Table 2.

Proposed clinical practice guidelines for RRT in the acute phase of EVD

ParameterClinical Guideline
ModalityCRRT recommended for initial treatment
Consider transition to PIRRT (using same CRRT equipment) for continued RRT until patient either (1) recovers renal function or (2) is capable of leaving biocontainment isolation (i.e., negative viral PCR studies in blood)
StaffIf possible at the institution, all patients should receive RRT using CRRT equipment by extensively trained ICU nurses as primary clinical nurses at bedside
Minimize additional staff entry in the biocontainment environment (i.e., specialty dialysis nurses)
AccessTemporary nontunneled dialysis catheter placed at bedside under direct ultrasound visualization. Extra precautions should be taken to contain bloody waste from this procedure
The right internal jugular vein is the preferred access site (with the left internal jugular vein as the backup site), given that this presents the lowest bleeding risk because patients with EVD may experience bleeding diatheses. Recommend that subclavian insertion sites be avoided
Unless portable chest imaging after access insertion is unavailable, femoral access sites should be avoided secondary to bleeding risks (retroperitoneal bleeding)
Consider use of nonreflux dialysis grade caps for dialysis vascular access
CRRT dosingNo EVD-specific dosing needs. Consistent with Kidney Disease Improving Global Outcomes statements, support target CRRT dose to deliver a total effluent dose of 20–25 ml/kg per hour10 unless higher dosing is needed to augment small solute and electrolyte clearance or correction of acidemia
AnticoagulationRCA is preferred and recommended in all patients to extend filter life and reduce potential staff exposures with filter exchanges
Effluent disposalCRRT effluent has a low infectious risk, but because it is handled in an EVD-positive area and a small dialyzer leak may be undetected, recommend that effluent be treated as hazardous and disposed of in a similar manner as individual institution/local guidelines require for disposal of other bodily fluids in EVD11
Nutrition support during CRRTEnsure that patients receive appropriate augmented nutrition support while receiving CRRT as recommended by clinical guidelines (total daily protein intake of approximately 2 g/kg per day)24,25