Intracranial pressure during hemodialysis in patients with acute brain injury

Abstract

BackgroundBecause osmotic fluid shifts may occur over the blood‐brain barrier, patients with acute brain injury are theoretically at risk of surges in intracranial pressure (ICP) during hemodialysis. However, this remains poorly investigated. We studied changes in ICP during hemodialysis in such patients.MethodsWe performed a retrospective study of patients with acute brain injury admitted to Rigshospitalet (Copenhagen, Denmark) from 2012 to 2016 who received intermittent hemodialysis (IHD) or continuous renal replacement therapy (CRRT) while undergoing ICP monitoring. Data from each patient's first dialysis session were collected. Area under the curve divided by time (AUC/t) for ICP was calculated separately before and during dialysis.ResultsThirteen patients were included. During dialysis, ICP increased from a baseline of 11.9 mm Hg (median; interquartile range 6.3‐14.7) to a maximum of 21 mm Hg (18‐27) (P = 0.0024), and AUC/t for ICP was greater during dialysis (15.2 (13.4‐18.8) vs 11.7 mm Hg (6.4‐15.1), P = 0.042). The maximum ICP increase was independent of dialysis modality, but peak values were reached earlier in patients treated with IHD (N = 4) compared to CRRT (N = 9) (75 [30‐90] vs 375 min [180‐420] after start of treatment, P = 0.0095). The maximum ICP increase correlated positively to the baseline plasma urea concentration (Spearman's r = 0.69, P = 0.017).ConclusionHemodialysis is associated with increased ICP in neurocritically ill patients, and the magnitude of the increase may be related to initial plasma urea levels.

Extracorporeal treatment for ethylene glycol poisoning: systematic review and recommendations from the EXTRIP workgroup

“…CKRT is preferred if it can be initiated faster than hemodialysis (e.g., unavailability of hemodialysis, nursing limitations), leading to attainment of a safe EG concentration, as illustrated in Additional file 1 : Figure S3. CKRT is preferable if a patient has marked brain edema, as it increases intracranial pressure to a lesser degree than intermittent hemodialysis [ 392 ]. Clinicians performing ECTR should optimize operator settings to maximize EG clearance (e.g., higher blood flow, higher effluent production, filters with higher surface area).…”

The CSF Diversion via Lumbar Drainage to Treat Dialysis Disequilibrium Syndrome in the Critically Ill Neurological Patient

“…Although previous case series have documented increases in ICP via invasive monitoring during hemodialysis, particularly in patients with traumatic brain injury [7,25], there is sparse evidence regarding ICP thresholds that may be necessary to undergo dialysis successfully without neurological sequelae in patients with DDS. Lund et al described successful management of elevated ICPs in a pediatric patient with anoxic brain injury and acute kidney failure from cardiac arrest, in which ICPs were reduced to 3 mm Hg with CSF diversion from an EVD prior to dialysis until she could be weaned off CSF drainage with eventual renal recovery [24].…”

Prolonged Intermittent Kidney Replacement Therapy

“…Other observational studies have also supported the interchangeability between CKRT and PIKRT when evaluating clinical outcomes such as mortality, ventilator dependence, and length of hospital stay (19,24). It should be noted that KDIGO and other society guidelines recommend CKRT as the modality of choice in patients with raised intracranial pressure based on data demonstrating rise in intracranial pressure during hemodialysis treatments (25). At this time, there are insufficient data to determine whether PIKRT can be safely implemented in those with traumatic brain injury and/or intracranial hypertension from other causes, and CKRT should remain the preferred modality for this high-risk group of patients.…”