From the College of Medicine, Medical University of South Carolina, Charleston, South Carolina.
Division of Nephrology, Department of Medicine, Medical University of South Carolina, Charleston, South Carolina.
ASAIO J. 2020 Jul;66(7):e90-e93. doi: 10.1097/MAT.0000000000001100.
The concept of osmotic stability during renal replacement therapy has received limited attention thus far. We report an illustrative case of a previously healthy 22 year old male presenting after prolonged ventricular fibrillation with 75 minutes of resuscitative efforts before regaining spontaneous perfusing rhythm. Central nervous system protecting hypothermia protocol and veno-arterious (VA) extracorporeal membrane oxygenator (ECMO) therapy were initiated at hospital admission due to refractory hypoxemia. Cardiovascular imaging procedures described global hypokinesis. Due to the combination of anuria, mixed acidosis and hemodynamic instability, we started continuous renal replacement therapy (CRRT) in continuous veno-venous hemodiafiltration functionality with added hypertonic saline solution (HTS) protocol, calculated to stabilize his serum sodium between 148 and 150 mEq/L. Serum osmolality also ranged between 321 and 317 mOsm/kg thereafter. Course was complicated by an acute right leg ischemia distal to VA ECMO cannula placement, requiring salvage therapy with cryoamputation. Vasoactive medication requirement and hemodynamics improved after the addition of intravenous (IV) hydrocortisone. Brain magnetic resonance imaging (MRI) 22 days post-arrest showed signals of limited hypoxic injury. He left the hospital in stable condition with limited neurologic sequelae. Therefore, the use of HTS during CRRT is a viable way to address potential or manifest cerebral edema and reduce the degree of cerebral injury.
到目前为止，肾脏替代治疗期间的渗透稳定性概念还没有得到太多关注。我们报告了一个典型的病例，一名 22 岁的健康男性，在长时间心室颤动后出现了心肺复苏 75 分钟，随后恢复了自主灌注节律。由于难治性低氧血症，在入院时开始了中枢神经系统保护低温协议和静脉-动脉（VA）体外膜肺氧合（ECMO）治疗。心血管成像程序描述了整体运动功能减退。由于无尿、混合性酸中毒和血流动力学不稳定，我们开始了连续性肾脏替代治疗（CRRT），采用连续静脉-静脉血液透析滤过功能，并添加高渗盐水（HTS）方案，旨在将血清钠稳定在 148 至 150 mEq/L 之间。此后，血清渗透压也在 321 至 317 mOsm/kg 之间波动。由于 VA ECMO 插管部位远端的急性右下肢缺血，需要进行冷冻截肢抢救治疗，病情变得复杂。在静脉注射（IV）氢化可的松的加入后，血管活性药物的需求和血液动力学得到了改善。心脏骤停后 22 天的脑磁共振成像（MRI）显示出有限的缺氧损伤信号。他在稳定的情况下出院，仅有有限的神经后遗症。因此，在 CRRT 期间使用 HTS 是解决潜在或明显脑水肿并减轻脑损伤程度的可行方法。
