Double CRRT in Profound Alcoholic Ketoacidosis and Shock: Salvage Extracorporeal Therapy in a Malnourished, Hyperosmolar Patient in the Intensive Care Unit (ICU)

Introduction: Ethanol toxicity rarely requires renal replacement therapy. However, in the presence of shock, starvation ketoacidosis, hyperosmolarity, and multi-organ dysfunction, extracorporeal support may be life-saving. Double CRRT—the simultaneous use of two CRRT circuits—is a rare rescue strategy, primarily reported in refractory lactic acidosis and toxin-induced crises. Case Description: A 47-year-old woman with alcohol and polysubstance use presented obtunded after drinking 2–3 pints of vodka daily for 7 days with no food intake. She was hypotensive (BP 50/40s), tachycardic, hypothermic, and oliguric. Labs showed pH 6.80, PCO2 10, AG 53, lactate 12, BHB 8, Cr 2.0, Na 152, serum osmolality 441, and blood alcohol level 368 mg/dL. She tested positive for fentanyl. Despite vasopressors, bicarbonate, insulin-dextrose, thiamine, and empiric antibiotics, severe acidemia persisted. Nephrology initiated dual CRRT circuits at 3:00 AM to rapidly correct acid-base and solute derangements. The second circuit was weaned by noon as her pH began to normalize. Over 72 hours, she stabilized, was transitioned to single CRRT, and remained off mechanical ventilation. She was ultimately discharged to rehab. Discussion: Double CRRT increases solute clearance and buffer delivery, enabling rapid correction of life-threatening acidosis when standard CRRT fails. This approach, described in metformin toxicity [1], has also been applied in severe intoxications and tumor lysis syndrome [2]. Limitations include catheter access, anticoagulation, and resource demands. In our case, early dual CRRT was pivotal in reversing shock and preventing intubation. Learning Points: 1-Consider dual CRRT in patients with severe acidosis unresponsive to single-circuit therapy. 2-Rapid correction of pH may prevent respiratory decompensation and mechanical ventilation. 3-Further studies are needed to guide protocolized use of double CRRT in critical care. References: 1. Reynolds HV, Pollock HHG, Apte YV, Tabah A. Achieving High Dialysis Dose via Continuous Renal Replacement Therapy in the Setting of Metformin-Associated Lactic Acidosis: A Case Series. A&A Pract. 2022;16(1):e01561. 2. De Simone E, et al. Efficacy of Continuous Venovenous Hemodiafiltration in Patients with Metformin-Associated Lactic Acidosis and Acute Kidney Injury. Sci Rep. 2025;15:8636.