Ekstrakorporeal membran oksijenatörü olan hastalarda bir hemodiyaliz tekniği

Abstract

Amaç: Bu çalışmada santral venöz kateteri yerleştirmeden, ekstrakorporeal membran oksijenasyonu (ECMO) hatlarında farklı bir enstrüman kullanılarak hemodiyalizin (HD) uygulanabilirliliğini ve güvenliliğini değerlendirmeyi amaçladık. Gereç ve Yöntemler: Mayıs 2013 - Eylül 2017 tarihleri arasında kliniğimizde ECMO takılmış, HD ile renal replasman tedavisi gerektiren 43 yetişkin hasta çalışmaya dahil edildi. Diyaliz makinesinin çıkışı, oksijenatörün venöz hattına, diyaliz makinasının girişi ise ECMO’nun arter hattının çıkışına iki 3-yollu musluklar kullanılarak bağlandı. HD gerçekleştirmek için çıkış devresinde basıncı ayarlamak için kullanılan enstrüman, en uygun hat basıncını ayarlamak için sıkıştırmamıza izin veren bir vida üzerinde bir kelepçe olarak tasarlanmıştı. Kan kreatinin, kan-üre nitrojeni, pH, baz açığı, laktat dehidrojenaz (LDH) değerleri değerlendirilerek HD öncesi ve sonrası karşılaştırıldı. Diyaliz sayısı ve süresi de analiz edildi. Bulgular: Bu teknikle ek morbidite ve mortalite olmaksızın tüm hastalarda HD başarılı bir şekilde uygulandı. HD'ye bağlı hiçbir komplikasyon görülmedi. Diyaliz sonrası kan üre nitrojen, kreatinin, pH, baz açığı değerleri istenilen seviyeye düştü (p<0.05). HD'den sonra LDH değerlerinde istatistiksel olarak hafif derecede anlamlı olmayan bir artış görüldü (p=0.446). Sonuç: Kulandığımız bu enstrüman, venöz ECMO hattından HD hattına olan basıncı arttırdı; düşük tansiyonda bile diyalizi ve ultrafiltrasyonu mümkün kıldı. Basit bir teknik ile çalışan bu alet sayesinde venöz kateter yerleştirmeden ECMO hatları kullanılarak başarılı filtrasyon ve diyaliz yapılması sağlanabilir.

Keywords

• ekstrakorporeal yaşam desteği
• böbrek hasarı
• hemodiyaliz
• renal replasman terapisi.

A technique of hemodialysis in patients with extracorporeal membrane oxygenation

Abstract

Aim: We aimed to evaluate the safety and feasibility of hemodialysis (HD) by using a screw compressor clamp on extracorporeal membrane oxygenation (ECMO) lines without placing a central venous catheter. Material and Methods: From May 2013 to September 2017, 43 adult patients with ECMO that required renal replacement treatment with HD were included.The inflow of the dialysis machine was connected to the outlet of the oxygenator, and the outflow was connected to the venous line using two 3-way taps. The tool that was used on the outflow circuit to perform HD is a clamp on a screw, allowing us to squeeze and de-squeeze to set the optimal line pressure. Creatinine, blood urea nitrogen, pH, base deficit, lactate dehydrogenase (LDH) values were evaluated, and compared pre/post-HD. Rate and duration of dialysis were also analyzed. Results: HD was successfully performed in all patients with this technique without additional morbidity and mortality. No related complications due to HD were observed. Blood urea nitrogen, creatinine, pH, base deficit values were decreased to the desired levels after dialysis (p<0.05). There was a slight insignificant increase in LDH values after HD (p=0.446). Conclusion: This screw compressor clamp increased the pressure on returning line of HD to the venous ECMO line; and made dialysis and ultrafiltration possible even in low blood pressure. This technique is very simple and allows to perform successful filtration and dialysis using ECMO lines without placing venous catheter

Keywords

• extracorporeal life support
• kidney injury
• hemodialysis
• renal replacement therapy

References

1. 1. Massetti M, Tasle M, Le Page O et al. Back from irreversibility: extracorporeal life support for prolonged cardiac arrest. Ann Thorac Surg 2005; 79: 178-83
2. 2. Wu MY, Lin PJ, Tsai FC, Haung YK, Liu K-S, Tsai FC. Impact of pre-existing organ dysfunction on extracorporeal life support for non-postcardiotomy cardiopulmonary failure. Resuscitation 2008; 79: 54-60.
3. 3. Rubin S, Poncet A, Wynckel A, Baehrel B. How to perform a haemodialysis using the arterial and venous lines of an extracorporeal life support. Eur J Cardiothorac Surg 2010; 37: 967-8
4. 4. Heywood JT. The cardiorenal syndrome: lessons from the ADHERE database and treatment options. Heart Fail Rev 2004; 9: 195–201.

5. 5. Askenazi DJ, Selewski DT, Paden ML et al. Renal replacement therapy in critically ill patients receiving extracorporeal membrane oxygenation. Clin J Am Soc Nephrol 2012; 7: 1328-36.
6. 6. Lin CY, Chen YC, Tsai FC et al. RIFLE classification is predictive of short-term prognosis in critically ill patients with acute renal failure supported by extracorporeal membrane oxygenation. Nephrol Dial Transplant 2006; 21: 2867-73.
7. 7. Goldstein SL. Overview of pediatric renal replacement therapy in acute renal failure. Artif Organs 2003;27: 781–5.
8. 8. Ronco C, Bellomo R, Ricci Z. Continuous renal replacement therapy in critically ill patients. Nephrol Dial Transplant 2001; 16: 67–72

9. 9. Maxvold NJ, Bunchman TE. Renal failure and renal replacement therapy. Crit Care Clin 2003; 19: 563–75
10. 10. Patel UD, Hernandez AF, Liang L et al. Quality of care and outcomes among patients with heart failure and chronic kidney disease: A Get with the Guidelines — Heart Failure Program study. Am Heart J 2008; 156: 674–81
11. 11. Quaini E, Pavie A, Chieco S, Mambrito B. The Concerted Action “Heart” European registry on clinical application of mechanical circulatory support systems: bridge to transplant. The Registry Scientific Committee. Eur J Cardiothorac Surg 1997; 11: 182–8
12. 12. Chen H, Yu RG, Yin NN, Zhou JX. Combination of extracorporeal membrane oxygenation and continuous renal replacement therapy in critically ill patients: a systematic review. Crit Care 2014; 18: 675.
13. 13. Simons AP, Weerwind PW. Re: How to perform a haemodialysis using the arterial and venous lines of an extracorporeal life support. Eur J Cardiothorac Surg 2011; 39: 1084-5.
14. 14. Seczyńska B, Królikowski W, Nowak I, Jankowski M, Szułdrzyński K, Szczeklik W. Continuous renal replacement therapy during extracorporeal membrane oxygenation in patients treated in medical intensive care unit: technical considerations. Ther Apher Dial 2014; 18: 523-34.
15. 15. Fleming GMBP. Renal function and renal supportive therapy during ECMO. In: Annich GM, Lynch WR, MacLaren G, Wilson JM, Bartlett RH, eds. ECMO Extracorporeal Cardiopulmonary Support in Critical Care 4th edn. Ann Arbor, MI: ELSO, 2012; 189–204
16. 16. Hardison DC, Fleming G. Hemofiltration and hemodialysis on ECMO. In: Short BL, Williams L, eds. ECMO Specialist Training Manual 3rd edn. Ann Arbor, MI: ELSO, 2012; 189– 96.