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• W2044077663 abstract "Acute kidney injury (AKI) is a common complication in the intensive care unit and in trauma victims of armed conflicts.1.Tolwani A. Continuous renal-replacement therapy for acute kidney injury.N Engl J Med. 2012; 367: 2505-2514Crossref PubMed Scopus (137) Google Scholar AKI has a poor prognosis, with life-threatening complications such as hyperkalemia, severe acidosis, and pulmonary edema and compromised oxygenation, unless renal replacement therapy is provided with intermittent hemodialysis or continuous renal replacement therapy.1.Tolwani A. Continuous renal-replacement therapy for acute kidney injury.N Engl J Med. 2012; 367: 2505-2514Crossref PubMed Scopus (137) Google Scholar, 2.Manns M. Sigler M.H. Teehan B.P. Continuous renal replacement therapies: an update.Am J Kidney Dis. 1998; 32: 185-207Abstract Full Text Full Text PDF PubMed Scopus (120) Google Scholar, 3.Shrier R.W. Wang W. Poole B. et al.Acute renal failure: definitions, diagnosis, pathogenesis, and therapy.J Clin Invest. 2004; 114: 5-14Crossref PubMed Scopus (631) Google Scholar These therapies typically require complex machines, expert staff, and expensive infrastructure that may not be available in armed conflicts.4.Misra M. The basics of hemodialysis equipment.Hemodial Int. 2005; 9: 30-36Crossref PubMed Scopus (47) Google Scholar The current armed conflict in Syria started in the middle of 2011. Initially, field hospitals were primitive and first responders were disorganized. Victims of massive hemorrhage or crush injuries did not reach hospitals fast enough for appropriate resuscitation, and they died in the field or shortly after arrival to these makeshift medical points. Subsequently, rapid evacuation and aggressive fluid resuscitation became available in organized field hospitals. In the Syrian armed conflict, the most common cause of early-onset AKI has been acute tubular necrosis related to either hemorrhagic shock at the time of injury or rhabdomyolysis as a result of crush injury or vascular compromise.5.Bywaters E.G. Beall D. Crush injuries with impairment of renal function.Br Med J. 1941; 1: 427-432Crossref PubMed Scopus (554) Google Scholar, 6.Teschan P.E. Post R.S. Smith Jr., L.H. et al.Post-traumatic renal insufficiency in military casualties. I. Clinical characteristics.Am J Med. 1955; 18: 172-186Abstract Full Text PDF PubMed Scopus (56) Google Scholar, 7.Smith Jr., L.H. Post R.S. Teschan P.E. et al.Post-traumatic renal insufficiency in military casualties. II. Management, use of an artificial kidney, prognosis.Am J Med. 1955; 18: 187-198Abstract Full Text PDF PubMed Scopus (59) Google Scholar Although statistics are not available, eyewitness reports have described victims who survived the initial shock but developed AKI and died because renal replacement therapy was not available.8.Leigh K. Syria E.R. Aleppo’s kidney crisis. Syria Deeply.2013http://beta.syriadeeply.org/2013/09/syria-er-aleppos-kidney-crisis/#.UrQU3vRDtyUGoogle Scholar There were no nephrologists available, and the financial and logistic resources for renal replacement therapy were extremely limited. In field hospitals in Syria, hemodialysis and peritoneal dialysis are not available, and AKI that requires renal replacement therapy typically has been fatal. It was an ethical and humanitarian imperative to find a solution for this reversible and treatable complication. During World War II and the bombing of London by the Germans in 1941, acute loss of kidney function was described in severely injured crush victims.5.Bywaters E.G. Beall D. Crush injuries with impairment of renal function.Br Med J. 1941; 1: 427-432Crossref PubMed Scopus (554) Google Scholar The mortality was 100%, because hemodialysis had not been developed for clinical use. Acute hemodialysis was first used in military casualties during the Korean War in 1950, and this led to a decrease in mortality from AKI from 90% to 50%.6.Teschan P.E. Post R.S. Smith Jr., L.H. et al.Post-traumatic renal insufficiency in military casualties. I. Clinical characteristics.Am J Med. 1955; 18: 172-186Abstract Full Text PDF PubMed Scopus (56) Google Scholar,7.Smith Jr., L.H. Post R.S. Teschan P.E. et al.Post-traumatic renal insufficiency in military casualties. II. Management, use of an artificial kidney, prognosis.Am J Med. 1955; 18: 187-198Abstract Full Text PDF PubMed Scopus (59) Google Scholar This treatment also was beneficial during the Vietnam War.9.Conger J.D. A controlled evaluation of prophylactic dialysis in post-traumatic acute renal failure.J Trauma. 