A 4.5-year-old boy was admitted to pediatric intensive care unit (PICU) with a 3-day history of non-projectile vomiting and fever. The patient was also experiencing loss of consciousness on admission and suffered a convulsion on the day after admission, with a concomitant sustained decrease in blood pressure and urine output. His urine output was <1 mL/kg/h.

On examination, he had generalized edema, and his weight was 21 kg, temperature 40.1 °C, blood pressure 68/41 mmHg, respirations 19 breath/min, and heart rate 110 beats/min. He had MODS including AKI, disseminated intravascular coagulation, acute myocardial injury, acute liver injury, and meningitis.

Laboratory data included: white cell count (WBC) of 21.2 × 10⁶/dL, hemoglobin (Hb) 9.2 g/dL, platelets 152 × 10³/dL, sodium 129 mEq/L, chloride 101 mEq/L, potassium 5.6 mEq/L, calcium 8.5 mg/dL, phosphorus 6.1 mg/dL, BUN 54 mg/dL, and creatinine 4.5 mg/dL. Arterial blood gas (ABG) analysis showed pH 7.15, HCO₃ ⁻ 9 mEq/L, and pCO₂ 32 mmHg. Liver function studies included alanine transaminase (ALT) 12,982 U/L, aspartate transaminase (AST) 14,782 U/L, total bilirubin 1.13 mg/dL, direct bilirubin 0.11 mg/dL, albumin 2.6 g/dL, creatinine kinase (CPK) 25175 U/L, C-reactive protein (CRP) 11 mg/dL, activated partial thromboplastin time (APTT) 65/s, prothrombin time (PT) 29.1/s, and international normalized ratio (INR) 5.74. Blood, urine, and spinal fluid cultures grew gram-positive staphylococcus bacteria. He was started on epinephrine infusion 4 μg/min and phenobarbital for the management of hypotension and control of seizures, respectively.

He remained in the hospital for additional 6 days before discharge. After discharge, the patient was followed up once monthly for 12 months. His development was normal and there was no relapse of symptoms/biochemical abnormalities.

A 5-week-old female neonate was transferred to the PICU because of MODS (congestive heart failure, AKI, lungs, hypoxic encephalopathy) due to neonatal asphyxia and meconium aspiration syndrome.

Upon admission to PICU, her temperature was 36 °C, respiration 26 breath/min, heart rate 123/beats/min, and blood pressure 65/42 mmHg. She weighed 3.7 kg and was 46 cm tall. Her daily urine output averaged <1.0 mL/kg/h.

Laboratory data included: WBC of 18.6 × 106/dL, Hb 14.2 g/dL, platelets 180 × 10 /dL, sodium 133 mEq/L, chloride 109 mEq/L, potassium 5.4 mEq/L, calcium 6.6 mg/dL, phosphorus 5.9 mg/dL, BUN 47 mg/dL, creatinine 5.3 mg/dL, ALT 496 U/L, AST 676 U/L, total bilirubin 1.42 mg/dL, direct bilirubin 0.62 mg/dL, albumin 3.1 g/dL, CRP 6 mg/dL, APTT 34/s, PT 16.3/s, and INR 1.32. ABG revealed pH 7.21, HCO₃ ⁻ 10 mEq/L, and pCO₂ 29 mmHg. The chest film showed bilateral pulmonary infiltration with pleural effusion. Blood, urine, and spinal fluid cultures showed no bacterial growth.

The patient was electively intubated for airway protection and treated with gentamicin and ampicillin. The antibiotic doses were adjusted according to the recommendation provided in Table 4.​7.

The patient’s electrolytes and urine output gradually normalized. Her urine output rose to 600–750 mL/day. BUN and serum creatinine fell to 21 mg/dL and 1.2 mg/dL, respectively. The serum electrolytes returned to normal levels and her liver function improved. After discharge, the patient was followed up once monthly for 9 months. Her development was normal and there was no relapse of symptoms or biochemical abnormalities.

The patient underwent bedside CRRT treatment for 65 h and was hospitalized for additional 14 days before discharge. After discharge, the patient was followed up once monthly for 12 months. Her development was normal, and there was no relapse of symptoms/biochemical abnormalities.

A 14-year-old boy was rushed to the hospital emergency department after rescued from a collapsed building for nearly 12 h. Emergency amputation of the right arm was performed due to severe crush injury. She developed MODS (heart failure, liver failure, respiratory distress syndrome, AKI, and disseminated intravascular coagulation) complicated with sepsis 2 days after the surgery.

