Abstract
Objective
The aim of the study is to investigate whether the multistage draining cannula strategy inserted via the femoral vein and with blood return to the jugular vein can improve the therapeutic efficiency in patients with vena cava drainage disorder compared to traditional hemodialysis therapy.
Design
This study was approved by the Review Board of the Ethics Committee of Zhongshan Hospital, Fudan University (No. B2022-380), and the need for obtaining signed informed consent was waived for this retrospective analysis.
Patients
Two adult patients with acute vena cava reflux disorder were analyzed retrospectively in the study.
Interventions
To minimize recirculation, a multistage draining cannula strategy in a suitable position inserted via the femoral vein and with blood return to the jugular vein was used in patients with vena cava obstruction.
Measurements and Main Results
Study endpoints included vasopressors equivalent dose, ICU outcome and other clinical outcomes. The results showed that blood purification based on dual-cannula in jugular-femoral venous was able to improve the hemodynamic state, reduce the vasopressors dosage and improve the outcome for critically ill patients with acute vena cava reflux disorder.
Conclusions
Blood purification therapy with dual-cannula in jugular-femoral venous may be an effective and feasible strategy for patients with acute superior or inferior vena cava “obstruction”.
Avoid common mistakes on your manuscript.
1 Introduction
In critically ill patients, acute kidney failure (AKI) is one of the most important causes of morbidity and mortality [1, 2]. The treatment of AKI usually requires renal support such as continuous renal replacement therapy (CRRT), intermittent hemodialysis (IHD) and prolonged intermittent renal replacement therapies (PIRRTs) [3]. However, the efficiency of blood purification may be affected by the recirculation of double-lumen cannulation for special cases including patients with acute vena cava reflux disorder from massive abdominal tumor or ascites [4]. Recirculation is defined as the return of dialyzed blood to the arterial segment of the access bypassing the systemic circulation [5]. When recirculation is present, the dialyzed blood flow is composed of recirculated blood flow. Hence the existing dual-lumen catheter could not enable an adequate dialysis dose due to the high recirculation and diminish the dialysis dose. For extreme cases like patients with acute vena cava disconnection or severe obstruction, the traditional blood purification treatment cannot work effectively [6]. In the study reported here, we successfully treated two patients using dual-cannula in jugular-femoral venous for blood purification (Fig. 1A and B) and found that it can improve dialysis adequacy and circulation status (Table 1).
2 Case 1
A 66 year-old female was diagnosed with retroperitoneal tumor. She was admitted to intensive care unit (ICU) after the surgical removal of the tumor together with the partial resection of inferior vena cava. On ICU admission, she occurred with hypovolemic shock, multiple organ dysfunction and disorder of consciousness (Fig. S1A). Due to the partial resection of inferior vena cava, postoperative cardiovascular complications including venous drainage obstruction and lower limb swelling occurred. To prevent the further injury from femoral venous catheterization to the stump of inferior vena cava, hemodialysis with one cannula in jugular venous was performed at first. However, the circulation status deteriorated and the dosage of vasopressors remained high. Given the situation, we considered one draining cannula in jugular venous ineffective for the recirculation in jugular venous. Therefore, we chose to drain the blood through femoral venous catheter and return the blood through jugular venous catheter to improve the perfusion of systemic circulation. The hemodynamic status improved greatly and then we gradually reduce the dosage of vasopressors. (Fig. 1C). Abdominal CT (computed tomography) showed that hepatic injury and intestinal swelling also improved (Fig. S1B). One week later, she successfully weaned from mechanical ventilation, transited to intermittent hemodialysis with only jugular venous catheter.
3 Case 2
A 58 year-old male was diagnosed with pancreatic neoplasm and radical pancreatoduodenectomy was performed 5 days after admission. On day 1 after operation, the patient was admitted into our ICU for sudden convulsion and severe shock. Computed tomography angiography (CTA) showed extensive thrombosis in superior mesenteric vein and portal vein after surgery (Fig. S1C). The possibility of portal vein obstruction was considered. Besides, the patient encountered oliguria with elevated creatinine, abnormal central venous pressure, tachycardia and high body temperature. To promote venous drainage into the inferior vena cava and improve circulation status, the patient was treated with dual-cannula hemodialysis via jugular-femoral venous. 24 h of urine volume and creatine level were recorded to evaluate the efficacy of dual-cannula hemodialysis. After 3 days of continuous hemodialysis, the renal function recovered, and the dosage of norepinephrine was reduced gradually with the improvement in circulation status (Fig. 1D). The oliguria and refractory ascites associated with portal vein obstruction decreased after the procedure. Abdominal CT showed intestinal edema was significantly improved (Fig. S1D). Given the clinical improvement, the patient was transformed from CRRT to intermittent hemodialysis for another 2 days.
4 Conclusion
Blood purification therapy with dual-cannula in jugular-femoral venous may be an effective and feasible strategy for patients with acute superior or inferior vena cava “obstruction”.
5 Discussion
The renal function and hemodynamic status was improved in both patients (Table 2). Case 1 was successfully weaned from vasopressors, mechanical ventilation and endured another two operations, although she died of intestinal fistula after surgery two weeks later; case 2 was totally recovered and discharged from hospital.