1975; 15: 1056-1063Crossref PubMed Scopus (159) Google Scholar In the late 1970s, there was a search for an alternative modality to conventional hemodialysis as renal replacement therapy in the intensive care unit for hemodynamically unstable patients. This led to the development of the first generation of slow continuous renal replacement therapy, known as continuous arteriovenous hemofiltration (CAVH), which was used in heart failure patients who had volume overload and diuretic resistance and patients who needed solute and fluid removal.10.Kramer P. Wigger W. Rieger J. et al.[Arteriovenous haemofiltration: a new and simple method for treatment of over-hydrated patients resistant to diuretics] (article in German).Klin Wochenschr. 1977; 55: 1121-1122Crossref PubMed Scopus (427) Google Scholar,11.Kramer P. Böhler J. Kehr A. et al.Intensive care potential of continuous arteriovenous hemofiltration.Trans Am Soc Artif Intern Organs. 1982; 28: 28-32PubMed Google Scholar Despite the subsequent widespread use of CAVH, serious limitations were recognized, including the dependence of CAVH on systolic blood pressure12.Omert L. Reynolds H.N. Wiles C.E. Continuous arteriovenous hemofiltration with dialysis (CAVH-D): an alternative to hemodialysis in the mass casualty situation.J Emerg Med. 1991; 9: 51-56Abstract Full Text PDF PubMed Scopus (5) Google Scholar and the risks associated with arterial access that included thrombosis, arterial injury, and excessive bleeding associated with anticoagulation.13.Tominaga G.T. Ingegno M. Ceraldi C. et al.Vascular complications of continuous arteriovenous hemofiltration in trauma patients.J Trauma. 1993; 35: 285-288Crossref PubMed Scopus (24) Google Scholar Therefore, a shift toward continuous venovenous-based therapy started. There are many challenges in the care of patients with AKI in field hospitals in Syria or other isolated areas that have mass casualties such as regions affected by natural disasters. These challenges include difficulties in operating and maintaining complex dialysis machines and the lack of reverse osmosis water treatment systems or reliable electricity.4.Misra M. The basics of hemodialysis equipment.Hemodial Int. 2005; 9: 30-36Crossref PubMed Scopus (47) Google Scholar The lack of security may disrupt communications and transportation and decrease the availability of experienced personnel. We evaluated the feasibility of continuous venovenous hemofiltration (CVVH) using a stand-alone blood pump as a form of renal replacement therapy for the treatment of AKI in field hospitals in Syria. Simplified protocols were implemented after a brief staff training session with remote real-time support because equipment and experienced staff were not available on site. The purpose of this paper is to report the experience with three patients who were treated for AKI with CVVH using a stand-alone blood pump. A 30-year-old man presented after having two gunshot wounds to the right chest and right abdomen, with multiple small- and large-intestinal injuries. He underwent emergency primary repair and left colostomy. He received blood transfusions with 5 units of packed red cells, and the postoperative hemoglobin was 103 g/l. The next day, he became dyspneic, and right tube thoracostomy yielded 1700 ml blood. The patient had a cardiac arrest, was resuscitated, and had operative right chest exploration that showed no source of bleeding. On postoperative day 2 after thoracostomy, the patient became anuric. Cystoscopy and retrograde pyelography did not show any injury to the collecting system. On hospital day 4, the morning laboratory tests showed creatinine 548 mmol/l, urea 21.8 mmol/l, and potassium level 6.3 mmol/l. Emergency treatment, which included intravenous calcium, insulin, and glucose, was given for hyperkalemia, and CVVH was started through a right subclavian vein hemodialysis catheter that was inserted by a second-year general surgery resident under sterile conditions (Table 1). At the end of the first session of CVVH, laboratory tests showed that the clearance was inadequate, with urea 25.7 mmol/l, creatinine 248 mmol/l, sodium 145 mmol/l, potassium 6.0 mmol/l, total calcium 1.80 mmol/l, and albumin 18 g/l. On the second day of CVVH, the ultrafiltration and replacement fluid rates were increased (Table 2). On this day, he had an increase in