These modalities are typically administered using standard intermittent hemodi-

ment therapy (CRRT) to IRRT as the patient’ s hemodynamic status improves during their critical care stay [7].

14, 17

, 18].

The safe rate

Hemodialysis CVC is made o

f polymers (polyurethane or silicone) to ensure adequate resistance combined with softness and hemocompatibility. Semirigid CVCs are preferred over rigid catheters to avoid trauma to the venous wall. Some of the newer polyurethane catheters are semirigid during insertion, then soften inside due to body temperature, minimizing trauma to the vessel wall. The outer diameter of the dual-lumen CVC usually varies between 11 and 14 French with the arterial and venous lumens arranged side by side or in a coaxial manner. To reduce recirculation, the arterial port ends about 2–3 cm proximally to the venous port. The catheters are available in different lengths to suit the site of insertion: the right internal jugular (IJ) vein typically requires a 15–16 cm catheter; the left IJ vein requires a 19–20 cm catheter, while a 24 cm catheter is required for the femoral veins. A triple-lumen temporary CVC can be available for administering medica­tions or intravenous fluids by the extra distal port. Tunneled, cuffed CVCs are made of silicone or other soft polymers for their less thrombogenic characteristic compared to temporary CVCs. The configurations of these catheters vary from double-lumen to two separate single-lumen catheters. These types of CVCs are usually inserted into the IJ veins, providing higher blood flow. Ultrasound guidance should be a mandatory requisite for all CVC insertions due to the variability in venous anatomy, and the right IJ vein is the ideal location for a temporary catheter, given its more direct route to the superior vena cava (SVC). In detail, the tip of the temporary CVC should be advanced to the junction of the SVC and the right atrium. CVC in the left jugular vein can present malfunction due to a more circuitous route to the right atrium with inadeq uate blood flow, while femoral veins should be the second choice, given their easy accessibility and infection risk. The use of subclavian veins for CVC insertion has to be avoided, given the concern for subclavian stenosis, especially in a patient who might develop end-stage renal disease requiring AVF or AVG in the ipsilateral arm to provide IRRT.

localization of the vessel.

critical in achieving the prescribed dose; thus, if the catheter is not functional, it should be changed over a guidewire or placed at a different site as soon as possible.

Temporary and tunneled CVCs are temic bacteremia or sepsis. This is usually a result of the contamination of the catheter lumen or the migration of skin bacteria through the entry site into the bloodstream. Temporary uncuffed catheters are associated with a higher risk of infection compared to tunneled CVC. The major risk factors for catheter-related bacteremia are the number of infusion ports, the frequency of manipulation, the severity of illness of the patient, indwelling time, emergency placement, and the experience of the operator and caregivers.

associated with exit site infection and sys-

CRRT i fluid overload and/or electrolyte abnormalities. The 2016 Surviving Sepsis Guide­lines suggest that clinicians administer the appropriate dose of antibiotic as soon as septic shock is recognized [20]. Many drugs used in critically ill patients with AKI can be titrated to effect; some examples are pain medications, sedatives, and vasopressors. However, the serum concentrations of most antibiotics cannot be measured or titrated in the clinical setting, and their use during CRRT can be empiric; consequently, the empiric dosing regimen has to be correct.

complexity of appropriate antibiotic dosing in critically ill patients, especially changing drug pharmacokinetic that is not characterized by universally accepted and reproducible data due to the inherent variability of RRT parameters and the patient’s clinical condition. Therapeutic drug monitoring (TDM) is being utilized for β-lactams (piperacillin or meropenem). For drugs that require TDM, ensure the blood sample is collected outside the CRRT system or from

a prefilter port to avoid underestimating the patient’s drug concentration as the clinician must ensure that the “appropriate” drug is selected with the adequate dose while accounting for CRRT clearance and the altered PK in critical illnesses [

Intermittent hemodialysis provides a rapid (usually 3–5 h) RRT, which is often performed thrice-weekly in outpatient regimens. IHD provides much higher extra­corporeal drug clearance than other RRTs. For example, the blood flow rate ranges between 250 and 450 mL/min for IHD, 150 and 400 mL/min for PIRRT, and 150 and 250 mL/min for CRRT. The dialysate flow rate ranges from 500 to 800 mL/min for IHD, 100 to 300 mL/min for PIRRT, and 1 to 3 L/h for CVVHD and CVVHDF. The ultrafiltration rates are 1–3 L per 3–5 h of IHD, 1–4L per 6–12 h of PIRRT, and 1–3 L/h for CVVH and CVVHDF . Drug package inserts provide drug dosing recommendations for hemodialysis patients. However, these dose recommendations are not applicable in critically ill patients receiving IHD since these PK data are predominantly generated in end stage kidney disease (ESKD) patients. PK parameters are not only markedly different in this patients’ population, but also, hypercatabolic critically ill patients may require more frequent IHD (>three times weekly) to control electrolyte and waste product removal [24]. Drug dosing regimens that are appropriate for a thrice-weekly hemodialysis schedule are unlikely to benefi

A chall apy to CRRT patients due to the presence of central venous catheters (CVCs), which is perceived as a barrier to proper physiotherapy. Recent evidence suggests that physical rehabilitation in patients receiving CRRT carries a very low risk of adverse events (AEs). Adverse events that may occur during rehabilitation with CRRT