routine and 20 slower CRRT starts. ‘Routine protocol’ starts reached the target pump speed more quickly than the slower CRRT start (p < 0.05). Heart rate was higher in the routine group compared to the slower group at baseline (p < 0.01) and remained so throughout. There were no significant changes in central venous pressure or mean arterial pressure, and no episodes of hypotension or hypertension, in either group, or in the subset of 17 CRRT starts in vasopressor-dependent patients. Conclusion: We cannot recommend a slower pump speed start based on our findings, but advocate for close haemodynamic monitoring, as haemodynamic changes in individual patients cannot be predicted in advance.

show abstract

Circuit Start during Continuous Renal Replacement Therapy in Vasopressor-Dependent Patients: The Impact of a Slow Blood Flow Protocol

Cited by 9 publications

References 24 publications

Interventions to prevent hemodynamic instability during renal replacement therapy in critically ill patients: a systematic review

Interventions to prevent hemodynamic instability during renal replacement therapy in critically ill patients: a systematic review

Hemodynamic impact of the connection to continuous renal replacement therapy in critically ill children

Haemodynamic Impact of a Slower Pump Speed at Start of Continuous Renal Replacement Therapy in Critically Ill Adults with Acute Kidney Injury: A Prospective Before-and-After Study

Contact Info

Product

Resources

About