1/ What causes #AKI with extracorporeal membrane oxygenation (ECMO)?
🗣️🗣️Let’s explore this 🔥topic from #NephMadness 2021
🧵#tweetorial #CriticalCare #NephTwitter @NSMCinternship @ASPNeph
Poll: How common is AKI in patients receiving ECMO?
🗣️🗣️Let’s explore this 🔥topic from #NephMadness 2021
🧵#tweetorial #CriticalCare #NephTwitter @NSMCinternship @ASPNeph
Poll: How common is AKI in patients receiving ECMO?
2/ Basics first:
⚡️ECMO: temporary mechanical assistance device that provides prolonged cardiopulmonary support
⚡️Venovenous (VV) ECMO→ full respiratory support
⚡️Venoarterial (VA) ECMO→ both respiratory and hemodynamic support
ajkd.org/article/S0272-…
⚡️ECMO: temporary mechanical assistance device that provides prolonged cardiopulmonary support
⚡️Venovenous (VV) ECMO→ full respiratory support
⚡️Venoarterial (VA) ECMO→ both respiratory and hemodynamic support
ajkd.org/article/S0272-…
3/ Why are we talking about #ECMO?🤔🤔
⭐️Data from @ELSOOrg (Extracorporeal Life Support Organization): ⬆️📈⬆️in number of centers performing ECMO, and the number of runs (courses) per year
⭐️Data from @ELSOOrg (Extracorporeal Life Support Organization): ⬆️📈⬆️in number of centers performing ECMO, and the number of runs (courses) per year
4/ Rates of #AKI in patients receiving ECMO as ⬆️⬆️ as 60-85%
⚡️Meta-analysis in pediatrics 👶 showed a pooled incidence of AKI & AKI requiring KRT of 62% and 41%
⚡️ Similar rates seen in adults
pubmed.ncbi.nlm.nih.gov/31683968/
⚡️Meta-analysis in pediatrics 👶 showed a pooled incidence of AKI & AKI requiring KRT of 62% and 41%
⚡️ Similar rates seen in adults
pubmed.ncbi.nlm.nih.gov/31683968/
5/
❓Question❓What causes AKI in patients requiring ECMO?
❓Question❓What causes AKI in patients requiring ECMO?
6/ Answer: All of the above!
⚡️AKI can be d/t patient related factors (things that made the patient unwell) and ECMO related factors (mechanical or physiological effects of ECMO)
⚡️Patient related factors include
⭐️Hypoxia
⭐️Nephrotoxins
⭐️Hypoperfusion
⭐️Systemic inflammation
⚡️AKI can be d/t patient related factors (things that made the patient unwell) and ECMO related factors (mechanical or physiological effects of ECMO)
⚡️Patient related factors include
⭐️Hypoxia
⭐️Nephrotoxins
⭐️Hypoperfusion
⭐️Systemic inflammation
7/
💥ECMO related factors causing AKI include:
⚡️Alterations in kidney perfusion
⚡️Abnormal RAAS
⚡️Heart-Lung-Kidney cross talk
ncbi.nlm.nih.gov/pmc/articles/P…
💥ECMO related factors causing AKI include:
⚡️Alterations in kidney perfusion
⚡️Abnormal RAAS
⚡️Heart-Lung-Kidney cross talk
ncbi.nlm.nih.gov/pmc/articles/P…
8/
💥ECMO membranes ⏩ SIRS like response⏩ AKI
⬆️ pro-inflammatory cytokines ➡️ complement activation ➡️ endothelial injury.
💥In spite of improved pumps, circuit designs and membranes in recent years, inflammation still remains an issue
💥ECMO membranes ⏩ SIRS like response⏩ AKI
⬆️ pro-inflammatory cytokines ➡️ complement activation ➡️ endothelial injury.
💥In spite of improved pumps, circuit designs and membranes in recent years, inflammation still remains an issue
9/
🩸Also, hemolysis d/t shear stress ⏩ AKI
⚡️Plasma-free hemoglobin (PFH) → oxidative damage, forms methemoglobin ➡️precipitates within renal tubules
⬆️⬆️ PFH ⏩ prolonged AKI, need for KRT, non-survival to discharge
pubmed.ncbi.nlm.nih.gov/30581228/
🩸Also, hemolysis d/t shear stress ⏩ AKI
⚡️Plasma-free hemoglobin (PFH) → oxidative damage, forms methemoglobin ➡️precipitates within renal tubules
⬆️⬆️ PFH ⏩ prolonged AKI, need for KRT, non-survival to discharge
pubmed.ncbi.nlm.nih.gov/30581228/
10/
🗣️🗣️ Now that we've established the relationship between ECMO and AKI, let’s talk about KRT
💥Common indications for KRT in patients on ECMO:
🌊Treatment of or prevention of volume overload (VO or FO, fluid overload in image)🌊
⚡️Severe AKI (pubmed.ncbi.nlm.nih.gov/22588147/)
🗣️🗣️ Now that we've established the relationship between ECMO and AKI, let’s talk about KRT
💥Common indications for KRT in patients on ECMO:
🌊Treatment of or prevention of volume overload (VO or FO, fluid overload in image)🌊
⚡️Severe AKI (pubmed.ncbi.nlm.nih.gov/22588147/)
11/
👉Here are 2 ICU mantras:
🎯 Fluid is a DRUG
🎯 Volume overload is bad!
