Table 2.
Responses to statements on rounds 1 and 2 of the survey regarding continuous kidney replacement therapy (CKRT) prescribing practices
| Round 1 (n = 147) |
Round 2 (n = 126) |
|||||
|---|---|---|---|---|---|---|
| always% | sometimes% | never% | always% | sometimes% | never% | |
| CKRT initiation | ||||||
| *I start patients on CKRT after they reach a positive fluid balance ≥ 10% in the absence of any other indications | 4.1 | 75.5 | 20.4 | 1.9 | 84.1 | 13.0 |
| *I start patients on CKRT after they reach a positive fluid balance ≥ 15% in the absence of any other indications | 12.2 | 73.5 | 14.3 | 9.5 | 86.5 | 4.0 |
| *I start patients on CKRT after they reach a positive fluid balance ≥ 20% in the absence of any other indications | 41.2 | 48.9 | 9.9 | 27.8 | 68.5 | 3.7 |
| *I start CKRT in a patient with a urine output < 0.3 ml/kg/h for ≥ 24 h in the absence of any other indications | 18.4 | 64.6 | 17.0 | 5.6 | 79.6 | 14.8 |
| I start CKRT in a patient with a serum creatinine 2–2.9 times baseline or greater in the absence of any other indications | 2.7 | 41.5 | 55.8 | |||
| I start CKRT in a patient with urine output < 0.5 ml/kg/h for ≥ 12 h in the absence of any other indications | 2.3 | 65.9 | 31.8 | |||
| I start CKRT in a patient with a serum creatinine that is 3 times baseline or greater in the absence of any other indications | 8.8 | 42.2 | 49.0 | |||
| I start CKRT in a patient with a decrease in eGFR to < 35 ml/min per 1.73 m2 in the absence of any other indications | 4.1 | 47.6 | 48.3 | |||
| CKRT dosing | ||||||
| *I prescribe dialytic dose using body surface area | 56.5 | 21.4 | 22.1 | 68.2 | 16.7 | 15.1 |
| *I use the admission weight of the patient when dosing based on weight or body surface area | 26.7 | 64.9 | 8.4 | 28.6 | 69.8 | 1.59 |
| *I use the ideal body weight of the patient when dosing based on weight or body surface area | 21.1 | 63.9 | 15.0 | 9.5 | 77.8 | 12.7 |
| *If I index dialytic dose to body surface area, I aim for a clearance of 2 L/h/1.73 m2 | 57.9 | 40.0 | 2.1 | 50.8 | 44.4 | 4.8 |
| *I use continuous venovenous hemodiafiltration (CVVHDF) as a mode of CKRT | 43.2 | 53.8 | 3.0 | 64.3 | 33.3 | 2.4 |
| *I use CKRT rather than intermittent hemodialysis for hyperammonemia | 46.9 | 43.2 | 9.9 | 44.4 | 51.6 | 4.0 |
| *I change the hemofilter after 72 h of therapy | 27.3 | 67.4 | 5.3 | 19.9 | 76.2 | 4.0 |
| I prescribe dialytic dose using weight | 25.9 | 26.5 | 47.6 | |||
| I use the current weight of the patient when dosing based on weight or body surface area | 4.6 | 59.5 | 35.9 | |||
| If I index patient dialytic dose to weight, I aim for a clearance of 20–30 ml/kg/h | 40.0 | 49.33 | 10.7 | |||
| If I index patient dialytic dose to weight, I aim for a clearance of 20–45 ml/kg/h | 35.9 | 53.9 | 10.3 | |||
| I use continuous venovenous hemofiltration (CVVH) as a mode of CKRT | 3.4 | 62.6 | 34.0 | |||
| I use continuous venovenous hemodialysis (CVVHD) as a mode of CKRT | 4.1 | 64.6 | 31.3 | |||
| I use slow continuous ultrafiltration (SCUF) as a mode of CKRT | 0 | 39.0 | 61.0 | |||
| I use customizable CKRT solutions | 23.9 | 42.2 | 34.0 | |||
| I modify my standard starting CKRT dialytic dose if I am treating a patient with hyperammonemia | 68.2 | 30.3 | 1.5 | |||
| I modify my standard starting CKRT dialytic dose if I am treating a patient for drug intoxication | 46.8 | 50.8 | 2.4 | |||
| I modify my standard starting CKRT dialytic dose if I am treating a patient with citrate accumulation | 41.0 | 56.1 | 3.0 | |||
| Anticoagulation strategy | ||||||
| *I use citrate as a regional anticoagulant for CKRT | 24.2 | 72.0 | 3.8 | 14.8 | 79.6 | 5.6 |
| *I use systemic heparin as an anticoagulant for CKRT | 5.3 | 86.4 | 8.3 | 3.7 | 92.6 | 3.7 |
