A retrospective review of fluid balance control in CRRT

Knowledge, attitude, practice, needs, and implementation status of intensive care unit staff toward continuous renal replacement therapy: a survey of 66 hospitals in central and South China

BACKGROUND

Continuous renal replacement therapy (CRRT) is a commonly utilized form of renal replacement therapy (RRT) in the intensive care unit (ICU). A specialized CRRT team (SCT, composed of physicians and nurses) engage playing pivotal roles in administering CRRT, but there is paucity of evidence-based research on joint training and management strategies. This study armed to evaluate the knowledge, attitude, and practice (KAP) of ICU staff toward CRRT, and to identify education pathways, needs, and the current status of CRRT implementation.

METHODS

This study was performed from February 6 to March 20, 2023. A self-made structured questionnaire was used for data collection. Descriptive statistics, T-tests, Analysis of variance (ANOVA), multiple linear regression, and Pearson correlation coefficient tests (α = 0.05) were employed.

RESULTS

A total of 405 ICU staff from 66 hospitals in Central and South China participated in this study, yielding 395 valid questionnaires. The mean knowledge score was 51.46 ± 5.96 (61.8% scored highly). The mean attitude score was 58.71 ± 2.19 (73.9% scored highly). The mean practice score was 18.15 ± 0.98 (85.1% scored highly). Multiple linear regression analysis indicated that gender, age, years of CRRT practice, ICU category, and CRRT specialist panel membership independently affected the knowledge score; Educational level, years of CRRT practice, and CRRT specialist panel membership independently affected the attitude score; Education level and teaching hospital employment independently affected the practice score. The most effective method for ICU staff to undergo training and daily work experience is within the department.

CONCLUSION

ICU staff exhibit good knowledge, a positive attitude and appropriately practiced CRRT. Extended CRRT practice time in CRRT, further training in a general ICU or teaching hospital, joining a CRRT specialist panel, and upgraded education can improve CRRT professional level. Considering the convenience of training programs will enhance ICU staff participation. Training should focus on basic CRRT principles, liquid management, and alarm handling.

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

<b><i>Introduction:</i></b> When starting continuous renal replacement therapy (CRRT), vasopressor-dependent patients are at risk of hemodynamic instability. Thus far, only a few studies have analyzed the impact of CRRT circuit replacement for vasopressor-dependent patients. Hence, we compared the effect of double-machine replacement protocol (DMRP) with single-machine replacement protocol (SMRP) for CRRT circuit replacement in vasopressor-dependent patients. <b><i>Methods:</i></b> The medical records of 96 vasopressor-dependent patients treated with CRRT in the general intensive care unit of the Shunde Hospital, Southern Medical University, between January 2017 and April 2018 were retrospectively analyzed. The major measures of the SMRP included returning the blood to the patient and sealing access catheter with heparin and starting a new CRRT machine with a slow blood pump, while DMRP involved simultaneous drawing and return of blood with two machines using a slow blood pump for circuit replacement. The primary outcome measures were changes in vasopressor dose and hemodynamic parameters, and the secondary outcome measure was the pause time difference between the two groups during the period. <b><i>Results:</i></b> A total of 53 patients were treated with SMRP and 43 patients with DMRP. Heart rate was higher in the SMRP group as compared to the DMRP group (<i>p</i> &#x3c; 0.05). There were no significant changes in central venous pressure, mean arterial pressure, and vasopressor dose in either group (<i>p</i> &#x3e; 0.05). The patients in the DMRP group had a significant reduction in CRRT pause time (5.62 ± 0.69 min in DMRP group vs. 37.01 ± 8.72 min in SMRP group, <i>p</i> &#x3c; 0.01). The DMRP group needed a lower volume of circuit purging and priming fluid related to CRRT circuit replacement (0 mL in DMRP group vs. 463 mL in SMRP group). <b><i>Conclusions:</i></b> Implementation of the DMRP for CRRT circuit replacement had a slight hemodynamic effect on vasopressor-dependent patients. It also reduced the pause time and volume of circuit purging and priming fluid related to CRRT circuit replacement compared with SMRP.