bloody output from the thoracostomy drain; therefore, he was treated with pulse heparin (each bolus, 500 U) in 5% dextrose in water and a constant infusion of 5% dextrose in water (250 ml/h) prepump in the priming port. At the end of the second CVVH session, laboratory tests showed urea 17.5 mmol/l, creatinine 469 mmol/l, sodium 148 mmol/l, potassium 5.4 mmol/l, total calcium 1.77 mmol/l, and albumin 15 g/l. The patient was considered stable for transfer, the family requested transfer to another hospital, and he was lost to follow-up.Table 1Clinical record of continuous venovenous hemofiltration for treatment of acute kidney injury in patient 1 in S Hospital: day 1aTable 2Clinical record of continuous venovenous hemofiltration for treatment of acute kidney injury in patient 1 in S Hospital: day 2aTable 2Clinical record of continuous venovenous hemofiltration for treatment of acute kidney injury in patient 1 in S Hospital: day 2a A 35-year-old man had been a prisoner for 1 week and had been subjected to torture including physical beating. He developed shortness of breath and anuria for 3 days. Upon arrival at the hospital, he was intubated immediately because of respiratory failure. Evaluation showed massive anasarca, hemoglobin level 81 g/l, and AKI with urea 45 mmol/l, creatinine 972 mmol/l, and potassium 8.1 mmol/l. The patient required renal replacement therapy and ultrafiltration to expedite extubation because limited electricity was available for prolonged mechanical ventilation. He was treated with CVVH (14 hours) through a right internal jugular vein hemodialysis catheter that was inserted by a fourth-year cardiology/medical resident under sterile conditions. Net ultrafiltration was 8280 ml (Table 3). He was extubated 4 hours after completion of CVVH, and the potassium level was 6.9 mmol/l. He was transferred to another facility and had several sessions of conventional outpatient hemodialysis. He recovered all kidney function and no longer receives hemodialysis.Table 3Clinical record of continuous venovenous hemofiltration for treatment of acute kidney injury in patient 2 in I Hospitala A 30-year-old full-term pregnant woman developed excessive bleeding that was attributed to uterine inertia after delivery of a stillborn child. She received blood transfusions (total, 19 units) and large amounts of intravenous fluids. She became unresponsive and was transferred to another hospital inside Syria. Evaluation showed that she was hypertensive, dyspneic, and hypoxemic. She was intubated and treated with mechanical ventilation and had abdominal exploration with lysis of adhesions and removal of a retained uterine packing. After brief clinical improvement without needing mechanical ventilation, she developed lethargy, oliguria that was unresponsive to large doses of furosemide, and recurrence of respiratory failure. Consultation with the hospital internist at day 2 after the transfer showed that she was febrile, unresponsive, hypertensive (blood pressure, 150/95 mm Hg), and oliguric (urine output during the prior 24 hours, 200 ml). Laboratory tests showed urea 44 mmol/l, creatinine 469 mmol/l, sodium 144 mmol/l, potassium 6.2 mmol/l, bicarbonate 15.4 mmol/l, chloride 124 mmol/l, and arterial pH 7.29. The central venous pressure was 32 cm H2O. Consultation was obtained with a nephrologist in the United States via Internet video phone (Skype, Microsoft, Luxembourg),14.Cousins S. Treatment via Skype: creative use of tech in war-torn Syria. Nature Middle East.2013http://www.nature.com/nmiddleeast/2013/131030/full/nmiddleeast.2013.196.htmlGoogle Scholar and it was recommended that the patient receive urgent renal replacement therapy. Conventional hemodialysis was not available in the intensive care unit. Use of the outpatient hemodialysis clinic in the same building was not feasible because of her unstable condition. In addition, there was a disruption of dialysis water treatment because of frozen inlet water caused by Winter Storm Alexa. Therefore, it was decided to perform CVVH despite the lack of any previous experience in the hospital (Table 4). CVVH was conducted through a left femoral vein hemodialysis catheter that was inserted by a fourth-year anesthesiology resident under sterile conditions (Figure 1). On CVVH day 3, no further calcium gluconate was available in the hospital, and calcium-containing peritoneal dialysis fluid, 4.25% hydrous dextrose low calcium (1.25 mmol/l), was used as part of the replacement