| *I use citrate as a regional anticoagulant in patients with liver failure | 22.1 | 56.5 | 21.4 | 18.5 | 61.1 | 20.4 |
| I use prostacyclin as an anticoagulant for CKRT | 0.7 | 23.1 | 76.2 | |||
| When I use heparin for anticoagulation on CKRT I follow ACT values | 29.9 | 37.3 | 32.8 | |||
| When I use heparin for anticoagulation on CKRT I follow PTT values | 30.3 | 48.5 | 21.2 | |||
| When I use heparin for anticoagulation on CKRT I follow Anti-Xa values | 15.2 | 50.0 | 34.9 | |||
| CKRT for patients ≤ 10 kg | ||||||
| *I prescribe CKRT for patients ≤ 10 kg | 51.7 | 48.2 | 0 | 51.8 | 48.2 | 0 |
| *I prescribe a blood prime when an extracorporeal circuit exceeds 10% of a patient’s circulating blood volume | 65.9 | 28.8 | 5.3 | 74.6 | 25.4 | 0 |
| The machine that I use for CKRT in patients ≤ 10 kg is The Cardio-Renal Pediatric Dialysis Emergency Machine (CARPEDIEM) | 8.3 | 39.6 | 52.1 | |||
| The machine that I use for CKRT in patients ≤ 10 kg is The Prismaflex System | 28.3 | 64.2 | 7.6 | |||
| The machine that I use for CKRT in patients ≤ 10 kg is The Aquadex SmartFlow System | 6.1 | 45.0 | 49.0 | |||
| Fluid removal strategy | ||||||
| *I begin removing fluid in the first hour of CKRT | 13.6 | 65.2 | 21.2 | 12.2 | 63.3 | 24.5 |
| *I assess fluid removal goals at least every 24 h | 85.0 | 13.6 | 1.4 | 90.7 | 9.3 | 0 |
| *I assess fluid removal goals at least every 12 h | 51.0 | 47.6 | 1.4 | 46.0 | 52.4 | 1.6 |
| *I assess fluid removal goals at least every 6 h | 22.0 | 65.9 | 12.1 | 7.4 | 74.1 | 18.5 |
| *At my center goals for fluid removal are determined primarily by the critical care medicine team | 43.2 | 42.4 | 14.4 | 18.4 | 57.4 | 24.1 |
| *At my center goals for fluid removal are determined by the critical care and nephrology teams together | 46.9 | 47.6 | 5.4 | 45.2 | 54.8 | 0 |
| *My primary consideration when deciding to initiate net ultrafiltration is hemodynamic status | 40.5 | 58.0 | 1.5 | 38.9 | 61.1 | 0 |
| *My primary consideration when deciding to initiate net ultrafiltration is fluid balance | 29.0 | 66.4 | 4.6 | 16.7 | 77.7 | 5.6 |
| *I achieve my goal net ultrafiltration rate by varying ultrafiltration rate only | 44.2 | 47.6 | 8.2 | 40.7 | 53.7 | 5.6 |
| I assess fluid removal goals at least every 4 h | 14.3 | 53.8 | 31.8 | |||
| I base my maximum fluid removal goal on the patient’s total blood volume | 26.5 | 36.7 | 36.7 | |||
| At my center goals for fluid removal are determined primary by the nephrology team | 3.8 | 53.4 | 42.8 | |||
| I achieve my goal net ultrafiltration rate by varying replacement fluid rate only | 0.8 | 38.5 | 60.1 | |||
| I achieve my goal net ultrafiltration rate by varying both the ultrafiltration rate and the replacement fluid rate | 12.2 | 44.2 | 43.5 | |||
| When calculating net ultrafiltration rate, I account for enteral intake | 58.6 | 35.7 | 5.7 | |||
| When hemodynamic instability occurs on CKRT my first intervention or recommended intervention is to reduce the ultrafiltration rate | 17.1 | 75.7 | 7.1 | |||
| When hemodynamic instability occurs on CKRT my first intervention or recommended intervention is to start a vasoactive agent | 7.1 | 81.4 | 11.4 | |||
| When hemodynamic instability occurs on CKRT my first intervention or recommended intervention is to provide a bolus of fluid | 10.4 | 75.4 | 14.5 | |||
| Quality monitoring | ||||||
| *I monitor filtration fraction | 54.6 | 28.8 | 16.6 | 56.3 | 33.3 | 10.3 |
| I measure delivered CKRT dose based on blood and effluent concentrations of urea nitrogen | 18.8 | 36.2 | 44.9 | |||
*
Survey statements with ≥ 75% response of “always” or “sometimes” on both rounds of the survey