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Crrt minia-final-2018
- 1. Dr. Osama El-Shahat Consultant Nephrologist Head of Nephrology Department New Mansoura General Hospital (international) ISN Educational Ambassador
- 2. © Is an extracorporeal blood purification therapy intended to substitute for impaired renal function over an extended period of time and applied for or aimed at being applied for Extended time 24 -72 h. Bellomo R., Ronco C., Mehta R, Nomenclature for Continuous Renal Replacement Therapies, AJKD, Vol 28, No. 5, Suppl 3, November 1996
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- 11. © Renal Indications Life-threatening indications Hyperkalemia Metabolic Acidosis Pulmonary edema Uremic complications Non Renal Indications Fluid removal in congestive heart failure& Fluid management in multiorgan failure Cytokine manipulation in sepsis Treatment of drug overdose Nutrition support
- 12. © Mode of therapy Principle method of solute clearance CVVH Convection CVVHD Diffusion CVVHDF Convection & Diffusion SCUF Ultrafiltration (fluids)
- 13. SCUF Syringe pump Return Pressure Air Detector Blood Pump Access PressureFilter Pressure BLD Hemofilter Patient Effluent Pump Return Clamp Pre Blood Pump Effluent Pressure
- 14. © CVVHF Return Pressure Air Detector Return Clamp Patient Access Pressure Syringe Pump Hemofilter Post Replacement Pump Pre Blood Pump Replacement Pump Pre Effluent Pump Effluent Pressure Filter Pressure
- 15. © CVVHD Return Pressure Air Detector Return Clamp Access Pressure Blood PumpSyringe Pump Filter Pressure Hemofilter Patient Effluent Pump Pre Blood Pump BLD Effluent Pressure Dialysate Pump
- 16. © CVVHDF Return Pressure Air Detector Return Clamp Patient Access Pressure Syringe Pump Hemofilter Pre Blood Pump Replacement Pump Pre Effluent Pump Effluent Pressure Filter Pressure Dialysate Pump
- 17. © Ronco C et al Kidney Int 56 ( suppl 72 ) s-8-s-14 , 1999
- 18. © 5.6.2: We suggest using CRRT, rather than standard intermittent RRT, for hemodynamically unstable patients. (2B) 5.6.1: Use continuous and intermittent RRT as complementary therapies in AKI patients. (Not Graded
- 19. © 5.4.1: We suggest initiating RRT in patients with AKI via an uncuffed nontunneled dialysis catheter, rather than a tunneled catheter. (2D) 5.4.2: When choosing a vein for insertion of a dialysis catheter in patients with AKI, consider these preferences (Not Graded): First choice: right jugular vein; Second choice: femoral vein; Third choice: left jugular vein; Last choice: subclavian vein with preference for the dominant side. Vascular access KDIGO® AKI Guideline March 2012
- 20. © • The length of the catheter chosen will depend upon the site used Size of the catheter is important in the pediatric population. • The following are suggested guidelines for the different sites: RIJ= 15 cm French LIJ= 20 cm French Femoral= 25 cm French Vascular access
- 21. © • Physician Rx and adjusted based on pt. clinical need. • Sterile replacement solutions may be: Bicarbonate-based or Lactate-based solutions Electrolyte solutions Must be sterile and labeled for IV Use Higher rates increase convective clearances You are aware what you replace
- 22. © Bicarbonate versus lactatebased fluid replacement in CVVH Prospective, randomized study Results Serum lactate concentration was significantly higher and the bicarbonate was lower in patients treated with lactatebased solutions Increased incidence of CVS events in pts ttt with lactate solution ◦ Hypotension ◦ Increased dose of inotropic support barenborck and colleague Barenbrock M et al; Kidney Int (2000 Replacement Fluids
- 23. © 5.5.1: We suggest to use dialyzers with a biocompatible membrane for IHD and CRRT in patients with AKI. (2C) High Flux membrane , synthetic , biocompatable , acting by providing both methods of detoxications: A. Diffusion : for low molecular weight toxins. B. Convection : for large molecules. KDIGO® AKI Guideline March 2012
- 24. © Modality Advantages Disadvantages Heparin Good anticoagulation Thrombocytopenia bleeding LMWH Less thrombocytopenia bleeding Citrate Lowest risk of bleeding Metabolic alkalosis, hypocalcemia special dialysate Regional Heparin Reduced bleeding Complex management Saline flushes No bleeding risk Poor efficacy Prostacycline Reduced bleeding risk Hypotension poor efficacy
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- 26. © www.kdigo.org
- 27. Dose ?
