Because existing anticoagulants may have contraindications and side effects, continuous renal replacement therapy (CRRT) without anticoagulants is nevertheless widely used. Although it does not produce major adverse effects without anticoagulant CRRT, it can raise the risk of clotting, which can lead to treatment cessation. Extracorporeal circulation lines with saline flush are frequently utilized as a non-pharmaceutical anticoagulation strategy. However, in the absence of anticoagulant CRRT, its clinical efficacy remains debatable. Therefore, this article reviews the specific procedures, flushing frequency, flushing effect, and adverse events of flushing extracorporeal circulation lines with normal saline when CRRT is free anticoagulant, generating fresh ideas for future research.
Objective To assess the relationship between the change in fluid overload at 48 h after initiation of continuous renal replacement therapy (CRRT) and 28-day mortality in critically ill patients with acute kidney injury (AKI). Methods A retrospective cohort study was performed using data from the MIMIC-IV database from 2008 to 2019. Patients who received CRRT for AKI for more than 24 h within 14 d of admission to the intensive care unit were included. The exposure variable was the proportion of change of fluid overload (ΔFO%, defined as the difference between body weight normalized fluid input and output) at 48 h after CRRT initiation, and the endpoint was 28-day mortality. Generalized additive linear regression models and logistic regression models were used to determine the relationship between the exposure and endpoint. Results A total of 911 patients were included in the study, with a median (lower quartile, upper quartile) ΔFO% of −3.27% (−6.03%, 0.01%) and a 28-day mortality of 40.1%. Generalized additive linear regression model showed that the ΔFO% at 48 h after CRRT initiation was associated with a J-shaped curve with 28-day mortality. After adjusting for other variables, as compared with the second quartile of ΔFO% group, the first quartile group [odds ratio (OR)=1.23, 95% confidence interval (CI) (0.81, 1.87), P=0.338] was not associated with higher risk of 28-day mortality, while the third quartile group [OR=1.54, 95%CI (1.01, 2.35), P=0.046] and the fourth quartile group [OR=2.05, 95%CI (1.32, 3.18), P=0.001] were significantly associated with higher risk of 28-day mortality. There was no significant relationship between ΔFO% groups and 28-day mortality in the first 24-hour after CRRT initiation (P>0.05), but there was a linear relationship between ΔFO% and 28-day mortality in the second 24-hour after CRRT initiation, the larger the ΔFO%, the higher the mortality rate [OR=1.10, 95%CI (1.04 1.16), P<0.001 for per 1% increase]. ConclusionIn critically ill patients with AKI, the ΔFO% greater than −3.27% within 48 h after CRRT initiation is independently associated with an increased risk of 28-day mortality, and the goals of CRRT fluid management may be dynamical.
Continuous renal replacement therapy (CRRT) is the treatment of choice for critically ill patients with hemodynamic instability who require renal replacement therapy. This review summarizes the impact of CRRT treatment on nutritional support in critically ill patients, including: energy increase caused by citrate-based anticoagulants, energy loss caused by glucose-free replacement fluid and dialysate, a large amount of amino acids loss in the effluent, and the influences on the way of lipid emulsion administration, capacity, electrolyte, vitamins, and trace elements. It is hoped that the intensive care unit doctors, nephrologists, and nutritionists can fully cooperate to determine the CRRT prescription and the nutritional support prescription.
Rhabdomyolysis-induced acute kidney injury (RIAKI) is a serious clinical disease in intensive care unit, characterized by high mortality and low cure rate. Continuous renal replacement therapy (CRRT) is a common form of treatment for RIAKI. There are currently no guidelines to guide the application of CRRT in RIAKI. To solve this problem, this article reviews the advantages and limitations of CRRT in the treatment of RIAKI, as well as new viewpoints and research progress in the selection of treatment timing, treatment mode, treatment dose and filtration membrane, with the aim of providing theoretical guidance for the treatment of CRRT in RIAKI patients.
