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Prowle J, Mehta R. Fluid balance management during continuous renal replacement therapy. Semin Dial 2021; 34:440-448. [PMID: 33755249 DOI: 10.1111/sdi.12964] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 02/16/2021] [Accepted: 02/16/2021] [Indexed: 11/30/2022]
Abstract
In critically ill patients, particularly in the setting of shock and sepsis volume management frequently results in a fluid overloaded state, requiring diuresis or intervention with renal replacement therapy. Achieving appropriate volume management requires knowledge of the underlying cardiovascular pathophysiology and careful evaluation of intravascular and extravascular volume status. In the presence of a failing kidney, fluid removal is often a challenge. Continuous renal replacement therapy (CRRT) techniques offer a significant advantage over intermittent dialysis for fluid control, however, any form of RRT in the critically ill patient requires careful attention to prescription and monitoring to avoid complications. In order to utilize these therapies for their maximum potential it is necessary to understand which factors influence fluid balance and have an understanding of the principles and kinetics of fluid removal with extra-corporeal techniques.
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Affiliation(s)
- John Prowle
- William Harvey Institute, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK.,Adult Critical Care Unit, The Royal London Hospital, Barts Health NHS Trust, London, UK.,Department of Renal and Transplant Medicine, The Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Ravindra Mehta
- Division of Nephrology, Department of Medicine, University of California, San Diego, CA, USA
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Gibney N, Cerda J, Davenport A, Ramirez J, Singbartl K, Leblanc M, Ronco C. Volume Management by Renal Replacement Therapy in Acute Kidney Injury. Int J Artif Organs 2018; 31:145-55. [DOI: 10.1177/039139880803100207] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Management of fluid balance is one of the basic but vital tasks in the care of critically ill patients. Hypovolemia results in a decrease in cardiac output and tissue perfusion and may lead to progressive multiple organ dysfunction, including the development of acute renal injury (AKI). However, in an effort to reverse pre-renal oliguria, it is not uncommon for patients with established oliguric acute renal failure, particularly when associated with sepsis, to receive excessive fluid resuscitation, leading to fluid overload. In patients with established oliguria, renal replacement therapy may be required to treat hypervolemia. Safe prescription of fluid loss during RRT requires intimate knowledge of the patient's underlying condition, understanding of the process of ultrafiltration and close monitoring of the patient's cardiovascular response to fluid removal. To preserve tissue perfusion in patients with AKI, it is important that RRT be prescribed in a way that optimizes fluid balance by removing fluid without compromising the effective circulating fluid volume. In patients who are clinically fluid overloaded, it is equally important that the amount of fluid removed be as exact as possible. Fluid balance errors can occur as a result of inappropriate prescription, operator error or machine error. Some CRRT machines have potential for significant fluid errors if alarms can be overridden. Threshold values for fluid balance error have been developed which can be used to predict the severity of harm. It is important that RRT education programs emphasize the risk associated with fluid balance errors and with overriding machine alarms.
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Affiliation(s)
- N. Gibney
- Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton - Canada
| | - J. Cerda
- Division of Nephrology, Albany Medical College and Capital District Renal Physicians, Albany, New York - USA
| | - A. Davenport
- Centre for Nephrology, Royal Free Hospital and University College Medical School, London - UK
| | - J. Ramirez
- Surgical Intensive Care Unit, Hospital Dr. Rafel Ángel Calderón Guardia, San Jose - Costa Rica
| | - K. Singbartl
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania - USA
| | - M. Leblanc
- Division of Nephrology and Critical Care, Maisonneuve - Rosemont Hospital, Montreal - Canada
| | - C. Ronco
- Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital - International Renal Research Institute Vicenza (IRRIV), Vicenza - Italy
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Mehta RL. Challenges and pitfalls when implementing renal replacement therapy in the ICU. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2015; 19 Suppl 3:S9. [PMID: 26729322 PMCID: PMC4699092 DOI: 10.1186/cc14727] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Several new methods of renal replacement therapy (RRT) are now available for treating patients in the ICU setting. However, utilization of RRT in the ICU is subject to considerable variation and the need for RRT is associated with worse outcomes. Several factors influence the application of dialysis and reflect the interplay of patient and process of care elements that are dynamic in nature. Despite multiple studies evaluating RRT and its application, there are gaps in our knowledge that must be overcome to improve outcomes. This article discusses some of the important issues that require attention in delivering RRT in critically ill patients and provides a framework for the optimal use of RRT in the ICU.