- 28. © • Vascular access Vascular spasm(initial BFR too high) Movement of catheter against vessel wall Improper length of hemodialysis catheter inserted • Fluid volume deficit Excessive fluid removal without appropriate fluid replenishment
- 29. © • Hypotension Intravascular volume depletion Underlying cardiac dysfunction • Electrolyte imbalances High ultrafiltration rates (high clearance) Inadequate replenishment of electrolytes by intravenous infusion, Inadequate replenishment of bicarbonate loss during CRRT
- 30. © • Acid/base imbalance Renal dysfunction Respiratory compromise • Blood loss Ineffective anticoagulation therapy Clotting of hemofilter Inadvertent disconnection in the CRRT system Hemorrhage due to over-anticoagulation Blood filter leaks
- 31. © ◦ Blood pressure ◦ Patency of circuit ◦ Hemodynamic stability ◦ Level of consciousness ◦ Acid/base balance ◦ Electrolyte balance ◦ Hematological status ◦ Infection ◦ Nutritional status ◦ Air embolus ◦ Blood flow rate ◦ Ultrafiltration flow rate ◦ Dialysate/replacement flow rate ◦ Alarms and responses ◦ Color of ultrafiltrate/filter blood leak ◦ Color of CRRT circuit
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- 34. © ESNT-CNE 2nd Course, Cairo Jan 2-5, 2013 Mr. Smith, 60 kg, ARF Required dose: 35ml/kg BW/hr CVVHDF ◦Pre: 30% ◦Post:70% ◦Pt., fluid removal: 100 ml/hr ◦Dialysate: ????? 34 Calculation: 60kg x 35 ml/kg/h = 2100 ml/h Flow rates 1000 ml Dialysate 1000 ml Replacement 700 ml Post-Replacement 300 ml Pre-Dilution (PBP)
- 35. © ESNT-CNE 2nd Course, Cairo Jan 2-5, 2013 Mrs. Jones, 100 kg, Polytrauma with Rhabdo Required dose: 35ml/kg BW/hr Mode: CVVHDF ◦Pre-Replacement : 50% Post 50% ◦Pt. fluid removal: 200 ml/hr 35 Calculation: 100kg x 35 ml/kg/h = 3500 ml/h Flow rates: 1650ml Dialysate 1600ml Replacement 800 ml Post-Replacement 800 ml Pre-Replacemnt
- 36. © ESNT-CNE 2nd Course, Cairo Jan 2-5, 2013 TYPICAL REGIMEN IN CRRT : o Priming of the circuit ( 5000 IU / L ) o Initial Heparin Bolus : 5 - 8 IU / kg o Infuse Heparin at : 5 to 12 IU / kg / hr ACT on post filter : Adjust heparin rate to keep ACT between 1.5 & 2.0 times AKI: Renal Replacement Therapy (RRT) CRRT: Anticoagulation STANDARD HEPARIN
- 37. © 37 Acute Renal Failure Sepsis Rhabdomyolyse Dose (ml/kg/BW/hr) 35 50 35 Blood flow (ml/min) 150-350 250-450 > 150 Patient 60 kg Dialysate Replacement Post Replacement Pre = PBP 60 x 35 = 2100 ml 900 ml 400 ml 800 ml 60 x 50 = 3000 ml 1200 ml 600 ml 1200 ml 60 x 35 = 2100 ml 500 ml 550 ml 1050 ml Patient 70 kg Dialysate Replacement Post Replacement Pre = PBP 70 x 35 = 2450 ml 1000 ml 450 ml 1000 ml 70 x 50 = 3500 ml 1300 ml 700 ml 1400 ml 70 x 35 = 2450 ml 500 ml 650 ml 1300 ml Patient 80 kg Dialysate Replacement Post Replacement Pre = PBP 80 x 35 = 2800 ml 1000 ml 600 ml 1200 ml 80 x 50 = 4000 ml 1400 ml 900 ml 1800 ml 80 x 35 = 2800 500 ml 750 ml 1550 ml Patient 90 kg Dialysate Replacement Post Replacement Pre = PBP 90 x 35 = 3150 ml 1050 ml 700 ml 1400 ml 90 x 50 = 4500 ml 1500 ml 1000 ml 2000 ml 90 x 35 = 3150 500 ml 900 ml 1750 ml