💥So, how do you calculate Volume overload? 🤔🤔
👉Here are 2 ICU mantras:
🎯 Fluid is a DRUG
🎯 Volume overload is bad!
💥So, how do you calculate Volume overload? 🤔🤔
12/
💥In patients requiring ECMO, volume overload (and #AKI) are predictors of mortality
💥 In 🧓🧑, 10% volume overload ⏩ Hazard Ratio for mortality 2.9 X (see VA)
💥In 👶👧, every 10% ⬆️⬆️in peak volume overload ⬆️⬆️ the odds of mortality 1.2 X (pubmed.ncbi.nlm.nih.gov/31045919/)
💥In patients requiring ECMO, volume overload (and #AKI) are predictors of mortality
💥 In 🧓🧑, 10% volume overload ⏩ Hazard Ratio for mortality 2.9 X (see VA)
💥In 👶👧, every 10% ⬆️⬆️in peak volume overload ⬆️⬆️ the odds of mortality 1.2 X (pubmed.ncbi.nlm.nih.gov/31045919/)
13/
⚡️Does the timing of KRT matter?
🎯 The data are mixed
⚡️Single center study⏩ ‘early CVVH’- within 48 hrs of ECMO initiation ➡️ increased mortality (pubmed.ncbi.nlm.nih.gov/23915590/ )
⚡️Multicenter study⏩ no association b/w timing of CKRT and mortality pubmed.ncbi.nlm.nih.gov/31953749/
⚡️Does the timing of KRT matter?
🎯 The data are mixed
⚡️Single center study⏩ ‘early CVVH’- within 48 hrs of ECMO initiation ➡️ increased mortality (pubmed.ncbi.nlm.nih.gov/23915590/ )
⚡️Multicenter study⏩ no association b/w timing of CKRT and mortality pubmed.ncbi.nlm.nih.gov/31953749/
14/
How is KRT done with ECMO?
⚡️with inline hemofilter
⚡️ or preferably with CKRT device integrated into ECMO circuit
💥Choose an approach for your team and standardize it
💥Pros and cons of the connections discussed in #ICURegion of #NephMadness
ajkdblog.org/2021/03/01/nep…
How is KRT done with ECMO?
⚡️with inline hemofilter
⚡️ or preferably with CKRT device integrated into ECMO circuit
💥Choose an approach for your team and standardize it
💥Pros and cons of the connections discussed in #ICURegion of #NephMadness
ajkdblog.org/2021/03/01/nep…
15/
⚡️The machines don’t always play nice with each other
⬆️pressure ⏰ ⏰on CKRT machine access or return side- depending on site of connection
Options
⚡️Reset access pressure limits to a positive range
⚡️Use clamps- but can ⬆️hemolysis
More options in image (PMID 27660903)
⚡️The machines don’t always play nice with each other
⬆️pressure ⏰ ⏰on CKRT machine access or return side- depending on site of connection
Options
⚡️Reset access pressure limits to a positive range
⚡️Use clamps- but can ⬆️hemolysis
More options in image (PMID 27660903)
16/
⚡️ECMO circuits are systemically anticoagulated with heparin, and thus CKRT circuit is usually ok
⚡️Regional citrate (in addition to heparin) can be used
⚡️This study showed better clotting-free circuit survival with dual regional citrate +heparin compared to heparin alone
⚡️ECMO circuits are systemically anticoagulated with heparin, and thus CKRT circuit is usually ok
⚡️Regional citrate (in addition to heparin) can be used
⚡️This study showed better clotting-free circuit survival with dual regional citrate +heparin compared to heparin alone
17/
In summary
💥AKI is common in patients receiving ECMO
💥CKRT is often needed to manage volume; perhaps better to start before significant volume overload occurs
Check #NephMadness #ICURegion for this and more🔥🔥topics!
ajkdblog.org/2021/03/01/nep…
In summary
💥AKI is common in patients receiving ECMO
💥CKRT is often needed to manage volume; perhaps better to start before significant volume overload occurs
Check #NephMadness #ICURegion for this and more🔥🔥topics!
ajkdblog.org/2021/03/01/nep…
18/
Thanks for joining me for this #tweetorial #NSMC
Thanks to @NSMCInternship @Nephro_Sparks @drM_sudha @docanjuyadav @amyaimei and Team #Twobules
Thanks for joining me for this #tweetorial #NSMC
Thanks to @NSMCInternship @Nephro_Sparks @drM_sudha @docanjuyadav @amyaimei and Team #Twobules
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