Practical aspects of renal support in AKI during the COVID-19 Pandemic

[Music] [Music] thank the kidney to Facebook Filmart upon being an almost Alaska beautiful now yeah I probably don't occur from live where it's me Jallianwala condo I [Music] generation clavicular dossier Nunez continent a known as condado the experience cantata we stay in Pai Kamini will core area and mass cantata with a real soul unless Contador yeah die enough advance wounded in town Psalms mcmooch arrives home heinous well he like Hooton yeah it doesn't have to go tight well there are more you tight America Fallujah camper fire even sittin over Tokyo Bay yeah they may follow T may max and the the photography even tonics made me able to sell of me out the food you have to Alice forces all across states [Music] [Music] you know so no medical detail of intensive Anatolian sense okay nevado Connie neonatal quindi amnion cocoa tea to tell you my minimal Toronto Pecola Buddha hello Camela pasto Connie menisci it's a token it's you're not on campus it's on its last one they call a kiss on nemesis so we need an a party a vivo a DOS implemented facilitate an and complained that soon a lamentable okay status which attend the China Evo bassanio de Longhi cynical local chemist Augusto plov identity clinic okay and up to simply she has to admit okosan Delta party that ponto de vista that punto de stad allah than qatal east a medievalist a bit on the NT and see what's happened to dr. 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Casey McGehee out I said they are what the gay action you see Coco by date and not mean and what scares me is that making those decisions and making those wrong decisions and the realization that that decision of that decision in 3-4 weeks time where you end up having a patient who in effect can be crippled by life-sustaining therapy which may not have been in their best interests or the family's best interest and that still scares me and I think it scares a lot of colleagues but intensive care is much more multidisciplinary now and I think that has helped our decision-making and has reduced that fear factor honesty and humility go a long way and most patients and relatives understand that we also human and mistakes can happen and should be openly discussed [Music] [Laughter] yes the nice Amish men and Hoda super FEMA mass theater after podium not on a show Camille p.m. Shakira pocket ass this is caribou parabolic general Holden a mathematician yet except a pro shop on the Pro Shop armistice phone asthma's don't wanna prove any message to her oh yeah Nakata firma another short man IP the ocean Quixote namaz don't know mathematician apakah Donatello mckameys together with my colleagues in particular the nursing colleagues we arranged a wedding for a patient who was at the end of his life and had decided to marry his long-term partner before he later died and it was very moving to be part of this very special event in the intensive care unit it's a real privilege to be able to support a patient and their family through that what I hope is the worst thing that ever happens to them in their lives to be able to support them through that hopefully to recovery or to support them through managing a dignified death if we fools go to DC blonde with work request Casillas neuquén you Thomas we Cox David Thoreau that's a group request propensity to Tom as it is easy but what for to keep I don't have any response important and even the humans wrong zip our zippers of castle adidas aqua [Music] let me know Olivia did CY fantasy another Abbado la vida the water hardness oh no quick thank you I got to speed a little bit more to the other place I didn't see another bad weather in Televi de sóller pinnacles the pursuit of sheer bulk of your enter okay since the deal on supplements Alec we be better in Zurich we aren't you intensive care medicine allows me to learn something new every day so every day I meet colleagues and I hear of their new technologies new advances and progress in their particular specialty but most importantly every day is a different day with new challenges and I enjoy the interaction with my colleagues and most importantly with patients and their relatives so it is it provides a great variety it's different every day and it's a specialty where progress is made on it on a regular basis don't go busy love water your photo goes to misty them over to that auntie I miss all the moving pieces down Kukui I need to cause and incense okay ye lot of eat ie deliver cope at SUNY but on you I don't see Dana movin on participe movin on Saturday more toe bootie memorial potty versus male Madame le manya mayuri so people get on a knee injury money equals o meda meda will minimally junk a little cottage carry a juice Toki in Bimini can even more fidelity a journey toward upon the mannequin surface of insulin sister Rosa stamina linearly money from the Muslim man grass [Music] [Music] [Music] [Music] [Music] I am an anesthesiologist and I am proud to be an intensivist we intensivists are working together to fight Kovach 19 together we are intensive care medicine we are fighting for mid-nineteen together we are intensive care medicine I am an anesthetist and I'm proud to be an intensivist we are working together to fight covert 19 together we are intensive care medicine intensivist with various specialty backgrounds work together as about the missionary team to prevent and treat temporary risk of death my name is Phil Nevada and I'm proud to be in surgery trained intensivist and work in intensive care we work together to beat kovat 19 together we are intensive care medicine [Music] hello good morning good evening to everybody who is listening to this webinar i'm ali suleiman and i'm a consultant in Krita care at st. Thomas's Hospital in London and it is a great honor to moderate this important session dealing with practical aspects of Rena support during the Kovach 19 pandemic we have the pleasure of to invited expert speakers who will touch on the challenges of practical in replacement therapy and I'm sure explore and share the experience with us and so without further delay I'd like to invite professor Pickers who is a professor of experimental intensive care medicine at Radford University in the Netherlands to share us his experience the particular aspect of dealing with the high demand of Reno support Peter over to you malece good morning evening or night everybody is listening indeed in the first talk I will talk about practical aspects of increasing the demand and maybe shortage of supply and personal and also fariko for specific issues related to API and renal replacement therapy let me see if I can move my screens so much of what I will tell you in the next 30 minutes is something that we discussed to create extends over the last few weeks in a net key meeting in the acute dialysis quality initiative and this at key meeting is specifically on cough it 19 induced API and organized by John Callum Louis Forney Mitra Nadeem Rafi Mehta and claudia Ronco and on the right you can see the Faculty of people that are actually participating on this and normally we have a meeting like this close to Ana suppose iam or a Congress and we will be in a nice place in the world that we would spend a few days on discussing specific items related to some form of API but nowadays of course this is not possible so this meeting virtually took place on the Fuji islands but we were all at home and doing the meeting by soon so this is one of the chairs John Kalam everybody knows him and this was how he did the meeting and believe it or not I asked him if I could share this