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Continuous Kidney Replacement Therapy Practices in Pediatric Intensive Care Units Across Europe
Marco Daverio1, Gerard Cortina2, Andrew Jones3
1Pediatric Intensive Care Unit, Department of Woman's and Child's Health, University Hospital of Padua, Padua, Italy.
Insights
Continuous kidney replacement therapy (CKRT) practices vary widely across European pediatric intensive care units (PICUs). This survey highlights significant differences in CKRT management, education, and patient care, necessitating standardization efforts.
Area of Science:
- Pediatric Nephrology
- Critical Care Medicine
- Clinical Practice Surveys
Background:
- Continuous kidney replacement therapy (CKRT) is crucial for critically ill children in pediatric intensive care units (PICUs).
- Current CKRT management practices in European PICUs are not well-documented.
Purpose of the Study:
- To describe and analyze current CKRT practices across European PICUs.
- To identify variations in organizational aspects, delivery, prescription, and liberation from CKRT.
Main Methods:
- A cross-sectional survey distributed to intensivists and nurses in 20 European countries.
- Data collected from 161 participating PICUs regarding CKRT protocols and procedures.
- Analysis of demographic characteristics, CKRT prescription, circuit management, anticoagulation, and fluid removal.
Main Results:
- Significant variation observed in CKRT prescription responsibility, circuit management, and nurse training.
- Continuous venovenous hemodiafiltration was the most common modality; normal saline was the primary priming solution.
- Practices for CKRT dosing, anticoagulation (heparin and citrate), filter changes, and fluid removal showed considerable heterogeneity.
- Protocols for liberation from CKRT also varied among participating PICUs.
Conclusions:
- European PICUs exhibit wide variations in CKRT practices, encompassing organizational elements, training, prescription, and discontinuation.
- Standardization of CKRT education, training, research, and guidelines is needed.
- Collaborative efforts are essential to reduce practice variability and improve patient outcomes in pediatric critical care nephrology.
Importance:
Continuous kidney replacement therapy (CKRT) is the preferred method of kidney support for children with critical illness in pediatric intensive care units (PICUs). However, there are no data on the current CKRT management practices in European PICUs.
Objective:
To describe current CKRT practices across European PICUs.
Design, Setting, And Participants:
This cross-sectional survey of PICUs in 20 European countries was conducted by the Critical Care Nephrology Section of the European Society of Pediatric and Neonatal Intensive Care from April 1, 2020, to May 31, 2022. Participants included intensivists and nurses working in European PICUs. The survey was developed in English and distributed using SurveyMonkey. One response from each PICU that provided CKRT was included in the analysis. Data were analyzed from June 1 to June 30, 2022.
Main Outcome And Measures:
Demographic characteristics of European PICUs along with organizational and delivery aspects of CKRT (including prescription, liberation from CKRT, and training and education) were assessed.
Results:
Of 283 survey responses received, 161 were included in the analysis (response rate, 76%). The attending PICU consultant (70%) and the PICU team (77%) were mainly responsible for CKRT prescription, whereas the PICU nurses were responsible for circuit setup (49%) and bedside machine running (67%). Sixty-one percent of permanent nurses received training to use CKRT, with no need for certification or recertification in 36% of PICUs. Continuous venovenous hemodiafiltration was the preferred dialytic modality (51%). Circuit priming was performed with normal saline (67%) and blood priming in children weighing less than 10 kg (56%). Median (IQR) CKRT dose was 35 (30-50) mL/kg/h in neonates and 30 (30-40) mL/kg/h in children aged 1 month to 18 years. Forty-one percent of PICUs used regional unfractionated heparin infusion, whereas 35% used citrate-based regional anticoagulation. Filters were changed for filter clotting (53%) and increased transmembrane pressure (47%). For routine circuit changes, 72 hours was the cutoff in 62% of PICUs. Some PICUs (34%) monitored fluid removal goals every 4 hours, with variation from 12 hours (17%) to 24 hours (13%). Fluid removal goals ranged from 1 to 3 mL/kg/h. Liberation from CKRT was performed with a diuretic bolus followed by an infusion (32%) or a diuretic bolus alone (19%).
Conclusions And Relevance:
This survey study found a wide variation in current CKRT practice, including organizational aspects, education and training, prescription, and liberation from CKRT, in European PICUs. This finding calls for concerted efforts on the part of the pediatric critical care and nephrology communities to streamline CKRT education and training, research, and guidelines to reduce variation in practice.
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