Both patients occurred severe shock due to the acute inferior vena cava reflux disturbance after operation. Consequently, current single-tube venous catheterization strategy could not effectively convey the blood from inferior vena cava to right atrium. Besides, severe congestion of abdominal organs and lower extremity swelling arose. Based on the two cases, we propose that dual-lumen catheters inserted in the femoral vein and with blood return to the jugular vein could recirculate less than just single catheter placement in femoral or jugular vein. Our work allows us to conclude that blood purification therapy with dual-cannula in jugular-femoral venous may be an effective and feasible strategy for patients with acute superior or inferior vena cava “obstruction”.
Acute kidney injury (AKI) is defined as an abrupt decline in kidney function and is assessed based on the glomerular filtration rate [7]. Acute kidney injury in critically ill patients is associated with high morbidity and mortality. Over the past decades, in most critically ill patients with severe acute kidney injury (AKI) and acute liver failure, continuous renal replacement therapy (CRRT) and intermittent hemodialysis has developed into major treatment therapy. Venous double-lumen dialysis catheters in an internal jugular vein or femoral vein are introduced as vascular access in CRRT [8]. However, the use of double-lumen catheters in either jugular or femoral vein may increase the recirculation in critically ill patients with vena cava reflux disorder or severe disconnection. Recirculation consists of having some newly dialyzed blood flowing into the same RRT circuit. It occurs when the input lumen extracts the dialyzed blood from the outflow lumen [9]. Access recirculation remains to be an underrecognized phenomenon in dialysis. For patients with acute vena cava disconnection or severe obstruction, the pressure from the outflow segment may diminish the effective overall dialysis dose. In this setting, CRRT partially loses it efficiency. To improve the circulation status and minimize recirculation, cannulation in two separated insertion sites via femoral vein and jugular vein was used. This multistage draining cannula strategy enables an adequate dialysis dose with a relative low recirculation rate. This modality can act as an extracorporeal bypass with less recirculation and more stable hemodynamics for these patients. Cost can also be reduced by reducing the need for blood sampling and laboratory analysis and ensuring the hemodialysis adequacy. Moreover, such modality can provide the patients with enough time to establish collateral circulation. A prospective controlled study with a large sample size is initiated to explore the exact impact of the blood purification treatment on circulation status, inflammatory response and outcome for such patients and to identify indications for such treatment in patients with AKI. (NCT05510713).
Data availability
All data, models, and code generated or used during the study appear in the submitted article.
References
Rachoin JS, Weisberg LS. Renal replacement therapy in the ICU. Crit Care Med. 2019;47(5):715–711.
Cox K, Banerjee D. Acute renal failure in critically Ill patients: current evidence-based practices. R I Med J. 2019;102(10):22–5.
Tandukar S, Palevsky PM. Continuous renal replacement therapy: who, when, why, and how. Chest. 2019;155(3):626–38.
Tan J, Mohan S, Herbert L, Anderson H, Cheng JT. Identifying hemodialysis catheter recirculation using effective ionic dialysance. Asaio J. 2012;58(5):522–5.
Besarab A, Sherman R. The relationship of recirculation to access blood flow. Am J Kidney Dis. 1997;29(2):223–9.
Depner TA. Catheter performance. Semin Dial. 2001;14(6):425–31.
Gaudry S, Palevsky PM, Dreyfuss D. Extracorporeal kidney-replacement therapy for acute kidney injury. N Engl J Med. 2022;386(10):964–75.
Palevsky PM, Liu KD, Brophy PD, Chawla LS, Parikh CR, Thakar CV, et al. KDOQI US commentary on the 2012 KDIGO clinical practice guideline for acute kidney injury. Am J Kidney Dis. 2013;61(5):649–72.
Huriaux L, Costille P, Quintard H, Journois D, Kellum JA, Rimmelé T. Haemodialysis catheters in the intensive care unit. Anaesth Crit Care Pain Med. 2017;36(5):313–9.
Funding
This work was supported by the Clinical Research Plan of SHDC [grant number SHDC2020CR4067]; the Shanghai Science and Technology Commission [grant numbers 20S31905300 and 20Y11900900].
Author information
Authors and Affiliations
Contributions
YRH and ZYG wrote the main manuscript text. YML, HYH, and BS prepared figures and table. MJJ reviewed the manuscript.
Corresponding author
Ethics declarations
Conflict of interest
The authors declare that they have no competing interests.
Ethics Approval and Consent to Participate
The research related to human use has been complied with all the relevant national regulations, institutional policies and in accordance with the tenets of the Helsinki Declaration, and has been approved by the authors’ institutional review board or equivalent committee.
Consent for Publication
Not applicable.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Supplementary Information
Below is the link to the electronic supplementary material.
44231_2023_42_MOESM1_ESM.tif
Supplementary file1 The computed tomographies indicated an improvement in hepatic injury and intestinal edema for both case 1 (A and B) and case 2 (C and D) after dual—cannula RRT (TIF 266 KB)
Rights and permissions
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/.
About this article
Cite this article
He, Y.R., Gu, Z.Y., Liu, Y.M. et al. Preliminary Study on the Effect of Blood Purification Therapy with Dual-Cannula in Jugular-Femoral Venous: A Report of 2 Cases. Intensive Care Res 3, 245–249 (2023). https://doi.org/10.1007/s44231-023-00042-7
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s44231-023-00042-7