ImportanceContinuous kidney replacement therapy (CKRT) is the preferred method of kidney support for children with critical illness in pediatric intensive care units (PICUs). However, there are no data on the current CKRT management practices in European PICUs.ObjectiveTo describe current CKRT practices across European PICUs.Design, Setting, and ParticipantsThis cross-sectional survey of PICUs in 20 European countries was conducted by the Critical Care Nephrology Section of the European Society of Pediatric and Neonatal Intensive Care from April 1, 2020, to May 31, 2022. Participants included intensivists and nurses working in European PICUs. The survey was developed in English and distributed using SurveyMonkey. One response from each PICU that provided CKRT was included in the analysis. Data were analyzed from June 1 to June 30, 2022.Main Outcome and MeasuresDemographic characteristics of European PICUs along with organizational and delivery aspects of CKRT (including prescription, liberation from CKRT, and training and education) were assessed.ResultsOf 283 survey responses received, 161 were included in the analysis (response rate, 76%). The attending PICU consultant (70%) and the PICU team (77%) were mainly responsible for CKRT prescription, whereas the PICU nurses were responsible for circuit setup (49%) and bedside machine running (67%). Sixty-one percent of permanent nurses received training to use CKRT, with no need for certification or recertification in 36% of PICUs. Continuous venovenous hemodiafiltration was the preferred dialytic modality (51%). Circuit priming was performed with normal saline (67%) and blood priming in children weighing less than 10 kg (56%). Median (IQR) CKRT dose was 35 (30-50) mL/kg/h in neonates and 30 (30-40) mL/kg/h in children aged 1 month to 18 years. Forty-one percent of PICUs used regional unfractionated heparin infusion, whereas 35% used citrate-based regional anticoagulation. Filters were changed for filter clotting (53%) and increased transmembrane pressure (47%). For routine circuit changes, 72 hours was the cutoff in 62% of PICUs. Some PICUs (34%) monitored fluid removal goals every 4 hours, with variation from 12 hours (17%) to 24 hours (13%). Fluid removal goals ranged from 1 to 3 mL/kg/h. Liberation from CKRT was performed with a diuretic bolus followed by an infusion (32%) or a diuretic bolus alone (19%).Conclusions and RelevanceThis survey study found a wide variation in current CKRT practice, including organizational aspects, education and training, prescription, and liberation from CKRT, in European PICUs. This finding calls for concerted efforts on the part of the pediatric critical care and nephrology communities to streamline CKRT education and training, research, and guidelines to reduce variation in practice.
made in table VII (that is, 13 surgeons by three types of operations and all operations together). Thirdly, no data are given to show whether or not survival is improved when surgery is done by specialists because, as the authors say, none of the surgeons specialised in this type of surgery. Furthermore, the postoperative mortality and complication rates for the four consultants with over 40% oftheir operations performed by surgeons in training were no worse than those for the other surgeons. Fourthly, comparing the hazard rates in the 10 years after surgery ignores the possibility that factors influencing postoperative mortality may well differ from those influencing longer term mortality. For example, postoperative mortality may be related to the technical skill of the surgeon, but longer term mortality might be related more to the surgeon's choice of procedure influenced by the patients' likely prognosis. Reporting large variability based on relatively small numbers resembles the situation on referral rates of general practitioners some time ago. Such studies had reported 20-fold variation in rates. Concern about this forms part of the government's justification for NHS reforms.' These studies were, however, based on small numbers of referrals and much of the variability could be attributed to random variation.4 Later studies involving larger numbers of referrals found significant but much smaller variations in referral rates.4 The paper by Messrs McArdle and Hole raises the important issue of significant variation in patients' outcome among surgeons. In our opinion there is insufficient adequate data and statistical back up to justify their conclusions. Further studies involving many more patients are required.
The work-up and management of patients with acute liver failure in paediatric critical care are often challenging. This chapter takes the readers through definitions, grading of severity, and diagnostic work-up of acute liver failure in children. General principles underlying the management of acute liver failure, including immediate resuscitation and retrieval; organ support, including renal replacement therapy; and the management of complications, including bleeding, are discussed. In particular, this chapter focuses on neuromonitoring and neuroprotection strategies in children with hepatic encephalopathy as a complication. The role of liver transplantation in fulminant liver failure and a brief overview of complications are also discussed.
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