fluid for intravenous infusion; the bicarbonate and normal saline infusions were stopped when the peritoneal dialysis fluid infusion was started. The patient received four CVVH sessions and had gradual improvement of her mental status and respiratory failure. After the fourth CVVH session, she was extubated and remained in the hospital for 12 additional days without needing renal replacement therapy. The urine output gradually increased to greater than 2 l/d and creatinine improved to 451 mmol/l before discharge home (Table 4).Table 4Clinical record of continuous venovenous hemofiltration for treatment of acute kidney injury in patient 3 in B HospitalaFigure 1Continuous venovenous hemofiltration arrangement for treatment of acute kidney injury in patient 3 in B Hospital, Idlib Province. The blood pump was powered by an automobile battery (16 V, Al-Najjar, Aleppo, Syria).View Large Image Figure ViewerDownload (PPT) The present cases show that CVVH using a stand-alone blood pump may be a feasible and effective renal replacement therapy in field hospitals in regions affected by war. CAVH typically does not cause hemodynamic instability, enables good control of electrolyte and acid–base balance, and is effective in removing fluids and improving pulmonary edema and in acute respiratory distress syndrome.1.Tolwani A. Continuous renal-replacement therapy for acute kidney injury.N Engl J Med. 2012; 367: 2505-2514Crossref PubMed Scopus (137) Google Scholar,15.Garzia F. Todor R. Scalea T. Continuous arteriovenous hemofiltration countercurrent dialysis (CAVH-D) in acute respiratory failure (ARDS).J Trauma. 1991; 31: 1277-1284Crossref PubMed Scopus (45) Google Scholar CAVH is simple and does not require highly technical equipment or trained personnel. Therefore, CAVH became very common. Furthermore, CAVH was modified by flowing dialysate through the hemofilter in a countercurrent fashion, later known as continuous arteriovenous hemodialysis (CAVHD). Although advanced intensive care units from the late 1970s to mid-1980s had CAVH or CAVHD available, the limitations of arterial-based hemofiltration therapy became evident, including the dependence on blood pressure as the propulsive force and high risks associated with arterial access.2.Manns M. Sigler M.H. Teehan B.P. Continuous renal replacement therapies: an update.Am J Kidney Dis. 1998; 32: 185-207Abstract Full Text Full Text PDF PubMed Scopus (120) Google Scholar,13.Tominaga G.T. Ingegno M. Ceraldi C. et al.Vascular complications of continuous arteriovenous hemofiltration in trauma patients.J Trauma. 1993; 35: 285-288Crossref PubMed Scopus (24) Google Scholar The development of CVVH and continuous venovenous hemodialysis (CVVHD), in which a double-lumen hemodialysis catheter is inserted into a central vein and a basic blood pump is used instead of the blood pressure to propel the blood, eliminated the total dependence on blood pressure. Therefore, arterial-based hemofiltration therapy has been replaced by pump-supported venovenous therapy. The basic blood pump immediately became the essential foundation of a generation of sophisticated and expensive commercial products, and within several years, CVVH or CVVHD competed with intermittent hemodialysis for renal replacement therapy in the intensive care unit.1.Tolwani A. Continuous renal-replacement therapy for acute kidney injury.N Engl J Med. 2012; 367: 2505-2514Crossref PubMed Scopus (137) Google Scholar,16.Zonies D. DuBose J. Elterman J. et al.Early implementation of continuous renal replacement therapy optimizes casualty evacuation for combat-related acute kidney injury.J Trauma Acute Care Surg. 2013; 75: S210-S214Crossref PubMed Scopus (15) Google Scholar The Syrian National Kidney Foundation, working with the Syrian American Medical Society, searched for a solution for AKI in field hospitals in Syria. The search was for a standardized approach that could be duplicated in varied settings.17.Perkins R.M. George R. Fox C.R. et al.Successful CAVH in an austere environment using readily available disposable hospital supplies.Nephrol Dial Transplant. 2007; 22: 1241-1246Crossref PubMed Scopus (7) Google Scholar Although CAVH seemed a good solution, serious limitations included the problem that supplies were no longer being manufactured, such as the CAVH tubing (length, 45–60 cm each for arterial and venous limbs). The airless hemodialysis tubing we proposed to use for CAVH was very long (length, 180 cm each for arterial and venous limbs), and this length made CAVH potentially unreliable.18.Syria Nephrology. CAVH-f set up video. YouTube.2013http://www.youtube.com/watch?v=oXhi2IFVKrIGoogle Scholar,19.Syria Nephrology. CVVH f set up SNKFP 08302013. YouTube. 