Safety of arteriovenous fistulae and grafts for continuous renal replacement therapy: The Michigan experience.

INTRODUCTION: Arteriovenous fistula or graft (AVF/AVG) use is widely considered contraindicated for continuous renal replacement therapy (CRRT), yet insertion of hemodialysis (HD) catheters can carry high complication risk in critically ill end-stage renal disease (ESRD) patients. METHODS: Single-center analysis of 48 consecutive hospitalized ESRD patients on maintenance HD who underwent CRRT using AVF/AVG from 2012 to 2013. Primary outcome was access-related complications. FINDINGS: Mean age was 60 years, 48% were male, and 88% required vasopressor support. Median duration of AVF/AVG use for CRRT was 4 days (range 1-34). Ten (21%) patients had access complications (5 bleeding, 5 infiltration, 1 thrombosis); 5 (10.4%) required catheter placement. Overall 31 (65%) patients survived to hospital discharge and AVF/AVG access was functional at the time of discharge in 29 (94%) patients. DISCUSSION: In our experience, use of AVF/AVG for CRRT can be performed with a low serious complication rate and low risk of access loss, potentially avoiding catheter-related complications.

Continuous Renal Replacement Therapy: Case Vignettes.

The most common indication for continuous renal replacement therapy (CRRT) in critically ill patients is acute kidney injury with hemodynamic instability. Typically, the patient has metabolic disturbances and potential or actual fluid overload that require intervention. Certain critical care diagnoses and/or conditions or therapies present unique CRRT management approaches. Case vignettes are used to present the unique management of CRRT in critically ill patients with rhabdomyolysis, heart failure, and respiratory failure requiring extracorporeal membrane oxygenation.

Extending the benefits of early mobility to critically ill patients undergoing continuous renal replacement therapy: the Michigan experience.

Evidence to support improved outcomes with early ambulation is strong in medical literature. Yet, critically ill continuous renal replacement therapy (CRRT) patients remain tethered to their beds by devices delivering supportive therapy. The University of Michigan Adult CRRT Committee identified this deficiency and sought to change it. There was no guidance in the literature to support mobilizing this population; therefore, we reviewed literature from devices with similar technological profiles. Revision of our institutional mobility protocol for the CRRT population included a simple safety acronym, ASK. The acronym addresses appropriate candidacy; secured, appropriate access; and potential device and patient complications as a memorable aid to help nursing staff determine whether their CRRT patients are candidates for early mobility. After implementing our CRRT mobility standard, a preliminary study of 109 CRRT patients and a review of incident reports related to CRRT demonstrated no significant adverse patient events or falls and no access complications related to mobility. This deliberate intervention allows CRRT patients to safely engage in mobility activities to improve this population's outcomes. A simple mobility protocol and safety acronym partnered with strong clinical leadership has permitted the University of Michigan to add CRRT patients to the body of early mobility literature.