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Richardson A, Whatmore J. Nursing essential principles: continuous renal replacement therapy. Nurs Crit Care 2014; 20:8-15. [PMID: 25347941 DOI: 10.1111/nicc.12120] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Revised: 06/16/2014] [Accepted: 06/24/2014] [Indexed: 11/30/2022]
Abstract
AIMS This article aims to guide critical care nurses with the care and management of patients on continuous renal replacement therapy (CRRT). BACKGROUND CRRT, a highly specialized therapy involving complex nursing care, is used widely in the intensive care unit to treat patients with acute kidney injury. METHODS A literature search was conducted using CINAHL, Medline from PubMed and BNI using the search terms CRRT or continuous veno-venous haemofiltration and nursing or nurses from 2000 onwards and limited to the English language. The appraised evidence and expert opinion is used in this article. RESULTS Four essential nursing principles for CRRT are reviewed (1) the importance of continuous assessment of the indications to influence the appropriate mode; (2) ensuring good vascular access; (3) the avoidance of unnecessary interruptions and (4) the prevention of complications. CONCLUSION The identified four essential nursing principles provide guidance on this complex aspects of nursing practice. Specific nursing research to guide the care and management of this therapy is limited so should be explored in the future. RELEVANCE TO CLINICAL PRACTICE Critical care nurses caring for and managing patients on CRRT require an understanding of how to deliver safe CRRT.
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Affiliation(s)
- Annette Richardson
- Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne NE7 7DN, UK
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Costanzo MR, Cozzolino M, Aspromonte N, Mistrorigo F, Valle R, Ronco C. Extracorporeal Ultrafiltration in Heart Failure and Cardio-Renal Syndromes. Semin Nephrol 2012; 32:100-11. [DOI: 10.1016/j.semnephrol.2011.11.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Volume management is an integral component of the care of critically ill patients to maintain hemodynamic stability and optimize organ function. The dynamic nature of critical illness often necessitates volume resuscitation and contributes to fluid overload particularly in the presence of altered renal function. Diuretics are commonly used as an initial therapy to increase urine output; however they have limited effectiveness due to underlying acute kidney injury and other factors contributing to diuretic resistance. Continuous renal replacement techniques (CRRT) are often required for volume management. In this setting, successful volume management depends on an accurate assessment of fluid status, an adequate comprehension of the principles of fluid management with ultrafiltration, and clear treatment goals. Complications related to excessive ultrafiltration can occur and have serious consequences. A careful monitoring of fluid balance is therefore essential for all patients. This review provides an overview of the appropriate assessment and management of volume status in critically ill patients and its management with CRRT to optimize organ function and prevent complications of fluid overload.
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Affiliation(s)
- Josée Bouchard
- Department of Medicine, University of California-San Diego, UCSD Medical Center, 200 W Arbor Drive, San Diego, CA 92103, USA
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Hsieh CW, Chen HH. Continuous Renal Replacement Therapy for Acute Renal Failure in the Elderly. INT J GERONTOL 2007. [DOI: 10.1016/s1873-9598(08)70023-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Costanzo MR. The role of ultrafiltration in the management of heart failure. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2006; 8:301-9. [PMID: 17038270 DOI: 10.1007/s11936-006-0051-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
In the United States, 90% of one million annual hospitalizations for heart failure are due to symptoms of volume overload. Hypervolemia contributes to heart failure progression and mortality. Treatment guidelines recommend that therapy for patients with heart failure be aimed at achieving euvolemia. Intravenous loop diuretics induce a rapid diuresis that reduces lung congestion and dyspnea. However, loop diuretics' effectiveness declines with repeated exposure. Unresolved congestion may contribute to high re-hospitalization rates. Furthermore, loop diuretics may be associated with increased morbidity and mortality due to deleterious effects on neurohormonal activation, electrolyte balance, and cardiac and renal function. Ultrafiltration is an alternative method of sodium and water removal, which safely improves hemodynamics in patients with heart failure. Application of this technology has been limited by the need for high flow rates, large extracorporeal blood volumes, and large-bore central venous catheters. A modified ultrafiltration device has overcome these limitations. Ultrafiltration may be a safe and effective alternative to intravenous diuretics in the treatment of decompensated heart failure.
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Affiliation(s)
- Maria Rosa Costanzo
- Midwest Heart Foundation, Edward Heart Hospital, 4th Floor, 801 South Washington Street, P.O. Box 3226, Naperville, IL 60566, USA.