A Quality Improvement Initiative to Reduce the Frequency of Delays in Initiation and Restarts of Continuous Renal Replacement Therapy

BACKGROUND

Continuous renal replacement therapy (CRRT) is a lifesaving intervention for critically ill patients. Delays in initiation, or an inability to resume CRRT following a temporary suspension in therapy (CRRT restart), can result in suboptimal CRRT delivery.

LOCAL PROBLEM

Intensive care units across the health care system were experiencing significant delays in CRRT initiation and restarts.

APPROACH

A multimodal quality improvement initiative was implemented across 7 adult intensive care units, which allowed unit-based staff nurses to initiate and restart CRRT, a task that had previously been delegated to non-unit-based dialysis nurses.

OUTCOMES

A 75% reduction in CRRT initiation delays and a 90% reduction in CRRT restart delays were observed in the 12 months following the initiative. There were no adverse events or increased disposable CRRT circuit usage following the initiative.

CONCLUSIONS

Implementation of CRRT initiation and restarts by unit-based nurses were achievable and resulted in substantial improvements in timeliness of CRRT delivery.

Effect of Blood Flow Rate on the Accuracy of Central Venous Pressure Measurement during Continuous Renal Replacement Therapy

BACKGROUND

The objective of this study was to study the influence of extracorporeal blood flow rate (BFR) on the accuracy of central venous pressure (CVP) measurement during continuous renal replacement therapy (CRRT).

METHODS

Eligible patients were randomly divided into 3 groups based on the location of catheters used for their CRRT and CVP measurement. CVP levels measured at increased extracorporeal BFR (from 0 to 300 mL/min) in the normal and reverse positions of inlet and outlet lines connected to the CV catheter (CVC) in the course of the CRRT session were collected.

RESULTS

CVP levels measured at different extracorporeal BFRs did not significantly differ between and among the 3 groups. Inversion of inlet and outlet lines connected to the catheters did not affect the accuracy of CVP measurement. BFR had a negative correlation with inflow/access pressure but a positive correlation with outflow/return pressure. Neither inflow pressure nor outflow pressure was correlated with CVP.

CONCLUSIONS

Extracorporeal BFR has no influence on the accuracy of CVP measurement during CRRT with the net machine balance adjusted to zero regardless of the location of the catheter and the connection method between catheters and CRRT lines. Thus, CRRT does not need to be discontinued to obtain an accurate CVP measurement.

Pulmonary Manifestations of Renal Disorders in Children

The causes of kidney disease in pediatric patients are evenly divided between congenital abnormalities of the kidney and urinary tract and acquired disorders. Nearly 10% to 15% of adults in the United States have chronic kidney disease (CKD); there are no comparable data in children. Regardless of patient age, CKD is a systemic problem that affects every organ system, including the lung. We review the tests used to diagnose and evaluate kidney disease and the main clinical syndromes that are likely to be encountered to aid the pulmonology consultant who is asked to evaluate patients with kidney disease.

Net ultrafiltration prescription survey in Europe

Background

Fluid overload is common in patients in the intensive care unit (ICU) and ultrafiltration (UF) is frequently required. There is lack of guidance on optimal UF practice. We aimed to explore patterns of UF practice, barriers to achieving UF targets, and concerns related to UF practice among practitioners working in Europe.

Methods

This was a sub-study of an international open survey with focus on adult intensivists and nephrologists, advanced practice providers, and ICU and dialysis nurses working in Europe.

Results

Four hundred eighty-five practitioners (75% intensivists) from 31 countries completed the survey. The most common criteria for UF initiation was persistent oliguria/anuria (45.6%), followed by pulmonary edema (16.7%). Continuous renal replacement therapy was the preferred initial modality (90.0%). The median initial and maximal rate of net ultrafiltration (UF^NET) prescription in hemodynamically stable patients were 149 mL/hr. (IQR 100–200) and 300 mL/hr. (IQR 201–352), respectively, compared to a median UF^NET rate of 98 mL/hr. (IQR 51–108) in hemodynamically unstable patients and varied significantly between countries.

Two-thirds of nurses and 15.5% of physicians reported assessing fluid balance hourly. When hemodynamic instability occurred, 70.1% of practitioners reported decreasing the rate of fluid removal, followed by starting or increasing the dose of a vasopressor (51.3%). Most respondents (90.7%) believed in early fluid removal and expressed willingness to participate in a study comparing protocol-based fluid removal versus usual care.