2013http://www.youtube.com/watch?v=OJdm6xjWVk8Google Scholar We recognized that the transformation from arterial-based hemofiltration therapy to the venous-based therapy was dependent on a blood pump. We adopted the blood pump as the solution. Although complex safety technology is essential, we gave more attention to practicality and adoptability than to safety because the only other option would have been to accept death caused by AKI and associated complications.3.Shrier R.W. Wang W. Poole B. et al.Acute renal failure: definitions, diagnosis, pathogenesis, and therapy.J Clin Invest. 2004; 114: 5-14Crossref PubMed Scopus (631) Google Scholar The CVVH method in the present report depended on a blood pump that was removed from a conventional dialysis machine and modified to work in harsh Syrian conditions.20.Syria Nephrology. Blood pump module for CVVH-f - SNKFP 081513. YouTube. 2013http://www.youtube.com/watch?v=u1PhXxhK-dMGoogle Scholar The CVVH stand-alone blood pump operated with electrical voltage from a 9-V battery, automobile battery (16 V), or old cell phone charger (12 V). The 9-V battery ran the pump for 2 hours at 17 r.p.m. or pump speed 200 ml/min, which was the ideal blood flow to prevent clotting in the hemofilter.1.Tolwani A. Continuous renal-replacement therapy for acute kidney injury.N Engl J Med. 2012; 367: 2505-2514Crossref PubMed Scopus (137) Google Scholar,21.Syria Nephrology. CVVH stand-alone blood pump works on 9-volt battery. YouTube. 2014http://www.youtube.com/watch?v=Guk0ANya8moGoogle Scholar The tubing had to be airless because there were no air detectors in the extracorporeal circuit, and the use of the arterial limb of the dialysis tubing set (Streamline, Medisystems, NxStage, Lawrence, MA) for both limbs of CVVH eliminated the blood–air contact surface. There were neither drip chambers nor air detectors in the present extracorporeal circuit. There was no dialysate, and the large volume of ultrafiltration and replacement fluids after hemofiltration enabled solute clearance by convection.19.Syria Nephrology. CVVH f set up SNKFP 08302013. YouTube. 2013http://www.youtube.com/watch?v=OJdm6xjWVk8Google Scholar It was preferable to avoid simultaneous use of convection and diffusion methods because of the lack of experience of personnel operating the system. However, after desirable fluid removal is achieved, it is possible to convert to a diffusion method by running peritoneal dialysis solution on the dialysate side of the hemofilter. Literature review showed no report of the use of peritoneal dialysis fluid intravenously, as used in patient 3, but it was given because of the urgent circumstances, and the fluid composition was similar to 5% dextrose in lactated Ringer solution (except for the absence of potassium and the presence of magnesium).22.Baxter Healthcare Corporation. Lactated Ringer’s and 5% Dextrose Injection, USP.2014http://www.accessdata.fda.gov/drugsatfda_docs/label/2011/016679s104,016682s105,016692s095,019367s026lbl.pdfGoogle Scholar Therefore, the potential benefits likely outweighed the risks of using the peritoneal dialysis fluid intravenously. Determination of the magnesium level was not available, but the level was lower in the peritoneal dialysis fluid (0.25 mmol/l) than the normal serum level of 0.65–1.05 mmol/l, and was not likely to aggravate any preexisting hypermagnesemia. The patient tolerated the infusion well, and there was no evidence of lactic acidosis, since the anion gap was not high. The risks of using lactate as a buffer instead of bicarbonate may also include the risk of vasodilation and hypotension associated with lactate, but this was not observed in patient 3.23.Aduen J.F. Burritt M.F. Murray M.J. Blood lactate accumulation: hemodynamics and acid base status.J Intensive Care Med. 2002; 17: 180-185Crossref Scopus (6) Google Scholar This patient remained normotensive or hypertensive during CVVH with peritoneal dialysis fluid as the replacement. However, caution is advised because low blood pressure and lactic acidosis may be worsened by lactate infusion in patients who are in shock. Although hemofiltration is less effective than hemodialysis in removal of potassium, some of the potassium is removed with hemofiltration