picture and he said yes of course you can do so so it's a consent and share so this is a virtual meeting on the Fuji Islands but we are all at home and we are discussing every aspect of cofee induced api and renal replacement therapy and what is very important is that we are still working on what will be the considerations and what will be the recommendations and so I have no final recommendations or figures yet but I was allowed to share already what we have so far so I will start with some background the kidneys are clearly involved in kovat 19 and what we see is traditional markers for example your create an F value that might go up if there is API of course but there's also a large proportion of patients deaths that have blood over proteins in the urine and I will come back to that later what also is of interest is that the RNA of the virus is actually found in the kidney tissue and so this could also have a direct effect on the kidneys or have a local inflammatory response in the kidneys and it's also relevant to realize that renal cells actually express h2 which is used for the virus to enter cells so this could also be a reason why the files could get into the cells and have effects right there so far we think that endothelial dysfunction problems with calculation compliment activation are likely important mechanisms of the occurrence of a key I in at least a subset of go fit 19 patients but there are also other reasons some of these patients have diarrhea many of them have a fever and of course this might also lead to API if they are for example dehydrated also organ crosstalk may appear it's known that the kidneys are in touch with the lungs at the heart and is also a mechanism of API in subset of patients and also critical care interventions we do know from previous work that if you're on a ventilator or if you receive fluids and your CVD is higher that this might also be related to Aki and also of course drugs that we use in the ICU some of them are nephrotoxic and again this might play a role in coded patients as well and finally there are baseline patient characteristics like age like chronic kidney disease that's already pre-existent that might contribute and so there's a lot of mechanisms that are illustrated in this figure that maybe if we look at the different phases of comfort 19 patients there might be a fiery face in the beginning later on when the inflammatory response is occurring there might be symptoms and respiratory problems and more later on in the ICU there might be multi organ failure and so it's likely that in the beginning there might be direct viral effects on the kidneys later on effects related to the inflammatory response to coagulation to endothelial damage and even later on natural toxins or mechanical ventilation etc are also exerting indirect effects on the kidney well if you break down the risk factors you could do it in this way so demographic risk factors older age diabetes maybe race genetics etc risk factors that are present during admission in the hospital the severity of the disease possibly the decree of the amount of virus the cytokine storm that we recognize in these patients etc and also during hospitalizations again fluid drip treatment and therefore toxic treatments etc so there are many many fire arrivals that are of relevance and that's why I think that's that's a huge difference in the reported incidences of Aki as well as renal replacement therapy in these patients so one of the reasons that the differences in incidences is so high is that there is inconsistent use of código consensus definition of Aki so I think it's really important that if you are planning to publish about Aki in these patients you should use accepted definitions of Aki in many pages of course they do not have a medical history so there's no baseline creatinine value for example and then it's always difficult where they came from or how it increased we do not know if there was pre-existing chronic kidney disease there are huge variation in temporal associations so basis might come to the hospital early or late did the C severity basis are admitted to the ICU because there's still a possibility but maybe later on there's no possibility in the ICU if every sick patients are treated in the water or some other place so the use differences in case mix-up which makes it difficult and makes it all so difficult to compare different parts of the world to see how it is in the at key meeting the group that was focusing on this part they looked at all the studies that have been published so far and they looked at the rate of Aki as well as the rate of real replacement therapy over the different parts of the world and as you can see that in the beginning the first reports that came out of China actually suggested that there was a fairly low or even no Aki involvement in patients with this disease but later on we found indeed that there was and there are still very large differences per continent so in you say it might be one out of three while only about 8% is reported in Europe nevertheless if you look at renal replacement therapy rates it seems that that is much higher in Europe compared to the USA or China so there are differences over the world but again it's also very much related to the definition of Aki and indications to start with replacement therapy for example the largest study up to now is a study from the area of New York recently published in this study over 5,000 patients in 13 hospitals were included all covered 19 patients and as you can see in this infographic more than one out of three had a ki divided over the different stages and what is of interest is that the highest incidence of Aki was during admission or the day after so very early on in the disease as you can see here again independent risk factors to develop a ki or to come in with a key i order AIDS black race cardiovascular medical history like hypertension or other cardiovascular disease diabetes the use of Facebook presses and the need of mechanical ventilation and that one was the big one because if you needed mechanical ventilation the the the risk of to develop of the half a ki was tenfold over tenfold so this is an important thing to know also from this study again the breakdown when the diagnosis of a ki was made as you can see most of the patient on admission or during day one this is different compared to my own experiments experience in the Netherlands well we saw most of the patients on day three or four developing API so there are used differences when people come to the hospital in what condition are they already for example so this is a summary and again I want to use this infographic to illustrate the very high incidence of patients with proteinuria with blood in the urine or both and that that might also be a signal that the kidneys are suffering already even if they do not fulfill Aki criteria at that moment so what about real replacement therapy in covered 19 patients I think it's very important that we have to distinguish two situations there might be no shortage yet of material and off personnel and so in that case you have to do as usual most of the times I will break it down in various aspects for vascular access we suggest to follow código guidelines and to use the right internal jugular and because one of the reasons is patients are in prone position and you can actually alert also to do a line in prone position and it's still accessible the second choice would be the femoral fin but in prone position this could be difficult the modality that you use should be based on the needs of the patients the local expertise the