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Yaroustovsky et al. Blood purification in intensive care patients

INTRODUCTION advantages and limitations, which form an algorithm of
therapeutic protocol choice. [9,10]
Extracorporeal blood purification is a modern
medical direction based on the modification of blood Cardiosurgery patients with MODS form an extremely
components outside the patient’s body aiming to serious group. First, one should pay attention to the
change their properties or remove pathological left and right ventricle efficiency, level of preload,
substances that cause or support the disease. The use volume overload of pulmonary circulation and
of these methods concerning the pathophysiological oxygenation index (PO /FiO ). At the time of initiating
2
2
process allows us to achieve therapeutic effects, even extracorporeal therapy, such patients usually
when traditional methods are ineffective. have severe gas exchange and hemodynamic
disturbances, which require a multicomponent
BLOOD PURIFICATION FOR ACUTE inotropic (epinephrine > 0.2 μg/kg/min, dobutamine
KIDNEY INJURYIN PATIENTS WITH > 5 μg/kg/min, dopamine > 7 μg/kg/min) and
MULTIPLE ORGAN DYSFUNCTION mechanical circulatory support [intra-aortic balloon
SYNDROME counterpulsation and extracorporeal membrane
oxygenation (ECMO)]. Patients with MODS have an
Renal replacement therapy (RRT) is a routine method increased preload [central venous pressure (CVP)
for intensive care patients with acute kidney injury > 18 mmHg, left atrial pressure (Pla) > 20 mmHg],
(AKI). However, the incidence of isolated AKI in adult low oxygenation index (PO /FiO < 150), edematous
2
2
intensive care unit (ICU) patients does not exceed syndrome, azotemia (creatinine > 350 μmol/L,
5.7%; up to 90% of the AKI in this group are part urea > 25 mmol/L), and electrolyte (hyperkalemia)
[1]
of a multiple organ dysfunction syndrome (MODS), and metabolic (lactic acidosis) disorders. After
indicating the severity of the patients’ condition. [2,3] the first several hours of dialysis, hemofiltration,
Similarly, AKI remains one of the serious complications hemodiafiltration (HD, HF, HDF), we observed
after open heart surgery in children. The reported preload reduction (CVP and Pla decreased > 10%)
incidence of AKI after cardiopulmonary bypass (CPB) and hemodynamic stabilization [cardiac index, left
ranges from 23-52% with up to 17% of these patients ventricular ejection fraction (LVEF) and arterial
require RRT. It prolongs the duration of ICU stays up pressure] against a background of inotropic support
[4]
to 3-4 weeks and increases mortality up to 40-90%. decline, up to 25% of the prescribed dose.
[5]
Isolated pediatric AKI corresponds to only 15%, and it
is more common in MODS. [6] In the pediatric ICU, the use of acute PD is justified
as the RRT method. PD does not adversely affect
The goal of extracorporeal blood purification in the ICU hemodynamics; it requires no systemic anticoagulation
today should be the treatment of MODS considering or vascular access, and it excludes the emergence
the pathophysiological aspects of it rather than the of disequilibrium syndrome. Moreover, this method
classical RRT in AKI. [7,8] The choice of the optimal blood is simple, efficient and safe, and it does not require
purification modality is based on the ability to correct complex expensive equipment. The indications for
water-electrolyte and metabolic imbalances and to PD in children after cardiac surgery are oligo/anuria,
decrease the manifestations of endo- and exotoxicosis, hypervolemia, edematous syndrome with cardiac
and other homeostatic disorders, thereby improving and respiratory insufficiency progression, azotemia
survival of critically ill patients. Multiple organ support and hyperkalemia. [5,11] PD allows one to decrease
therapy is an effective clinical approach. Various circulatory insufficiency, in particular, to raise mean
systems and procedures for extracorporeal blood arterial pressure (MAP) and LVEF with inotropic support
purification including diffusion, convection, filtration, decline, to normalize ventricular filling pressure and
adsorption, and apheresis directly affect the molecular preload and postload (CVP and Pla), to optimize the
and electrolyte composition of the blood, allowing one circulating blood volume and correct edema syndrome
to correct, recover and maintain homeostasis. [Figure 1]. The favorable effect of slow and constant
filtration in PD helps reduce tissue hyperhydration,
Dialysis, convection and filtration can be used today improve pulmonary gas exchange and increase the
not only for RRT. Hemodialysis (HD), hemofiltration oxygenation index. Individualized programs and
(HF) and hemodiafiltration (HDF) are pathogenically dosages of PD and appropriate parenteral nutrition
valid and effective methods in MODS. Pediatric AKI, make it possible to predict the course of AKI, along with
especially in underweight children, usually requires the stabilization and further decrease of azotemia. [12]
the contemporary use of peritoneal dialysis (PD)
and extracorporeal methods. Each technique has its More “aggressive” blood purification in infants is
50 Vessel Plus ¦ Volume 1 ¦ June 27, 2017