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Ronco C, Ricci Z, Bellomo R, Baldwin I, Kellum J. Management of fluid balance in CRRT: a technical approach. Int J Artif Organs 2006; 28:765-76. [PMID: 16211526 DOI: 10.1177/039139880502800802] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND The possibility of making fluid balance errors during continuous renal replacement therapy has been identified since the beginning of this modality of treatment. The advent of automated machines has partially overcome this problem. Nevertheless, there are conditions and operation modes in which the potential for fluid balance errors is still present. OBJECTIVE To analyse fluid balance management in CRRT therapies across a range of currently marketed machine. METHODS The tests were conducted in vitro, utilizing saline solution for the blood circuit and regular dialysate/reinfusate for the dialysate/reinfusion circuit. The methodology used was based on the voluntary creation of a fluid balance error by altering the correct flow in the circuit of the different machines. Subsequently, the time for alarm occurrence and the threshold value for fluid balance error was evaluated. The alarm was overridden and the overall fluid error allowed by the machine was evaluated. Each machine was tested in conditions of different dialysate/filtrate flow rates and in different simulated treatment modalities. RESULTS Fluid balance errors can be easily avoided not only by a correct and careful adherence to the protocols of use of the current CRRT machines, but also by the compliance to prescriptions and programmed controls during therapy. Most importantly, if an alarm appears on the machine, one can try to override it without major problems; major problems may occur when multiple override commands are operated without identifying the problem and solving it adequately. CONCLUSION Machines seem to be designed with adequate safety features and accurate alarm systems. However, features and alarms can be manipulated by operators creating the opportunity for serious error. Physicians and nurses involved in prescription and delivery of CRRT should have precise protocols and defined procedures in relation to machine alarms to prevent major clinical problems.
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Affiliation(s)
- C Ronco
- Department of Nephrology, Dialysis and Transplantation, San Bortolo Hospital, Viale Rodolfi 37, 36100 Vicenza, Italy.
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Abstract
PURPOSE OF REVIEW The use of continuous renal replacement therapy in pediatric critical care has increased in the last 10 years. Adaptive makeshift machinery has been replaced with dedicated volumetric and/or gravimetric devices that afford accurate blood flow and ultrafiltrate production rates. While renal dysfunction continues to be related to primary renal disease, the incidence of secondary causes of acute renal failure continue to grow, especially in patients following cardiothoracic surgery, bone marrow transplantation, respiratory failure and multi-organ dysfunction syndrome. RECENT FINDINGS Although much of the outcome data for continuous renal replacement therapy has been retrospective in nature, these therapies are safe for use in the sickest of intensive care unit patients. Moreover, early data from the prospective pediatric continuous renal replacement therapy registry suggests that early intervention with continuous renal replacement therapy, as well as goal-directed fluid resuscitation may lead to improved survival in critically ill patients. In patients with sepsis and septic shock, continuous renal replacement therapy offers a means for blood purification. SUMMARY Though randomized placebo controlled trials are lacking at this time, center-based results suggest that continuous renal replacement therapy may prove beneficial to critically ill patients with sepsis and/or septic shock.
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Affiliation(s)
- Kevin R Bock
- Division of Critical Care Medicine, Schneider Children's Hospital, New Hyde Park, New York 11040, USA.
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Affiliation(s)
- Ravindra L Mehta
- University of California, San Diego, San Diego, California, USA.
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Mehta RL, Clark WC, Schetz M. Techniques for assessing and achieving fluid balance in acute renal failure. Curr Opin Crit Care 2002; 8:535-43. [PMID: 12454538 DOI: 10.1097/00075198-200212000-00009] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Fluid therapy, together with attention to oxygen supply, is the cornerstone of resuscitation in all critically ill patients. Hypovolemia results in inadequate blood flow to meet the metabolic requirements of the tissues and must be treated urgently to avoid the complication of progressive organ failure, including acute renal failure. The kidney plays a critical role in body fluid homeostasis. Renal dysfunction disturbs this homeostasis and requires special attention to issues of fluid balance and fluid overload. In addition, fluid therapy is the only treatment that has been shown to be effective in the prevention of acute renal failure. Special attention to volume status is therefore required in patients at risk for acute renal failure. Hypovolemia is also a major causal factor of morbidity during hemodialysis and may contribute to further renal insults. Although the importance of fluid management is generally recognized, the choice of fluid, the amount, and assessment of fluid status are controversial. As the choice of fluids becomes wider and monitoring devices become more sophisticated, the controversy increases. This article provides an overview of the concept of fluid management in the critically ill patient with acute renal failure.
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Affiliation(s)
- Ravindra L Mehta
- Department of Medicine, Division of Nephrology, University of California, San Diego, California, USA.
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