fail ability of staff and equipment so the basic rule again is do as you always do and do what your experience is I will come back to that later one important difference that might be there is that in Kovac 19 patients and especially in the very early phase of the disease they they suffer hyper calculation and that means that if you're not used to using anticoagulation for reading replacement therapy you will have to consider that because filter lifespan will be very short in the beginning so ante calculation an important issue the next speaker will come back to that in detail I will say some things about it in the next slides another thing not related to anticoagulation but what you can do is change the mode that you are using so using these modes you can actually decrease the filtration fraction and thereby the risk of clotting is less so this is related to vascular access and as you can see is the femoral penis taken for comparison and that the internal jugular Fein is not significantly different so the ranking is if you are thinking of about permanent catheters is not really applicable here I think a tunnel is best and then femoral and internal jugular are similar and the subclavian is less so this is something that stays the same and also the size of the catheter is of importance and it's very likely that's even more important in these patients that have such a high tendency for trombonist so try to use the larger ones there's a nice commentary in critical air from an Italian group that have recommendations for use of vascular access in these specific group of patients and one thing and may sound obvious but it's really helpful is that you could have specific and dedicated vascular access teams so that if you are intensive care physician you can focus on all the intensive care stuff but you don't have to spend time on keeping lines to people so that's something that could be really helpful and have other people that are experienced in that to help out another suggestion of this group was that it might be difficult because of the isolation measures to make x-rays of lines to see if their position is okay and you could do it easily and keep using ultrasound for example so that's something to consider as well and at the same time you need of course still use your infection prevention measures in it's as important as always I would say so in summary if there's no shortage of people if there's no shortage of material the basic rule is do as you usually do use the same indications to start reading replacement therapy use the same dose the same fidelity the same indications to stop with your replacement therapy the only thing that might be different is to intensify anticoagulation therapy and I will say something about that now so it's now recognized that go fit 19 patients have a very high incidence of Trumble and below embolic events and this is a study from the Netherlands and they showed that indeed about one out of three patients suffer pulmonary embolism or another Trumbo and Baalak offense so this is extremely high incidence and indeed if you start using and the calculation systemic anti collation so not related to read replacement therapy is clear that the survival of these patients is been officially influenced so this is a very relevant issue that is ongoing in these patients so what we suggest indeed is that you thoroughly evaluate their hyper calculation price to starting green replacement therapy and then you can use a stepwise approach to escalate the enter calculation that you will use I would suggest that if you are not using citrate do not start using style citrate during this pandemic because it's something that you need to build experience it's dangerous if you do that well and so you should not change sales in the midst of storm so do what you usually do but you might want to intensify it and also reported what we do for example is that we we give it to the to the system so we infuse for example heparin to the to the regional system but of course it gets back to the patient and so there's not really a difference between regional and systemic and the calculation and you can still measure the effects in that patient and so you can use something to aim for in anti calculation of that patient so the things that I said are summarized in this table if you look back this presentation on YouTube you can pause it and read it as you want to so what about if there is a shortage and then there will be a short end so it's if there's the second wave or in certain areas of the world and the other thing is that there's more demand for it but this is all getting worse if there's local global locked down and the supply chains are also affected so in that case this is a really nice paper that illustrates that what you should do is make projections of demand how much do you need and when do you need that and it's really important especially for real replacement therapy resources that if you are better in anticoagulation you will burn down your filters less quickly of course and so very important to also intensify and look at that part of treatment what they showed is that you can actually make assumptions so you can say well I know what I use what I normally do I know how long a catheter lasts on average I know how many nurses I need etc you can have specific strategies to have less resources that you need and based on that you can actually calculate and make a table like this that if I have 3000 or 5000 patients in a week very large numbers I need this much of disposables of personnel etc and this is really important to do in advance so that you can anticipate on what is coming and see if you will be able to do this yes or no but we made a preliminary figure that if there is a pandemic there's more demand there's less capacity for different reasons and so there's a potential crisis in giving or RT to these patients and so there are different costs that you would aim for I think if you are preparing you can start anticipating and deal and find things start training personnel resources etc if there is actually if you are in the search you have to do things and there can be a crisis and so there can be local responses there regional and national responses and we describe what you can do to actually try to maintain this treatment available the availability for these patients so what also is needed is that there could be a problem that there could be hospitals or Institute that are actually hoarding materials and so there will be short as another place so it's really important that there is a multicenter collaboration or even a national overview to make sure that what is available is equally distributed and that so these are things that we learned I guess over the last couple of months and that we should actually be more proactive in in case anything like this would happen again so again a long list to look back on the YouTube movie clip and all kinds of suggestions that are possible to be more efficient in the consumption of the stuff that you need again it's something to look back up so the next thing I want to discuss is that there are of course different modalities that you are all aware of and this table actually illustrates what could be an advantage or a disadvantage for that specific treatment modality and I think most of the I see use would use continuous renal replacement therapy but you might think that you could switch earlier than you would normally you do - for example intermittent heal in dialysis so there are this is widely available also you can treat multiple patients per day on a machine etc and here it is more