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Integrated continuous renal replacement therapy (CRRT) and extracorporeal membrane oxygenation circuit: post-oxygenator connection of the CRRT inlet (arterial) line and pre-oxygenator connection of the CRRT outlet (venous) line with a Luer (L) lock
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Severe burns often cause various systemic complications and multiple organ dysfunction syndrome, which is the main cause of death. The lungs and kidneys are vulnerable organs in patients with multiple organ dysfunction syndrome after burns. Extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT) have been graduall...
Context in source publication
Context 1
... third approach has minimal impact on ECMO but increases the risks of invasive procedures, bleeding and infection and the dosage of CRRT anticoagulants [34][35][36][37]. Different methods are available to connect the CRRT machine to the ECMO circuit: pre-pump connection of the CRRT inlet (arterial) and outlet (venous) lines ( Figure 3); post-pump connection of the CRRT inlet and outlet lines ( Figure 4); post-pump connection of the CRRT inlet line and pre-pump connection of the CRRT outlet line ( Figure 5); and post-oxygenator connection of the CRRT inlet line and pre-oxygenator connection of the CRRT outlet line with a Luer lock ( Figure 6) [38,39]. ECMO combined with CRRT is an optional regimen for critically ill patients whose condition is refractory to [40,41]. ...
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Citations
... The methodology was used to a significant extent during the COVID pandemic [355,356]. There are some case reports on the successful use of ECMO in burn patients, so despite a low level of evidence, it is part of the armamentarium for the treatment of severe ARDS or smoke inhalation injury [357][358][359][360][361][362][363][364][365]. ...
... A multicenter international survey showed that the indications for starting CRRT on ECMO were fluid overload treatment (43%), fluid overload prevention (16%), acute kidney injury (35%) and electrolyte imbalance (4%) [52,53]. However, the detailed indications, timing, anticoagulation strategy, infection, nutrition support and wound management varied between studies and need further optimization for burn patients [54]. ...
Background:
Respiratory and circulatory dysfunction are common complications and the leading causes of death among burn patients, especially in severe burns and inhalation injury. Recently, extracorporeal membrane oxygenation (ECMO) has been increasingly applied in burn patients. However, current clinical evidence is weak and conflicting. This study aimed to comprehensively evaluate the efficacy and safety of ECMO in burn patients.
Methods:
A comprehensive search of PubMed, Web of Science and Embase from inception to 18 March 2022 was performed to identify clinical studies on ECMO in burn patients. The main outcome was in-hospital mortality. Secondary outcomes included successful weaning from ECMO and complications associated with ECMO. Meta-analysis, meta-regression and subgroup analyses were conducted to pool the clinical efficacy and identify influencing factors.
Results:
Fifteen retrospective studies with 318 patients were finally included, without any control groups. The commonest indication for ECMO was severe acute respiratory distress syndrome (42.1%). Veno-venous ECMO was the commonest mode (75.29%). Pooled in-hospital mortality was 49% [95% confidence interval (CI) 41-58%] in the total population, 55% in adults and 35% in pediatrics. Meta-regression and subgroup analysis found that mortality significantly increased with inhalation injury but decreased with ECMO duration. For studies with percentage inhalation injury ≥50%, pooled mortality (55%, 95% CI 40-70%) was higher than in studies with percentage inhalation injury <50% (32%, 95% CI 18-46%). For studies with ECMO duration ≥10 days, pooled mortality (31%, 95% CI 20-43%) was lower than in studies with ECMO duration <10 days (61%, 95% CI 46-76%). In minor and major burns, pooled mortality was lower than in severe burns. Pooled percentage of successful weaning from ECMO was 65% (95% CI 46-84%) and inversely correlated with burn area. The overall rate of ECMO-related complications was 67.46%, and infection (30.77%) and bleedings (23.08%) were the two most common complications. About 49.26% of patients required continuous renal replacement therapy.
Conclusions:
ECMO seems to be an appropriate rescue therapy for burn patients despite the relatively high mortality and complication rate. Inhalation injury, burn area and ECMO duration are the main factors influencing clinical outcomes.
... In addition, CRRT was implemented in a patient who was diagnosed with an acute kidney injury (AKI) to correct metabolic disturbances and control volume (Karkar & Ronco, 2020). In addition, CRRT may decrease internal contrast media levels, thereby alleviating allergic reactions (Song et al., 2021). ...
Gadopentetate dimeglumine (Gd‐DTPA) is commonly used for enhancement in magnetic resonance imaging, but rarely causes serious adverse reactions. The patient presented in this report had a cardiac arrest and multiple organ dysfunction syndrome within a short time after administration of Gd‐DTPA. Immediately after receiving an intravenous injection of Gd‐DTPA, the patient felt nausea and chest tightness, and developed systemic erythema. He was successfully treated using veno‐arterial extracorporeal membrane oxygenation (ECMO) combined with continuous renal replacement therapy without any serious complications or neurological deficits. We report a patient who was successfully treated for Gd‐DTPA‐induced cardiac arrest with ECMO. Thus, ECMO may be an effective treatment for cardiac arrest secondary to anaphylaxis.