Objective To evaluate the changes of right ventricular function in patients with obstructive sleep apnea hypopnea syndrome (OSAHS) before and after continuous positive airway pressure (CPAP) treatment by two-dimensional speckle tracking imaging (2D-STI). Methods Fifty patients with moderate and severe OSAHS were selected for CPAP treatment, and another 40 healthy volunteers were selected as a control group. 2D-STI and traditional echocardiography were conducted in the study group before treatment, after 3 months of continuous treatment and after 6 months of continuous treatment and in the control group. Results The differences between the control subjects and the OSAHS patients were statistically significant in right ventricular global longitudinal strain (RVGLS), right ventricular free lateral wall longitudinal strain (RVLLS), apical segment of the right ventricular free wall longitudinal strain (Apical RV-SL), basal segment of the right ventricular free wall longitudinal strain (Basal RV-SL), and media segment of the right ventricular free wall longitudinal strain (Media RV-SL) (all P<0.05). RVGLS, RVLLS and Apical RV-SL were significantly improved after 3 months of CPAP treatment (all P<0.05). Basal RV-SL was significantly improved after 6 months of CPAP treatment (P<0.05). Conclusions The right ventricular function of patients with OSAHS is abnormal. CPAP treatment can improve the right ventricular function of OSAHS patients. 2D-STI can accurately assess the changes of right ventricular function.
ObjectiveTo analyze and reduce the defects in nursing records for blood transfusion by continuous quality improvement (CQI) method, in order to prevent blood transfusion related medical disputes. MethodsIn October 2014, CQI team was established to analyze the reason for transfusion record defects and make standardized process and quality monitoring forms for nursing record of blood transfusion. Six months after the implementation of CQI, 40 records were randomly selected before the CQI implementation (April to September 2014) and after the implementation (April to September 2015) for comparison and analysis. ResultAfter 6 months of implementation of CQI, nursing record defects of blood transfusion decreased significantly from 228 to 55 items. ConclusionUsing CQI method can effectively reduce nursing record defects of blood transfusion. CQI can also improve the quality of nursing records and prevent medical disputes caused by blood transfusion.
ObjectiveTo explore the application effect of information-based circuit teaching mode for training refresher nurses in continuous renal replacement therapy (CRRT).MethodsCRRT refresher nurses studied in West China Hospital of Sichuan University from January 2016 to December 2019 were selected. The CRRT refresher nurses who were selected as the control group (studied from January 2016 to December 2017) accepted the conventional teaching method. The CRRT refresher nurses who were selected as the test group (studied from January 2018 to December 2019) accept the information-based combined with circuit teaching mode for teaching and training. After 6 months of training, the theoretical performance, operation performance, teaching satisfaction and the incidence of adverse events were compared between the two groups.ResultsA total of 112 CRRT refresher nurses were enrolled. Among them, there were 52 nurses in the control group and 60 in the test group. The scores of theory achievement (t=−2.421, P=0.017), operation achievement (t=−2.305, P=0.023) and teaching satisfaction [including teaching effect (t=−4.067, P<0.001), operation skill (t=−5.013, P<0.001), teaching mode (t=−5.589, P<0.001) and teaching content (t=−2.586, P<0.001)] of refresher nurses in the test group were higher than those in the control group. There was no significant difference between the control group (4 cases) and the test group (1 case) in the occurrence of adverse nursing events (adjusted χ2=1.169, P=0.280).ConclusionThe information-based circuit teaching mode has achieved good results in the teaching of CRRT refresher nurses, which is conducive to improving the post competency of CRRT refresher nurses.
ObjectiveTo explore the practical effects of multi-disciplinary team (MDT) management model in the management of multidrug-resistant organisms (MDROs).MethodsIn 2015, the multi-drug resistant MDT was established, and MDT meetings were held regularly to focus on the problems in the management of MDROs and related measures to prevent and control nosocomial infections of MDROs.ResultsThe detection rate of MDROs from 2014 to 2017 was 9.20% (304/3 303), 7.11% (334/4 699), 8.01% (406/5 072), and 7.81% (354/4 533), respectively. The difference was statistically significant (χ2=11.803, P=0.008), in which the detection rates of carbapenem-resistant Acinetobacter baumannii (CRABA), carbapenem-resistant Pseudomonas aeruginosa, and carbapenem-resistant Enterobacteriaceae (CRE) changed significantly (χ2=39.022, 17.052, 12.211; P<0.05). From 2014 to 2017, the proportion of multi-drug resistant infections decreased year by year, from 84.54% to 52.82%, and the proportion of multi-drug resistant hospital infections also declined, from 46.05% to 23.16%; the nosocomial infection case-time rate decreased from 0.24% to 0.13% year-on-year; the proportion of multi-drug resistant hospital infections in total hospital infections was 9.07%, 11.17%, 10.47%, and 6.16%, respectively; in the distribution of multi-drug resistant nosocomial infection bacteria, the proportion of methicillin-resistant Staphylococcus aureus, CRABA, CRE hospital infections accounted for the number of MDROs detected decreased year by year. The use rate of antibiotics decreased from 46.58% in 2014 to 42.93% in 2017, and the rate of pathogens increased from 64.83% in 2014 to 84.59% in 2017.ConclusionThe MDT management mode is effective for the management and control of MDROs, which can reduce the detection rate, infection rate, hospital infection rate, and antibacterial drug use rate, increase the pathogen detection rate, and make the prevention and control of MDROs more scientific and standardized.