On examination she was unconscious and edematous. Her weight was 36 kg, temperature 39.5 °C, heart rate 167 beats/min, respiration 14/min, and blood pressure 90/57 mmHg. Diffused rales and crackles were heard in both lungs. Purulent secretion was noticed at the amputation site. Many contusion wounds were seen over the entire body. The infant was intubated for airway protection (FiO₂ 70 %) and treated with antibiotics.

Laboratory tests showed: WBC 18,204 × 10⁶/L, Hb 6.8 g/dL, Hct 19 %, and platelet count 45 × 10⁶/L. Serum sodium was 131 mEq/L, potassium 6.8 mEq/L, chloride 98 mEq/L, bicarbonate 11 mEq/L, creatinine 5.3 mg/dL, BUN 67 mg/dL, total bilirubin 9.2 mg/dL, direct bilirubin 7.8 mg/dL, albumin 3.3 g/dL, ALT 230 IU/L, AST 651 IU/L, CK 8621 IU/L, myoglobin 5400 ng/mL, PT 20.1 s, APTT 120 s, and TT 45.2 s. Chest X-ray revealed bilateral pleural effusion. Blood, urine, spinal fluid, and wound cultures grew multiple pathogenic microorganisms including Klebsiella pneumoniae, Staphylococcus aureus, and Staphylococcus epidermidis, which were treated with meropenem plus vancomycin. The antibiotic doses were adjusted according to the recommendations provided in Table 4.​8.

The CRRT treatment was continued for 102 h. At this point, the patient’s clinical status improved considerably. Her temperature was 38.1 °C, heart rate 98 beats/min, respiratory rate 17/min, and blood pressure 134/74 mmHg. Her urine output rose to 1.600–2.4 L/day. The patient’s BUN and serum creatinine fell to 27 mg/dL and 1.5 mg/dL, respectively. The WBC decreased to 9.5 × 10⁶/L and platelet count increased to 178 × 10⁶/L. Serum electrolytes, liver function, and coagulation abnormalities returned to normal. She remained in the hospital for additional 16 days before discharge. After discharge, the patient was followed up once monthly for 12 months. His development was normal and there was no relapse of symptoms/biochemical abnormalities.

In all these cases, we believe that early intervention with CRRT may have inhibited the cytokine cascade/systematic inflammatory response and the associated inflammatory injury [7, 11]. The amelioration of uremia and fluid overload likely contributed to the efficacy of treatment [19–25].

CRRT treatment of 265 h for the first patient is relatively rare [26, 27]. This duration of treatment was necessary to stabilize the patient’s internal environment, provide nutritional/metabolic support, and allow for the implementation of other supportive treatment. Cases 2 and 3 are unique because there have been few reports of survival in neonates with MODs and children with MODS and sepsis following the crush injury [15–17].

For these patients, an AN69 membrane filter M60 with good biocompatibility, high permeability, and strong adsorption capacity was used [28, 29]. The area of the filter was relatively large (0.6 m²). The membrane, which can also be used under hypotension, causes a weak activation of complement and leukocytes and has a small impact on hemodynamics. The high permeability of this membrane may help to improve the anti-inflammatory cytokine to pro-inflammatory cytokine ratio, downregulate the body’s inflammatory response, and ameliorate the systemic inflammatory response [11].

One of the keys to early intervention in the neonate was placement of a central venous catheter. The smallest M60 filter was used and the tubing was prefilled with whole blood. Further, at the beginning of CRRT, the BFR was low, thus preventing a subsequent drop in blood pressure. Attention was also paid to body heat preservation and heating the vascular access point [4, 30–33].

A 5-year-old girl with new onset AKI due to septic shock has pulmonary edema and hyperkalemia. She is intubated with a FiO₂ of 65 % and a peep of 10. Her laboratory studies showed sodium 170 mEq/L, potassium 6.5 mEq/L, BUN 78 mg/dL, creatinine 3.9 mg/dL, and osmolality 488 mOsm/L. A trial of loop diuretic failed to induce diuresis.

Which form of RRT is least efficient?

CRRT yields the least efficient clearance (0.1–8 L/h) compared with peritoneal dialysis 0.5–2 L/h or hemodialysis 30–50 L/h.

A 9.5-kg male infant presents with lethargy. The child is afebrile; blood pressure is 75/40 mmHg, heart rate 130 beats/min, and respirations 50/min. On examination he appeared lethargic and “floppy” with poor neurologic tone.

Laboratory data showed hemoglobin of 15; creatinine of 0.9 mg/dL, potassium of 4.3 mEq/dL, calcium of 9.5 mg/dL, phosphorus of 6.0 mg/dL (nL), bicarbonate of 14 mEq/L, and ammonia of 1533 μmol/L (normal <40 μmol/L).