via convection. In the present patients, this modest decrease in potassium level was enough to save their lives until kidney function improved or another form of renal replacement therapy became available. The challenges in using CVVH in the present study included the unavailability of certain blood tests. In patients 1 and 2, enzymatic carbon dioxide or pH measurements were not available. We assumed that 10 liters ultrafiltration would remove 200 mmol bicarbonate when the serum bicarbonate level was 20 mmol/l, and we estimated that a 100-kg person would need 1 mmol/kg/d bicarbonate; therefore, we replaced 300 mmol sodium bicarbonate in a 10-hour CVVH session by infusing 1 liter of 5% dextrose with 150 mmol sodium bicarbonate peripherally at 200 ml/h for 10 hours. Training was a difficult challenge. It was necessary to train physicians and staff to perform a procedure that they had not seen previously. Videos were made to explain the concepts, and protocols were simplified. Training was performed with practice sessions during a brief course. Real-time audiovisual supervision was provided with live and remote guidance (‘tele-CVVH’) (Skype).14.Cousins S. Treatment via Skype: creative use of tech in war-torn Syria. Nature Middle East.2013http://www.nature.com/nmiddleeast/2013/131030/full/nmiddleeast.2013.196.htmlGoogle Scholar This technology enabled direct communication between the emergency health responders (members of the Syrian American Medical Society) and local health providers in the field hospitals. This method is a cost-effective and practical alternative to intermittent hemodialysis or continuous renal replacement therapy in the intensive care unit for AKI patients when conventional hemodialysis is not available. Although the challenges of renal replacement therapy are not unique to a specific disaster, the extent of these challenges may vary. Therefore, complete understanding of these challenges at a specific location may require analysis of the site and situation. Under these austere circumstances and except in cases of significant abdominal trauma, peritoneal dialysis with manual exchanges constitutes a viable alternative to CVVH. Barriers to the implementation of this technique in Syria include lack of all needed supplies and unfamiliarity of staff with peritoneal dialysis catheter insertion and exchange procedure techniques. Our group is in the process of overcoming these barriers by providing hands-on and online training to staff and securing affordable supplies. We expect peritoneal dialysis to be available in the future. Nevertheless, because a substantial proportion of AKI cases may have significant abdominal pathology, the availability of peritoneal dialysis does not negate the need for CVVH in field hospitals. In summary, this report presents a useful method for renal replacement therapy in circumstances when conventional hemodialysis is not available and should be used only in circumstances such as this, when it is a matter of life or death and no other options exist. Further study of this method and simplified technology is justified for additional protocol development and validation. Protocols for priming of the extracorporeal circuit, fluid replacement, and anticoagulation were drafted by nephrologists of the Syrian National Kidney Foundation, a group of nephrologists of Syrian origin who are based in the United States. The protocols were designed with the consideration of unavailability of testing for phosphate, magnesium, carbon dioxide, or pH. The only tests that were reliably available (albeit not necessarily accurate) were sodium, potassium, total calcium, complete blood count, urea, and creatinine. Some blood tests were available in the hospital; for tests that were not available, samples were transported to a different hospital or outside laboratory, and results were unavailable until the next business morning. Record-keeping accuracy and standardized medical records were lacking. The care for patients 1 and 2 was provided by a second-year resident in internal medicine from the University of Aleppo; training was received in a 1-day face-to-face course, and real-time support was provided by a Syrian National Kidney Foundation nephrologist with a video call through the Internet (Skype) before and during CVVH. The care for patient 3 was provided by an internist who had experience in treating end-stage renal disease, a fourth-year resident in anesthesiology from the University of