labor-intensive and you only have one machine for a patient on a day so you have to think about these items as well to decide if nothing if there's a really big problem and a crisis is pending I think we should also consider PD this is something that we do not often do in the ICU nevertheless is widely available there's no clotting concerns you do not need any Finas access so these are benefits but there are disadvantages as well we do not have much experience with it the patients are in prone position which might be in handy and so you should have protocols if you want to do this if there is a shortage of machines or filters so again it's simple no anti calculation needed no filter needed however there's limited experiments and patients are in prone position of course the last few things I want to share with you is that we will also make a table of drugs that are especially important in these patients like remedy so fear for example and what we actually know at this moment about their pharmacokinetics and it's unfortunate but we do not know that much most of the patients that are on really replacement therapy are excluded from trials that are investigating the clinical efficacy of these drugs so we do not know much and we need more information on this because one out of three patients actually suffers a ki and so we will have patients that need these drugs and our organ replacement therapy as well I will not go through it but there's not much known at this moment and it's something that we need to focus on what about the outcome of these patients with Kovac 19 and API as with many other diseases in the intensive care unit there is a state's dependent increase in mortality in these patients as well if it stays three Aki two out of three patients might eventually die according to the literature so far and again there are some differences between different areas in the world of course but this is something also relevant to consider so my overall conclusions to summarize my presentation is mostly do as you normally do do not go change something in what you do not have any experience in etc the important thing that might be different than what you normally do is an T calculation and you might want to intensify that in these patients one for their clinical outcome and also for filter lifespan if it's there the second thing is that you need to anticipate a search and you need to anticipate shortages of material machines and personnel and make a plan how you will handle that and with that I thank you for your very kind attention and I want to thank the faculty of the at key that actually worked on all these different items and that's the end of my presentation thank you thank you very much Peter for a very informative talk very useful and I'm sure there will be lots of questions and I'd like to invite the colleagues listening have the bulk of the questions at the end after aunt ones talk but I maybe I could just ask you one question one is related to PD and reintroducing new techniques clearly this would require a training program I don't know whether your nurses are used to doing PD or intermittent hemodialysis in the intensive care unit and how did you how would you recommend to overcome these challenges yes so the paper that I refer to is actually also giving some instructions how to anticipate and how to train for it because I think it's simple in its nature but nevertheless you need to know how to do it of course and so we did not come to the point that we had such a shortage of filters that we need to go there but I know from people from other places in the world that they did and the choices do not do anything at all and let the patient die or to do something else so my overall message is really important that overall do not change something don't think well I've never used citrate but maybe it's better now let's start it in the midst of this pandemic because it's dangerous you need to you're too busy and as a high risk of making errors and and having actually more side effects than benefit so overall I say do as you normally do but if you're really in a crisis and the choice is like letting a patient die because you do not have the machine or the filters then you have to do something else and I would suggest actually to collaborate with your people from their policy departments discuss this make agreements on who is doing what and have people that are experienced in PD as well run this or train the people if you actually come to that face I'm sure that's something people learned in the Kovach pandemic that it's so crucial to collaborate with your colleagues and with colleagues outside the intensive care unit I'm sure there will be more questions but I think we should just move on to the next talk to Antoine stroke who will cover practical management of Reno support at the bedside and then address questions at the end and again I'd like to invite all the listeners to write down their questions and we will ask them so on Tuan a good friend and colleague of mine we say an intensive care professor at the University of Lausanne in Switzerland with a lot of experience in Reno support at the bedside someone over to you thank you very much Mally's for the kind introduction thank you everybody to be with us during this for this webcast and webinar yes so indeed I will continue with the practical management of Reno support in curvy 19 and try to give you some help and some insights a to a studio and I fully agree with the previous statement made and I don't think we should completely change the way we practice medicine although maybe at least in Europe we seem to be perhaps between two waves and some of the suggestion we my we come I come up would be but perhaps things we could implement in the meantime to prepare for for the the hopefully not but for the following wave so I've got a few disclosures that I need to make and besides that we can start and Peter Pickers has done a very nice introduction so I can go very quickly with the incidence of coving of kki in Covey's 19 we all agree it's very it's something that has a high incidence obviously depends on the definition use and the settings it's definitely a marker of severity and it's a negative prognostic factor for survival and again depending on the on the centers on the indications some of the patients would they care I will require we know replacement therapy and it's a fairly fairly big proportion of them and about 10 to 20 percent will receive this therapy will require this therapy and again like he was already previously said there's a link between the virus in fact in the Aki and I'm not going to go through all the mechanisms as Peters already done it but there is definitely direct toxicity from the virus there is the cytokine storm and all the inflammation related issues that are leading to Aki the hemodynamic and the Barrow traumatic and the increased intra-abdominal and intrathoracic pressures that the the altered mo dynamics the left ventricular function etc and I will insist a little bit more on the last last elements which is definitely an issue in SARS cough too that we don't face so so much with other kind of of pneumonias or a RDS is the coagulopathy so this coagulopathy in in kovat 19 is definitely something that is playing a significant role significant role in the in the patella the physiology of the disease not only contributes to Aki but today - probably the lung issues as well and definitely contributes to the high mortality of the disease it's characterized with an increased fibrinogen and d-dimer's sometimes criteria for di C are met but this is rarely the case and on a