Conclusions

There was a significant variation in UF practice and perception among practitioners in Europe. Future research should focus on identifying the best strategies of prescribing and managing ultrafiltration in critically ill patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12882-020-02184-y.

Physician and Nurse Research in Multidisciplinary Intensive Care Units

BACKGROUND

Although clinical care is multidisciplinary, intensive care unit research commonly focuses on single-discipline themes. We sought to characterize intensive care unit research conducted by physicians and nurses.

METHODS

One hundred randomly selected reports of clinical studies published in critical care medical and nursing journals were reviewed.

RESULTS

Of the 100 articles reviewed, 50 were published in medical journals and 50 were published in nursing journals. Only 1 medical study (2%) used qualitative methods, compared with 9 nursing studies (18%) (P = .02). The distribution of quantitative study designs differed between medical and nursing journals (P < .001), with medical journals having a predominance of cohort studies (29 articles [58%]). Compared with medical journal articles, nursing journal articles had significantly fewer authors (median [interquartile range], 5 [3-6] vs 8 [6-10]; P < .001) and study participants (94 [51-237] vs 375 [86-4183]; P < .001) and a significantly lower proportion of male study participants (55% [26%-65%] vs 60% [51%-65%]; P = .02). Studies published in medical journals were much more likely than those published in nursing journals to exclusively involve patients as participants (47 [94%] vs 25 [50%]; P < .001). Coauthorship between physicians and nurses was evident in 14 articles (14%), with infrequent inclusion of authors from other health care disciplines.

CONCLUSIONS

Physician research and nurse research differ in several important aspects and tend to occur within silos. Increased interprofessional collaboration is possible and worthwhile.

Estimation of Body Fluid Status by Fluid Balance and Body Weight in Critically Ill Adult Patients: A Systematic Review

BACKGROUND

The charting of daily fluid balances and measurement of body weight changes are two noninvasive methods commonly used in the intensive care unit for estimating body fluid status. The determination of body fluid status plays an important role in the management of critically ill patients where aggressive fluid resuscitation is often required. This can adversely affect patient outcomes if changes in fluid distribution are not detected early in patients who are susceptible to fluid overload.

AIM

To synthesize the best available evidence on the accuracy of daily fluid balance charting compared with the measurement of body weight for the estimation of body fluid status in critically ill adult patients.

METHODS

The review considered studies that investigated the accuracy of charting daily fluid balances or changes in body weight measurements or used both noninvasive methods in the estimation of body fluid status. The search sought to identify published, English language studies from 1980 until February 2018. Databases searched included MEDLINE, CINAHL, EMBASE, TRIP, Scopus, TROVE, ProQuest Dissertations, Australian and New Zealand Trials Registry, and Cochrane Central Register of Clinical Trials. Three reviewers independently assessed retrieved studies that matched inclusion criteria using standardized critical appraisal instruments.

RESULTS

The review included 13 cohort studies. Effectiveness of daily fluid balance charting was affected by inaccuracies observed in seven studies. Inability to obtain consecutive daily body weight measurements reduced the accuracy of monitoring changes in five studies. Seven studies found measurement of daily fluid balance inconsistent with changes in body weight.

LINKING EVIDENCE TO ACTION

The accuracy of charting fluid balance is suspect. Measurement of body weight is hard to accomplish. A combination of the two commonly used methods is more likely to be effective in estimating body fluid status than reliance on one single approach.

Continuous Renal Replacement Therapy Update: An Emphasis on Safe and High-Quality Care

Continuous renal replacement therapy (CRRT) was introduced more than 40 years ago as a renal support option for critically ill patients who had contraindications to intermittent hemodialysis and peritoneal dialysis. Despite being the most common renal support therapy used in intensive care units today, the tremendous variability in CRRT management challenges the interpretation of findings from CRRT outcome studies. The lack of standardization in practice and training of clinicians along with the high risk of CRRT-related adverse events has been the impetus for the recent expert consensus work on identifying quality indicators for CRRT programs. This article summarizes the potential complications that establish CRRT as a high-risk therapy and also the recently published best-practice recommendations for providing high-quality CRRT.