The use of continuous renal replacement therapy in series with extracorporeal membrane oxygenation

Abstract

A large percentage of patients on extracorporeal membrane oxygenation (ECMO) require continuous renal replacement therapy (CRRT) usually performed through a different venous access or by introducing a filter into the ECMO circuit. Here, we evaluated the efficacy and safety of including a CRRT machine in the circuit by connecting its inlet line after the centrifugal pump and its outlet line before the oxygenator. We tested the function of the combined system initially in a closed circuit, followed by an experimental animal study, and, finally, in a clinical trial with six children. Both machines functioned adequately and there were no significant changes in the pressures of the ECMO circuit after the introduction of the CRRT device, thus achieving the preset negative balances and normalization of the serum urea and creatinine concentrations. The mean life of the filters was about 138 h, and only one filter needed changing due to clotting. Our study shows that the introduction of a CRRT device into the ECMO circuit is a safe and effective technique that improves fluid balance, increases filter life, and does not cause complications. For these reasons, this may be a good method for performing CRRT in patients on ECMO.

Terapia de reemplazo renal continua en el paciente con oxigenación por membrana extracorpórea: consideraciones para la combinación de ambas terapias

“…La técnica en línea tiene la ventaja de permitir un volumen de cebado más pequeño en comparación con el empleado cuando se suma el circuito de la máquina de TRRC. Pero también tiene desventajas: las bombas de infusión son incapaces de contener la filtración, no se monitorizan las presiones en el circuito de hemofiltración y la coagulación o la rotura del filtro no se pueden detectar tempranamente 3 . El control de la ultrafiltración puede ser especialmente deficiente cuando se requiere ultrafiltrar más de 800 ml en 24 h 17,21 .…”

“…El uso de terapia de reemplazo renal continua (TRRC) en pacientes en ECMO mejora el equilibrio hídrico, resuelve desequilibrios electrolíticos, mejora el aporte calórico y reduce la necesidad de diuré-ticos 3 .…”

Interaction between Renal Replacement Therapy and Extracorporeal Membrane Oxygenation Support

“…Santiago et al reported that this last option is safe and effective in controlling both nitrogenous waste and the water balance without incurring any additional risks to the patient [19,20].…”

“…First, if an ultrasonic probe is not placed to measure the flow, the blood flow through the hemofilter will remain unknown. Second, the infusion pumps are not accurate when they are used to prevent fluid loss in a high-pressure system [18,19] and can generate a large discrepancy between the desired and actual ultrafiltrate volumes. The third option involves the use of a dialysis machine that is connected to the circuit.…”

Extracorporeal Membrane Oxygenation and Continuous Renal Replacement Therapy

“…This, in turn, can predispose to the potential life-threatening hemolysis, disseminated intravascular coagulation and enhanced systemic inflammation. The hemolysis through the medium of hemoglobinuria can precipitate renal injury [2,3]. …”