clinical point of view it can lead to clotting everywhere along the vascular tree arterial thrombosis with catastrophic consequences stroke myocardial infarction with an incidence ranging between five and perhaps ten percent this is this is not something rare this is something that we see and more even more scary or whatever is more scary but even more frequent at least is that the venous thrombosis particularly scary when they touch too long and can consist in a large pulmonary embolism and on top of these there are some micro thrombosis that can be found in the micro circulation that is very difficult to really diagnose and probably play a very important role in the pathophysiology of the disease and in so this micro circulation alteration definitely would be associated with Aki as well as thrombosis within the the kidney and there is this series of our autopsies from China but they were able to demonstrate the presence of intra glomerular from boses really in some of the of the patient of a tree in this case a series of 25 or plus patients so clearly thrombosis is part of the physiology of of Co v19 of the disease it's a link with Aki and it's something we have to deal with and again like we said in the previous presentation anticoagulation is absolutely mandatory for this patient we need to give prophylactic and anti coagulation to all patients and probably a bit more than just a simple prophylactic anticoagulation and when you do renal replacement therapy you need to be even more obviously there are all these different reasons and that's in any case if we have blood circulating and extra corporal circuit blood for any surface contact a blood pump you have a low relatively low blood flow you have a treatment that's going on for aiming for to go on for a long period of time so the circuit is a risk of clotting in the first place and then you you might wanna or you might want to introduce anticoagulation anyway but when you have procoagulant state such as covered it is all the more important to to really administer some anticoagulation otherwise the circuit will already have a very short period of time so I think Molly is for sharing this this these slides with me this is an electron microscopic of CRT filter capillary and you can see here and the virus in the coagulopathy can impair the therapy and lead to clotting which we completely include the lumen and impair the flow but also to another phenomenon which is called clogging and is actually a deposit of protein cakes or code of daddy that is going to create a layer over the surface of the membrane it will not change the flow within the the capillaries but it will decrease the capacity of the membrane to to actually purify the blood people the crisis decrease its permeability and the ability to diffuse the water and both these alterations are highly prevalent in kovat 19 due to coagulation alterations and this is really the last thing you want because on one hand you have limited resources you have limited ability to manage the therapy and then on the other end you have this therapy that is becoming more and more complicated if you if you have clogging it will decrease the efficacy of the therapy you will generate alarms and your nurses are going to have to deal with these alarms and to try and fix the problems and eventually the filter life will become shorter and you will need replacement and again they will have to work more and also you have to use more kids and you already are short of them so you really want to make everything possible to minimize clothing of a few of your CRT circuits and here there's nothing I would say that is really new because this is something you want to optimize anyway but it's just something that would be probably nice to have in an in a normal situation but that's becoming a particular really paramount importance in the situation where resources and manpower are limited really want to focus on the actual best practice for CRT which which we should try and aim for anyway so I have several tips that I will argue and propose you to consider and exactly like you were said in the previous presentation I don't think we should change everything we do if you don't know how to use citrate it's probably not the time in the midst of a crisis to change to that anticoagulation regimen however perhaps when you're preparing for a second wave or thinking this could be the time to now move to this SI trait to these anticoagulation and that is true for all the other different tips that I'm going to give you so perhaps take that as a nun and as an emergency thing to change in urinate today but maybe to implement in a sort of mid to long term so anticoagulation is has been traditionally administered in a conventional systemic way using mostly heparin and the problem with heparin is that it's associated with the risk of bleeding and because we don't want our patients to bleed we tend to under those the heparin and the anticoagulation is often inadequate with this regimen so therefore regional anticoagulation such as of which citrate is is becoming the prototype nowadays is becoming a really seductive alternative and regional citrate anticoagulation is of course not associated with the risk of bleeding it can improve filter life we get back to that and we definitely improve circuit permeability because it's a very highly efficient anticoagulation of the circuits and obviously as it was already alluded to it is more complex and it can lead to issues but the fact is the literature is there's numerous publication these are randomized control trial different settings using different modes that have clearly established the superiority of citrate in terms of filter life and the much longer circuit lifespan with we said with this modality of anticoagulation this is data from a center simply observational but just to show you that in real life outside and a randomized control trial where you really want to have the best results possible this is retrospective data and we simply look at the the filter life of all a circuit over a period of one year and we were really impressed to see how much of a difference there was as you can see there is almost four fold the median duration of the circuit were almost full fold when the circuit was run in citrate as compared to heparin and this this was essentially due of course to a lower much lower rate of circuit interruption for clotting and is translated on a much higher dose per session so much longer filter life with citrate less complications less downtime and eventually if you put this all together lower cost and again this is not new this is not something that's special for the Coheed curvy but this is something that's been recommended by the kid aegyo society already in 2013 so seven years ago so we should all move to these technology or to these modalities that are just what we probably should be doing anyway and citrate is really the way to go and it's all the more important when you're facing these situation again there can be complications and this is not something to move to do lightly and the number one complication is citrate accumulation although very rare and in certain circumstances really those patients that have really circulatory shock very refractory and perhaps liver failure very severe or poisoning but that occurs really rarely if you following a real strongly strictly validated protocol you can't just start doing citrate and think you know you need to be really following a protocol and this protocol should be really aiming at low using a lowest possible blood flow because as you as you as you probably know citrate