Driscoll Ian R, Wallace Andrew, Rosario Francisco A, Hensley Sarah, Cline Kirt D, Chung Kevin K
U.S. Army Institute of Surgical Research, 3698 Chambers Pass, Fort Sam Houston, TX 78234.
Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814.
Mil Med. 2018 Mar 1;183(suppl_1):189-192. doi: 10.1093/milmed/usx134.
Overseas contingency operations which occur in areas lacking medical infrastructure pose challenges to the stabilization and transportation of critically ill patients. In particular, metabolic derangements resulting from acute kidney injury (AKI) make long-distance aeromedical evacuation risky. Here, we report the first modern use of in-flight continuous veno-venous hemofiltration (CVVH) for intercontinental aeromedical evacuation. Hospital and transport records were reviewed for a 31-yr-old male active duty service member who sustained 40% total body surface area full thickness burns after high-voltage electrical exposure in the southern Philippines. He was evacuated to the Burns Centre at Singapore General Hospital, where CVVH was initiated for anuric AKI secondary to rhabdomyolysis. The United States Army Institute of Surgical Research (USAISR) Burn Flight Team transported the patient to the USAISR Burn Center at Fort Sam Houston, TX, USA. CVVH was performed in-flight for 15 h out of 19.5 h of total flight time. CVVH settings were maintained as follows: blood flow 250 mL/min; replacement fluid rate 3,500 mL/h; and no ultra-filtrate removal. Unfractionated heparin at 500 units/h was utilized for regional anticoagulation. No filter clotting was encountered; a planned filter change was performed during a midway refueling stop. Pre-flight hyperkalemia was managed with low-potassium replacement fluid. No fluid was removed in the setting of large wound insensible losses. The patient remained hemodynamically stable and required no vasoactive medications. Continuous veno-venous hemofiltration can be used safely during high-altitude flight to evacuate casualties with AKI from distant contingency operations. The use of portable hemodialysis equipment in this case also proves the feasibility of deploying renal replacement therapies to more forward facilities than previously considered.
在缺乏医疗基础设施的地区开展海外应急行动，对重症患者的稳定和转运构成了挑战。特别是，急性肾损伤（AKI）导致的代谢紊乱使长途航空医疗后送具有风险。在此，我们报告首次在洲际航空医疗后送中现代使用飞行中连续性静脉-静脉血液滤过（CVVH）的情况。回顾了一名31岁男性现役军人的医院和转运记录，该患者在菲律宾南部遭受高压电暴露后全身40%体表面积全层烧伤。他被后送至新加坡总医院烧伤中心，在那里因横纹肌溶解继发无尿性AKI而启动了CVVH。美国陆军外科研究所（USAISR）烧伤飞行团队将患者转运至美国得克萨斯州萨姆休斯顿堡的USAISR烧伤中心。在总共19.5小时的飞行时间中，CVVH在飞行中进行了15小时。CVVH设置维持如下：血流速度250毫升/分钟；置换液速率3500毫升/小时；且无超滤清除。采用500单位/小时的普通肝素进行局部抗凝。未出现滤器凝血情况；在中途加油停留期间按计划更换了滤器。飞行前的高钾血症通过低钾置换液进行处理。在存在大量伤口不显性失水的情况下未进行液体清除。患者血流动力学保持稳定，无需血管活性药物。在高空飞行期间，连续性静脉-静脉血液滤过可安全用于从遥远的应急行动中后送AKI伤员。在这种情况下使用便携式血液透析设备也证明了将肾脏替代治疗部署到比以前认为的更前沿设施的可行性。
