This symposium provides an overview of the (r)evolution in intensive care medicine. The programme is based on lectures of 20 minutes where each speaker presents in two 10 minute talks (in der Beschränkung zeigt sich erst der Meister) the good things that happened in the last 40 years in critical care vs our mistakes or what is missing with respect to that topic. At the end of the session the speakers participate in an interactive round table discussion with online voting to get the audience involved. Will be discussed: Theoretical concepts, basic physiology and pathophysiology, monitoring, and future directions.

1. Renal support and blood purification
Prof. Zsolt Molnár1,2
zsoltmolna@gmail.com
1Medical Director: CytoSorbents Europe, Berlin, Germany
2Professor: Institute for Translational Medicine, University of Pécs, Pécs, Hungary

2. Why kidneys get into trouble?

3. DO2= (SV•HR) • (Hb•1.39•SaO2+0.003•PaO2) ~ 1000ml/min
VO2 = CO • (CaO2 - CvO2) ~ 250 ml/min
Global VO2 and DO2

5. DO2= (SV•HR) • (Hb•1.39•SaO2+0.003•PaO2) ~ 1000ml/min
VO2 = CO • (CaO2 - CvO2) ~ 250 ml/min
Fluid Blood Oxygen
Analgesia, sedation
Global VO2 and DO2

6. Resuscitation and outcome
Jones AE, et al. Crit Care Med 2009; 37:1649 –1654
Adequate resuscitation has a pivotal
role on outcome

7. 120% of
SBV
30% of
SBV
15% of
SBV
ARF is a life threatening condition:
RRT is a life saving intervention
What is best practice?

12. Outside these indications timing is
uncertain - individualization

14.  Slow continuous ultrafiltration
(SCUF)
 Continuous veno-venous
hemofiltration (CVVH)
 Continuous veno-venous
hemodialysis (CVVHD)
 Continuous veno-venous
hemodiafiltration (CVVHDF)
 Continuous veno-venous high-flux
hemodialysis (CVVHFD)
 Intermittent hemodialysis (IHD)
 Intermittent hemofiltration (IHF)
 Intermittent hemodiafiltration (IHDF)
 Intermittent high-flux dialysis (IHFD)
CONTINUOUS RENAL REPLACEMENT
THERAPIE (CRRT)
INTERMITTENT RENAL REPLACEMENT
THERAPIE (IRRT)
PROLONGED INTERMITTENT RENAL
REPLACEMENT THERAPIES (PIRRT)
 Sustained low-efficiency dialysis
(SLED)
 Slow low-efficiency extended daily
dialysis (SLEDD)
 Extended daily dialysis (EDD)

15. CVVH vs. CVVHD p= 0.76
CVVH vs. CVVHDF p= 0.82
IHDF vs. IHD p=0.76
CVVH vs. HVHDF p= 0.14
M
O
R
T
A
L
I
T
Y

16. p= 0.83
M
O
R
T
A
L
I
T
Y
HOSPITAL

17. ICU
p= 0.47
M
O
R
T
A
L
I
T
Y

18. p= 0.0077
CHANGE IN MAP vs BASELINE
M
O
R
B
I
D
I
T
Y

19. VASOPRESSOR REQUIREMENT
M
O
R
B
I
D
I
T
Y
p= 0.081

20. CRRT PIRRT IHD
FLUID REMOVAL
METABOLIC CORECTION
DISEQUILIBRATION SYNDROME
HD STABILITY
INTRACRANIAL PRESSURE STABILITY
IMMOBILIZATION
SMALL MW SUSTANCE REMOVAL
Right modality for the right goal

22.  Tunnelled only after 2 weeks
 Average treatment time: 12-13 days
Bellomo R et al. NEJM 2009; 361:1627–1638
Palevsky PM et al. NEJMed 2008; 359:7–20
 No difference in infection
Parienti JJ et al. JAMA 2008; 299: 2413–2422.
 Vascular stenosis
 most: subclavian vein – less: RIJV
Agarwal AK et al. Semin Dial 2007; 20:53–62
Yevzlin AS et al. Semin Dial 2008; 21:522–527
 Dysfunction
Parienti JJ et al. Crit Care Med 2010; 38:1118–1125
 Recirculation
 12–15 cm RIJV; 15–20 cm LIJV; 24 cm FV
Oliver MJ. Semin Dial 2001; 14:432–435

24. CVVH (60% sepsis)
20 vs 35 - 45 ml/kg/h
CVVHDF (63% sepsis)
20 vs 35 ml/kg/h
CVVHDF (50% sepsis)
25 vs 40 ml/kg/h
CVVH
24-36 vs 72-96 l/24 h
28-day mortality
Renal recovery
+
-
-
-
CVVHH
25-30 vs > 35 ml/kg/h
-
High volume vs. Conventional HF
Dinamic dosing: „Precision CRRT”

25. pneumonia + AKI
Hypercatabolism with
Increased urea production
Improvement
Urea reduced
Feeding
Urea increases
Diuretics refracter DCM
fluid-overload
Residual renal funtion
High soluble substance clearence
Oliguria
Worsening urea, creat
Postop patient
With complications

26. Extracorporeal blood purification

27. Acid Base
Pro-
coagulation
Anti-
coagulation
Oxidants
Anti-oxidants
Pro-
inflammation
Anti-
inflammation

28. Pro-
inflammation
Anti-
inflammation
Nature Reviews | Immunology Volume 13 | December 2013 | 862-874

29. Organ dysfunction
+
dysregulated host
response

30. Cytokine adsorbtion…
…and not only in septic patients but in any condition with a
CYTOKINE STORM!
To regain balance!

31. The rationale of bulk removal:
Let’s go fishing!

32. Capture rate:
1:1

33. Capture rate:
Lot:Few

35. Limitations:
- Higher predicted (37%) then observed (23%) mortallity
- ET levels were not measured

36. Survival
benefit

37. ECMO
CRRT
CytoSorb
How to apply? – part of CRRT

38. Almost 3
years...

41. Note: Because of low patient numbers, no statistics for APACHE II Score <15 is displayed
APACHE II Score: Mortality by outcome, grouped by APACHE II Score levels - ITT
except preemptive use, only patients with APACHE II and outcome known
3 1 3 23 32 36 39 78No of patients
28.6
46.8
64.4
77.6
91.6
47.8 50.0 55.6
69.2
65.4
0 - <5 5 - <10 10 - <15 15 - <20 20 - <25 25 - <30 30 - <35 >= 35
APACHE II: score, grouped
0
20
40
60
80
Numberofpatients
0
20
40
60
80
100
APACHEIIpredictedandobservedmortal...
Hospital mortality, 95% Confidence Limits
APACHE II: predicted mortality [%], 95% Confidence Limits
Frequency
Pred. mortality:
~ 90%
Actual mortality:
65%

42. Control CytoSorb
MODS
MODS/SOFA maybe too robust for 24-48 hours

43. Vasopressor
70%
decrease

44. PCT

45. >80% risk
Shock reversal 65% & observed mortality: 55%

46. Case series 13 surgical 13 medical on CRRT

49. How to go on?

51. Some answers:
Dosing of Early Cytokine Removal In
Septic Shock (DECRISS) trial