is always that the administration of citrate is linked to the blood flow the more blood flow the more citrate and the more citrate the more likely it is that your patient might have accumulation of the the molecule and then if you are our Center with low experience what you might want to do is start with a citrate for those patients that really have no risk patients no shock no problems of liver no issues and if you really limit your patients your indication to those patient there and you probably safe in the vast majority of the patient follow monitoring the calcium the total over ionized calcium ratio and and it's extremely important to do so that's the first tip is use regional citrate anticoagulation was as much as possible move towards this utilization the second one is also consistent what's been said is you'd cdhd and again this is not something that's specific to the curvy but it is probably something that's really how better for filter life span and simply stated when you use hemofiltration so the Purim of filtration the CV vh mode you will have some form of ammo concentration by definition because what you will do is filter the plasma remove some some some water and electrolytes and this will progressively lead to a concentration of the blood and you will have an increased concentration of the platelets of the the coagulation factors and that will lead ultimately if you do that too much to a to clotting obviously their work around you Dupree died Lucien you have a high blood flow but clearly you need to keep the filtration infraction the ratio of filtration over the blood flow under 20% that implies the highest possible blood flow but the given those it's not always easy to have a very high blood flow especially if the patient has shark or eyes a bulimic or the catheter is a problem so it's complicated these issues never happen in film in CVV HD mode simply because filtration fraction is only limited to that of the food removal that you affect the net through removal that you want to achieve so it is not never going to be a problem in this mode there's other advantages of using CVV HD is you can very effectively run the therapy with very low blood flow a hundred 120 mils per minutes instead of 250 in CB th mode and again that would mean you're gonna have to use less citrate you will put less strain on the catheter you don't need to use pre dilutions because the pre dilution is only there to counteract the effect of mo concentration you should not be worried about the clearance because at least for the small molecules and the urea creatinine all the molecules that we really want to clear with the CE RT is the clearance is exactly similar between the two modality and on because there's less filtration there's going to be less clogging less protein cake formation so all good reasons to prefer this modality as and particularly in this setting then there's something that may be more of a user tip that really supported and really supported by the literature is that the in case of the clotting you might want to consider high cutoff membranes and you have them so we all use high flux filters nowadays but there are some high cutoff membranes that have actually been marketed mostly to to enable middle molecule clearance and hopefully in the hope of improving again treating the cytokine storm and you can see here the clearance of small molecules is essentially not different but those of their large larger molecules like myoglobin or ir6 is is higher in these high cutoff filter so that's not the reason why I would suggest that you use it but sometimes and not in all patients you you might experience early clogging of the of the circuit even inside with citrate anticoagulation and my experience we found that using this high cutoff membranes in these situations we're improving the the situation in some case again that's that's mostly a user tip the next one is consistent what we again what's been said it's optimizing vascular access and we can't repeat that often enough that the most important component of the CRT circuit the best anticoagulant for a circuit is the catheter if you have a dysfunction in catheter you can put all the hepa rain all the citrate that you want in the the way your circuit will clot and it will not work because the hemodynamic is is wrong so the vascular access and needs to be of a certain size but again if it's going to be partly cluttered you the bigger is the better and of course the flow is is proportional to the resistance of to the flow is a proportional to the diameter so you the widest catheter as possible that you can that you can obtain and at least I would recommend to a French the the right the right material the right design put it in the right vessel and most importantly care about the catheter think about the catheter if something goes wrong with the circuit you're better off replacing a line earlier than later because you will eventually find and save some time then when we talk about catheter in in in Co V there is these option a few of our patients thank God there's only a limited number of our Kovac patient that require ECMO mostly VV ECMO and this is a connection that we can consider it's not something I would necessarily recommend in to use as a default some centers are doing that and it depends on your experience but you can consider that if you really have issues with the catheter in some patients where you count regular catheter there's different way to connect these these catheters in my Center we really try to use it as a last resort only and only if we cannot find any other alternative vascular access and I guess here the most important thing is really to follow again a strict protocol and to really clarify who between the nurse and the perfusionist is doing what to avoid major complications and again all CRT machines are not able to connect to a situ the high pressure environment of an ECMO or negative pressures so you need to decide on the setting based on your local equipments and then this is also where I would like to stress that you can consider to use different modalities that you normally use I like to to say that intermittent remote dialysis is like a formula one it's extremely powerful it can deliver the equivalent clearance that we need over 24 hours in less than three or four hours so you only need to apply the therapy once or twice every other every day or every other day and obviously in periods like doubling or a tripling of your number of patients then it might increase in of patient you might treat per day you also don't absolutely need anticoagulation you probably will need to give some but at least you don't have to be so worried because the circuit will not last as far as long as CRT and it's less of an issue let's let's say but it also requires some trained staff it's also required some technical practicalities you might not be used to using this modality and again this is not something but often this modality is applied by nephrologist even for outpatient clinics so maybe this is perhaps easier to implement in the time of a crisis then some other RT modality and perhaps this is time to rediscover it solutions and techniques like sled or high-dose a CRT for a shorter period of time these things that have been a little bit fallen outside the main scope in the majority of units but perhaps this is done with my Center we considered we didn't have to eventually but we considered moving to too high dose CRT and treating two patients with a single machine if we had the need for that and the last thing that you can just discuss is adjunct therapies when you have a CRT