... Early fluid resuscitation, continuous renal replacement therapy, selective administration of low-dose dopamine to dilate mesenteric vasculature and early enteral feeding have all contributed to improvements in the clinical outcome of severe burns [15][16][17][18][19]. Over the past decade, these advances have improved the overall survival rate of severe burn patients; however, the incidence of cases with severe GI dysfunction remains stubbornly high [20]. ...
Background:
Data on severe and extensive burns in China are limited, as is data on the prevalence of a range of related gastrointestinal (GI) disorders [such as stress ulcers, delayed defecation, opioid-related bowel immotility, and abdominal compartment syndrome (ACS)]. We present a multicentre analysis of coincident GI dysfunction and its effect on burn-related mortality.
Methods:
This retrospective analysis was conducted on patients with severe [≥ 20% total burn surface area (TBSA)] and extensive (> 50% TBSA or > 25% full-thickness TBSA) burns admitted to three university teaching institutions in China between January 1, 2011 and December 31, 2020. Both 30- and 90-day mortality were assessed by collating demographic data, burn causes, admission TBSA, % full-thickness TBSA, Baux score, Abbreviated Burn Severity Index (ABSI) score, and Sequential Organ Failure Assessment (SOFA) score, shock at admission and the presence of an inhalation injury. GI dysfunction included abdominal distension, nausea/vomiting, diarrhoea/constipation, GI ulcer/haemorrhage, paralytic ileus, feeding intolerance and ACS. Surgeries, length of intensive care unit (ICU) stay, pain control [in morphine milligram equivalents (MME)] and overall length of hospital stay (LOHS) were recorded.
Results:
We analyzed 328 patients [75.6% male, mean age: (41.6 ± 13.6) years] with a median TBSA of 62.0% (41.0-80.0%); 256 (78.0%) patients presented with extensive burns. The 90-day mortality was 23.2% (76/328), with 64 (84.2%) of these deaths occurring within 30 d and 25 (32.9%) occurring within 7 d. GI dysfunction was experienced by 45.4% of patients and had a significant effect on 90-day mortality [odds ratio (OR) = 14.070, 95% confidence interval (CI) 5.886-38.290, P < 0.001]. Multivariate analysis showed that GI dysfunction was associated with admission SOFA score and % full-thickness TBSA. Overall, 88.2% (67/76) of deceased patients had GI dysfunction [hazard ratio (HR) for death of GI dysfunction = 5.951], with a survival advantage for functional disorders (diarrhoea, constipation, or nausea/vomiting) over GI ulcer/haemorrhage (P < 0.001).
Conclusion:
Patients with severe burns have an unfavourable prognosis, as nearly one-fifth died within 90 d. Half of our patients had comorbidities related to GI dysfunction, among which GI ulcers and haemorrhages were independently correlated with 90-day mortality. More attention should be given to severe burn patients with GI dysfunction.
... Typically, a professional operator, an intensivist or nephrologist, is responsible for setting up the CRRT machine to the ECMO circuit (17). During operation, the management of combined therapies involves circuit controlling, monitoring of hemodynamics, anticoagulants, and respiratory parameters to prevent complications such as hemorrhage, hemolysis, infection and limb ischemia (102,103). ...
Extracorporeal membrane oxygenation (ECMO) provides pulmonary and/or cardiac support for critically ill patients. Due to their diseases, they are at high risk of developing acute kidney injury. In that case, continuous renal replacement therapy (CRRT) is applied to provide renal support and fluid management. The ECMO and CRRT circuits can be combined by an integrated or parallel approach. So far, all methods used for combined extracorporeal lung and kidney support present serious drawbacks. This includes not only high risks of circuit related complications such as bleeding, thrombus formation, and hemolysis, but also increase in technical workload and health care costs. In this sense, the development of a novel optimized artificial lung device with integrated renal support could offer important treatment benefits. Therefore, we conducted a review to provide technical background on existing techniques for extracorporeal lung and kidney support and give insight on important aspects to be addressed in the development of this novel highly integrated artificial lung device.
We sought to review the role of extracorporeal membrane oxygenation (ECMO) for the management of burn and smoke inhalation injury in the adult patient population. Therefore, we conducted a systematic search of the literature according to specific combination of key words to ascertain the effectiveness of this support strategy. A total of 26 articles were filtered out of 269 and considered suitable for this study. The PICOS approach and PRISMA flow chart were followed for the purposes of our review. Although there is growing evidence supporting the role of ECMO as an option for burn injury in the adult patient population, this strategy should be considered if a likely successful outcome is expected.
Acute respiratory distress syndrome (ARDS) can develop early in burn patients with inhalation injury in the presence of cytokine storm and the proinflammatory response can be a supplemental factor for ARDS aggravation. We report the case of a 41-years old male with 25% total body surface area deep partial thickness burns to upper body extremity and grade II inhalational injury who developed severe ARDS, nosocomial pneumonia, and septic shock. Veno-venous extracorporeal membrane oxygenation (VV ECMO) and continuous renal replacement therapy (CRRT) with hemoadsorption were successfully used at different moments to overcome critical situations. Although debatable, the use of ECMO in burn patients with severe ARDS could be considered when conventional treatment fails. The use of CRRT combined with hemoadsorption may limit the proinflammatory response sustained by the combination between major burn, ECMO and sepsis.