Aleppo, and a chronic hemodialysis technician, with real-time support with a video call through the Internet (Skype) before and during CVVH. Many factors determined patient selection, including medical indications for renal replacement therapy in AKI, stability of the patient for transfer to and from a nearby outpatient hemodialysis clinic, current mechanical ventilation (being on a ventilator with high oxygen requirement favored CVVH), safety of transfer routes, identity of the patient, and complex security issues. The blood pump was the most important component of the extracorporeal circuit. We removed the blood pump from three dialysis machines that were no longer being used (Fresenius 2008K, Fresenius Medical Care, Waltham, MA), removed the electronic component, and modified the pump to work with limited power supplies such as a 9-V battery, automobile battery, or cell phone charger. The arterial tube of the streamline dialysis set was used for both the arterial and venous limbs of the CVVH extracorporeal circuit (Streamline, Medisystems, NxStage, Lawrence, MA). This arterial tube had no drip chamber or air–blood contact, decreasing the critical need for an air detector (Figure 2). The blood pumps and the tubing were shipped from the United States to Turkey and hand-carried to Syria. The conventional hemofilters (Fresenius) were acquired from neighboring chronic outpatient hemodialysis units. The dialysis catheter was a conventional double-lumen hemodialysis catheter (various brands available at different locations). The ultrafiltration collection system was improvised locally at the bedside using a set of intravenous tubing and a graded urine collection bag for measurement of ultrafiltration. All replacement fluids were infused through a separate central venous catheter. Intravenous normal saline was infused at various rates. Bicarbonate infusion (a conventional bicarbonate drip, with 150 mmol/l sodium bicarbonate in 1 liter of 5% dextrose) was infused at 200 ml/h for 10 hours. Calcium was given as calcium gluconate (2 or 3 g, slow intravenous push over 10 minutes) at various times and was infused in a port in the central venous catheter separate from the bicarbonate drip. In one patient (patient 3), peritoneal dialysis solution with 4.25% hydrous dextrose calcium (1.25 mmol/l) (2000-ml bags, Qatar Pharma, Doha, Qatar) was used as a replacement fluid intravenously in a central venous catheter instead of normal saline, bicarbonate, and calcium. Icodextrin-based peritoneal dialysis solutions were not infused intravenously as a replacement fluid because of theoretical risks of volume overload, osmotic nephrosis, and known interference with glucose measurements in non-glucose-specific assays that may cause pseudohyperglycemia and overtreatment with hypoglycemic agents.24.Baxter Healthcare Corporation Baxter EXTRANEAL (icodextrin) peritoneal dialysis solution.2014http://www.baxter.com/downloads/patients_and_caregivers/products/extraneal_pi.pdfGoogle Scholar,25.Burkart J.M. Patient information: peritoneal dialysis (beyond the basics). UpToDate.2014http://www.uptodate.com/contents/peritoneal-dialysis-beyond-the-basicsGoogle Scholar Amino acids containing peritoneal dialysis solution as an osmotic agent or as an additive to glucose-based solutions were avoided because of risks that this may cause severe acidosis and worsening azotemia.26.Bruno M. Gabella P. Ramello A. Use of amino acids in peritoneal dialysis solutions.Perit Dial Int. 2000; 20: S166-S171PubMed Google Scholar During the procedure, the side port for dialysate on the hemofilter proximal to the blood pump was capped, and the distal dialysate port was kept open for ultrafiltration drainage and collection. No financial support was received. The authors are grateful to Dr. Kidney at S Hospital, Dr. AZ at I Hospital, and Drs. K and B at B Hospital; for security reasons, they were not listed as coauthors, but they provided major contributions by performing CVVH and data collection. The authors thank Martha R. Morris, Deborah A. Burchel, and Charles Watson (Fresenius Medical Care, Waltham, MA); Kevin Kelley (DaVita, Denver, CO); and Steve Alford (NxStage, Lawrence, MA) for technical assistance." @default.
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• W2044077663 title "Continuous venovenous hemofiltration using a stand-alone blood pump for acute kidney injury in field hospitals in Syria" @default.
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