Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA.
Division of Pediatric Critical Care, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA.
Blood Purif. 2022;51(6):523-530. doi: 10.1159/000518348. Epub 2021 Sep 1.
Continuous renal replacement therapy (CRRT) has become a primary treatment of severe acute kidney injury in children admitted to the intensive care unit. CRRT "downtime" (when the circuit is not active) can represent a significant portion of the prescribed treatment time and adversely affects clearance. The objective of this study was to evaluate factors associated with CRRT "downtime" and to determine whether instituting a tandem therapeutic plasma exchange (TPE) protocol could significantly and robustly decrease circuit downtime in patients receiving both therapies.
This is a retrospective cohort study of 116 patients undergoing CRRT in the pediatric, neonatal, or cardiac ICU at UPMC Children's Hospital of Pittsburgh from January 2014 to July 2020. We performed multivariable logistic regression to determine factors associated with CRRT downtime. We instituted a tandem TPE protocol whereby TPE and CRRT could run in parallel without pausing CRRT in April 2018. We analyzed the effect of the protocol change by plotting downtime for patients undergoing CRRT and TPE on a run chart. The effect of initiating tandem TPE on downtime was assessed by special cause variation.
For 108/139 (77.7%) sessions with downtime data available, the median (IQR) percentage of downtime was 6.2% (1.7-12.7%). Multivariable logistic regression showed that TPE was significantly associated with CRRT downtime (p = 0.003), and that age, sex, race, catheter size, and anticoagulation were not. For patients undergoing TPE, the median (IQR) percentage of downtime was 14.7% (10.5-26%) and 3.4% (1.3-4.9%) before and after initiation of tandem TPE, respectively (p < 0.001). The difference in downtime percentage met criteria for special cause variation.
Interruptions for TPE increase CRRT downtime. Tandem TPE significantly reduces CRRT downtime in patients undergoing both procedures concomitantly.
连续肾脏替代疗法（CRRT）已成为重症监护病房收治的严重急性肾损伤患儿的主要治疗方法。CRRT“停机时间”（回路不活跃时）可能占规定治疗时间的很大一部分，并对清除率产生不利影响。本研究的目的是评估与 CRRT“停机时间”相关的因素，并确定是否实施串联治疗性血浆置换（TPE）方案是否可以显著降低同时接受两种治疗的患者回路停机时间。
这是一项回顾性队列研究，纳入了 2014 年 1 月至 2020 年 7 月期间匹兹堡大学医学中心儿童医院儿科、新生儿科或心脏重症监护病房接受 CRRT 的 116 名患者。我们进行了多变量逻辑回归，以确定与 CRRT 停机时间相关的因素。我们实施了串联 TPE 方案，该方案允许 TPE 和 CRRT 可以同时运行，而无需暂停 CRRT。2018 年 4 月，我们通过绘制正在接受 CRRT 和 TPE 的患者的停机时间运行图来分析方案变更的效果。通过特殊原因变化评估启动串联 TPE 对停机时间的影响。
对于 108/139（77.7%）个有停机时间数据的疗程，中位数（IQR）停机时间百分比为 6.2%（1.7-12.7%）。多变量逻辑回归显示，TPE 与 CRRT 停机时间显著相关（p=0.003），而年龄、性别、种族、导管大小和抗凝剂无关。对于接受 TPE 的患者，在启动串联 TPE 之前和之后，中位数（IQR）停机时间百分比分别为 14.7%（10.5-26%）和 3.4%（1.3-4.9%）（p<0.001）。停机时间百分比的差异符合特殊原因变化的标准。
TPE 的中断会增加 CRRT 的停机时间。串联 TPE 可显著降低同时接受两种治疗的患者的 CRRT 停机时间。