The child was electively intubated for airway protection. Foley catheter was placed for urine collection. Arginine chloride (250 mg/kg/2 h followed by 250–500 mg/kg/day), carnitine (1.0 g iv bolus followed by 250–500 mg/kg/day), sodium phenylacetate/sodium benzoate (250 mg/kg/2 h + 250 mg/kg/day), vitamin B12 (1 mg), and biotin (10 mg) all began once urine and plasma for amino and organic acids were obtained.

Blood ammonia levels collected at 1 h intervals. At 6 h of CVVHD the ammonia was ~200 μmol/L.

You are consulted to see a 4-year-old admitted to the pediatric intensive care unit with vasopressin-dependent gram-negative septic shock secondary to community-acquired pneumonia. His medical condition is complicated by respiratory failure, pericardial rub, and oliguric AKI. His serum potassium is 6.6 mEq/L, creatinine 3.8 mg/dL, and BUN 63 mg/dL.

A 16-year-old male status post-bone marrow transplant for aplastic anemia was admitted to ICU for management of AKI complicated by pulmonary failure requiring mechanical ventilation, sepsis, and liver failure secondary to graft-versus-host disease (GVHD). CVVHD was initiated for management of multiorgan dysfunction syndrome (MODS) , fluid overload , and hyperkalemia (K⁺ 6.7 mEq/L) with electrocardiogram changes. He was treated with gentamicin 180 mg iv q24 h and vancomycin 1 g iv q24 h. Blood levels of gentamicin and vancomycin 12 h post-infusion were 3.8 mg/L and 21 mg/L, respectively, while dialysis rate was 1000 mL/h. The dialysis rate increased to 1200 mL/h, and repeat blood levels 12 h post-gentamicin and vancomycin infusion were <0.4 and <4 mg/dL.

A 17-year-old female, 60 kg, was admitted to ICU for acute peritonitis . She was rushed to the operating room because of an acute abdomen. On postoperative day 2, she became septic. Her blood pressure was 81/58 mmHg while on dopamine drips. Her urine output is <100 mL/day. She is intubated and is on mechanical ventilator. Serum creatinine and BUN levels were 6.1 and 87 mg/dL, respectively. WBC was 13.2 × 10⁹/dL, HCT 30 %, platelet counts 156 × 10³/dL, CRP 190 mg/dL, PTT 49 s, ACT 210 s, liver function normal, arterial blood pH 7.14, PaCO₂ 22.5, sodium 132 mEq/L, potassium 5.9 mEq/L, chloride 98 mEq/L, and bicarbonate 14 mEq/L.

A previously healthy 2½-year-old girl was presented to the PICU with a 3-day history of high fever and erythematous rash and vesicles over her hands, feet, and mouth due to enterovirus 71 -related hand, foot, and mouth disease. On examination she appeared lethargic with reduced consciousness. Her weight was 16.9 kg, temperature 40 °C per rectum, blood pressure 70/30 mmHg, heart rate 190 beats/min, and respirations 33 breath/min. The oxygen saturation was 78 % in room air. She had cool, mottled skin and a prolonged capillary refill time was noted. Results of arterial blood gas showed pH 7.25, pCO₂ 40 mmHg, PO₂ 81 mmHg, bicarbonate 12 mEq/L, and oxygen saturation 78 % in room air.

A chest X-ray showed bilateral pulmonary edema with normal heart size. Electrocardiography showed sinus tachycardia. Echocardiogram showed severe dilated left ventricular dilation. The central venous pressure was 5.8 cmH₂O. She immediately required endotracheal intubation and positive pressure ventilation support. Normal saline 20 mL/kg was given over 30 min with vasopressin infusion including dobutamine 0.4 μg/kg/min, epinephrine 0.5 μg/kg/min, and milrinone 15 μg/kg/min.

Laboratory investigations revealed the following values: WBC 17,600 × 10⁶/L, neutrophils >10,000 × 10/L, lymphocyte 3110 × 106/L, hemoglobin 11.7 g/dL, platelet count 165 × 10³/L, APTT 34 s, BUN 34 mg/dL, creatinine 1.1 mg/dL, glucose 98 mg/dL, sodium 124 mEq/L, potassium 5.6 mEq/L, chloride 98 mEq/L, bicarbonate 17 Eq/L, calcium 8.1 mg/dL, total bilirubin 2.1 mg/dL, aspartate aminotransferase 45 IU/L, alanine aminotransferase 3.8 IU/L, lactate dehydrogenase 534 IU/L, ammonia 56 mg/dL, C-reactive protein 3.2 mg/L, total protein 6.4 g/dL, and albumin 3.3 g/dL.