device you have access to the blood and there is this theory this up and coming possibility of providing multi organ support with the CRT platform and so support not only the kidney but also the heart the lung with the extra corporal co2 removal and the liver and particularly in the context of Kovach remove some cytokines and one of the the possibilities to use these cartridges of of generating heme absorptions that would undifferentiated mediators inflammatory mediators but also cytokines anti-inflammatory cytokines this is obviously something quite new experimental than what we can say it's easy to do we can just plug it into the device and it's relatively safe at least on the shown there's a rationale for it we've seen that for apps takes methods on or trust Elizabeth which have a sort of similar rationale seem to improve the outcomes of the patient but obviously before it's get generalized to its utilization should be tested in clinical trials and the same comment applies for a car a car is an attractive idea and its really nice to be able to support the ventilation with the CRT device the main limitation is that you really to have some form of meaning fools here to remove all you need to have a very high blood flow which then prevents the utilization of citrate for the the thing we've discussed above and also there's no evidence that it actually really improves the outcome of the patient so you should be tested as well in clinical trials so that brings me to my conclusions and in these situations of limited resources it's all the more important to optimize CRT to minimize the staff workload and to optimize resources and something we haven't really discussed actually but that is central to this discussion is to really select the right patients that that would benefit from the therapy and also the right timing for initiation you might be maybe more liberal or more more selective in your Center but I think you need to reduce this inclusion it's true we should do as much as possible what we do normally but you might want to know not even rationals rationalize care but at least you know just more be a bit more careful perhaps wait a bit longer if you're in the early kind of units and when you do see RTE you can optimize it by utilizing citrate regional anticoagulation CVV HD mode make sure you have an adequate access replace it as soon as you have issues with it consider this high cutoff filters if you if they're available in your units especially if you have this early clogging issues and also consider talking to a nephrologist and bringing some interpreting dialysis machine or do some form of hybrid therapies with your CRT devices and again if you have them and if you you think this is the right thing you can consider adjunct therapies and particularly instance in special situations thank you very much thank you very much don't one for an excellent overview and not surprisingly there are a lot of questions now in the chat box and I will try to summarize them and put them together so we had questions related to the fact that I think Peter you said volume depletion is a common cause of a ki or is it can be a cause and the question is how do you assess fluid status volume stages in patients risk of it and it has a follow-up question from somebody else whichever ad which says so how to use how do you set fluid balance in patients with a ki in particular those who need window replacement therapy yes it's a relevant question and I think assessment of flu folium status is the one thing in intensive care medicine that is really difficult and we have to deal with it every day so I guess there's nothing that's special on comfort and that we should do what we usually do so from passive lack racing to post pressure variation etc the usual measures to give us an idea on what intravascular volume is and if patient needs fluids the issue in the Kovac patients of course is because there is so compromised for the lungs that people are really reluctant to give fluids to them and so and that might be good in most of the patients but there are definitely some patients that might suffer from that if for example the kidneys suffer from dehydration so my message would be uses the same thing that you do always to try to have an idea of the four status of that given patient and if needed and if you think that dehydration might play a part in the API that you see in that patient then you should read consider being reluctant when effluents or giving some fluent cell for the kidneys thank you very much I have a question for Antoine and I think not one you highlighted CRT but the question was is there evidence that CRT is superior compared to intermittent team analysis or PD in covert well not that I'm not that I know of I mean I don't think there's any comparison that's been undertaken and again I think everybody should stick to the modality I think they the topic was mostly to discuss CRT because this is commonly used in many I see use but obviously I touched on intermittent dialysis so no there's no evidence I mean we can say that overall outside Covey's there's no evidence that either mortality is superior in terms of mortality there is some data suggesting that perhaps fluid balance control could be easier with the continuous with the continuous modality for obvious reasons you have if you want to remove fluid to a patient and you have to do it over four hours it's going to be more dramatic that if you have to do it over 24-48 hours and then you might lead to complications you might be maybe you're not you don't dare remove as much fluid because you know you you're not going to be able to do it or the patient might not tolerate so you're you're more careful with the fluid removal or you do it anyway and then you might harm that the kidney even further and decrease the the potential to recovery so I think this is the advantage of continuous is having this fine tuning for fluid fluid balance control during the therapy but there's no real evidence to support this great then we have quite a few questions which relate to cytokines cytokine remover blood purification and maybe if I summarized them the first question one question is is there a role for blood purification and removal of interleukin and maybe I think Peter you may be the right person for this given your general interest in this topic I think so what we see in these patients indeed that there are elevated levels in the blood of inflammatory mediators and also that the this concentration is related to outcome and that is logical the more sick you are the more the higher the levels the worse your outcome that Association does not mean per se that if you do something about these levels by for example blood purification filters that you would improve outcome so I think that geographical basis is there then we have no data to show that there is any benefit on clinical endpoints and so I am afraid at this moment the statement that we can only make is that we personally would need data of patients in a way that is actually open to interpretation so that means that you need a contemporary Asst control group and not just show that if you put them on the filter that their cytokines or other inflammatory mediators go down because that happens anyway but you need to show if they come down to a crazy rate or if there's any sign of clinical benefit that's one thing and the other thing that might be side effects of these filters is that this is not related to real replacement therapy so that means that you would need faster access you would need a machine there might be shortage of machines so and it's not necessary