Hypernatremia is one of the commonly syndromes in critically ill patients. Severe hypernatremia has a low incidence (0.6%–1.0%) but with a very high mortality (58%–87%). Conventional treatments include the limitation of sodium intake and the supplement of sodium free liquid according to the assessed water lost. The reduction rates of conventional treatments are commonly not effective enough to decrease the serum sodium concentration in severe euvolemic or hypervolemic hypernatremia patients. Continuous renal replacement therapy (CRRT) has been reported to be effective on the reduction of sodium level in severe hypernatremia patients. However, the evidences on the use of CRRT for hypernatremia are limited. Our present review summarizes the current evidences on the prevalence of hypernatremia, the outcome of hypernatremia patients, the conventional treatment of hypernatremia, and the advantages and indications of CRRT for the management of hypernatremia. Additionally, we introduce our experiences on the management of hypernatremia using CRRT as well.
Objective To compare the effect of two types of intermittent pressure on formation of pressure ulcer in rabbit hind l imbs and to investigate the mechanism of gradually changed intermittent pressure produced by waves bed in the prevention of pressure ulcer. Methods Gracil is (3 cm2) in both hind l imbs of 12 adult Japanese white rabbits were randomlyloaded with gradually changed intermittent pressure (50-160 mm Hg, 1 mm Hg=0.133 kPa) and sustained pressure (100 mmHg) serving as the experimental group and the control group, respectively. The experiment was terminated after 4 cycles, and a single cycle included 2 hours of compression and 30 minutes of compression-release. Blood velocity of hind l imbs and blood perfusion of wound were detected by bidirectional doppler blood flow detector and laser doppler perfusion imaging detection system before compression and at every 10 minutes in compression-release period of each cycle (0, 10, 20 and 30 minutes). After the termination, gross observation of the wound was conducted, pathomorphological changes of tissues from compressed area were observed by HE staining, and contents of NO, malondialdehyde (MDA), and superoxide dismutase (SOD) in muscle tissue were measured using colorimetry method. Results No significant difference was evident between two groups in terms of blood flow velocity before compression (P gt; 0.05); the blood flow velocity of two groups decreased significantly at 0 minute in every compressionrelease period of each cycle, and no significant differences were noted between two groups (P gt; 0.05); the blood flow velocity of theexperimental group was higher than that of the control group at 10, 20 and 30 minutes (P lt; 0.05). No significant difference was noted between two groups in terms of wound blood perfusion before compression (P gt; 0.05); the wound blood perfusion of two groups decreased significantly at 0 minute in every compression-release period of each cycle, and no significant differences were noted between two groups (P gt; 0.05); the difference between two groups was not significant at 10 minutes in the first cycle (P gt; 0.05), and the experimental group was higher than the control group at 20 and 30 minutes in the first cycle (P lt; 0.05). In the following 3 cycles, the recovery of perfusion in the experimental group was faster than that of the control group (P lt; 0.05). Gross observation showed the experimental group had less effusion than the control group. The experimental group had intact cutaneous appendage, less inflammatory cell infiltration, and no obvious ulcer formation, whereas the control group had obvious skin ulcer, depletion of cutaneous appendage, and more inflammatory cells infiltration. Significant differences were noted between two groups in terms of NO, MDA, and SOD content (P lt; 0.05). Conclusion Gradually changed intermittent pressure can maintain the blood perfusion of tissue, reduce ischemia-reperfusion injury and cell apoptosis, and prevent the formation of pressure ulcer.