for renal replacement therapy so it's difficult and dependent on the local situation if you would be able to do so but my view is at this moment that there's no evidence of clinical benefit so far unfortunately aunt one is a question which relates to this and it's the question is is there a role for the Ox iris membrane in qubit 19 so again this is this is I don't think this there's any data supporting ox iris in this in these in this situation it's a very similar rationale it's another so I mentioned a situs or band and I showed the slide there are other blood proof occations devices and I fully agree with the Peters statement there's no data supporting any of these these modalities and so in my unit we haven't we haven't really used it so it's it's something that is again theoretical and it is worth thinking about but I would not suggest as a recommendation to use it as a regular some units where we'll use these kind of devices in a regular basis so they're free I mean it's it's it's available it's on the market but I don't think again that there's strong evidence that actually even any evidence that we should be using it in patients with Co V could I give you a follow-up question because I don't one because you touched on PD and the question is is there any evidence of eye interleukin clearance during PD I'm not aware of I don't know how to respond to this question I don't I I don't have never I don't use peritoneal dialysis and I don't have so cytokine clears I don't know I can't I can't whisper maybe Peter can help no there's no evidence of that and I think that we know from normal conventional renal replacement there be that the effect on cytokine clearance is also very very limited and so if you compare that to these specific blood purification filters and maybe also of relevance for people that are watching is that it's really important to realize that there are different kinds of filters for blood purification and they have different properties so there's some that focus on removal of cytokines like a sinus or some of removal of endotoxin like the P mix filter and the observers filter that was mentioned actually does a bit of both and also is a renal replacement therapy filter which the other ones are not and there's also another filter of Xterra that's also able and they show that in in vitro that's able to remove the virus from the blood and so we do know that the very small proportion of patients do have RNA in their blood circulating so maybe there is a subgroup that might benefit from it but we do not know what the clinical benefit would be and thank you both could I heard of the press a question related to the fact that we've had some positives to the trial results with dexamethasone and the question is are you aware of any role for steroids in Kovac associated Aki off the topic it's not really relate to Torino support but it's important because if we reduce Aki then we don't have a problem with the challenges of we no support anymore I think is really worthwhile to look into the data of the trial and to see what the effects are on developing API so you have to look at patients that come in with Aki maybe there's an effect on how many of these patients will need no therapy and there are patients that come in with no API or stage one and you can follow up what will be their development of API my slides we do think that the inflammatory response might be responsible of part of the API and so if you give steroids early and you influence that inflammatory response there might be an effect on the kidneys that's true but it would be worthwhile to look into the data it's a large trial if there is specific data on the kidneys and to see if there's where there is a benefit and if there is a mortality benefit that means that there should be a benefit of organ dysfunction otherwise there would be no mortality benefit so it's really worthwhile I guess to look is this something that's working on the lungs is it something that's working on the kidneys predominantly that is responsible for this survivor benefit thank you now we have either run slightly but I'd like to give you a final question both of you and the question is what have you learned in the first wave of the kovat pandemic and how do you prepare for the next one and the potential arena I don't know wants to start on Antoine yeah so what I've learnt is I think like everybody I learned to to be prepared to prepare for the worst hope for the best and it was really a very very anxious times where you you didn't know and we still don't by the way but you didn't know we all talked about this way we don't know how high and you don't know how how long so this is this was the question and be really humble and work as a team I think it really reinforced our team here inside the ICU but also with other specialties and learn that we can work together and you know when you go over this rivalry these fights these discussions and everything endless you can be so efficient and we've achieved so much it's so little time this is really whatever what I'm gonna take takeaway from this movie the covet period and yes we are maybe expecting a second wave maybe preparing for a second ways we don't know so what we have changed we we and this is pretty much what I the the flow of my presentation we are trying to when you talk about renal replacement therapy we're always aiming to have optimized optimal therapy and this is what you want to do anyway but this shortage really stressed that there are things that we need to improve and we need to to move toward this model that I that I that I described to to to optimize this part and it's not the only part of the course of the therapy but when we talk about CRT you want to optimize and to minimize the the consequences for the for the patients great thank you and Peter how do you prepare for the most renal challenge I think two things the perfect the one thing is anti calculation I think in the beginning we burned a lot of filters and we already had a shortage and then we started to intensify it and then we found that indeed filter lifespan could be as usual if you intensify anticoagulation and the second thing I agree with the Antoine I think people that are intensive faced and work in the ICU want to do it all themselves that's our nature I guess and we really have to learn to delegate and and ask others for help to be able to efficient ourselves as much as possible and so indeed we had teams that would turn the patient that we had our colleagues from anesthesiology would actually do all the transports between the the hospitals what we normally do and so this helped a tremendous lot and I think we could ever take that one step further I have people helping us out and so the weekend focus or very specific intensive care issues so on behalf of the European intensive care society I'd like to thank you both for excellent talks and sharing your experience given that it's a new disease and we're still learning it's a disease which is now five months old but we have learned a lot and I'm sure there is more to learn so sharing your experience been very very useful thank you and I'd like to thank the European Society of intensive care medicine for organizing this fantastic and very useful webinar given the challenges in the last few months thank you enjoy your afternoon evening morning wherever you are and thank you to everybody including the technicians who helped us with every now [Music] [Music] [Music] [Music] [Music]

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Id: W9AkEoY2UHo

Length: 85min 35sec (5135 seconds)

Published: Thu Jun 18 2020