Continuous Renal Replacement Therapy current.pdf · Cost of acute renal failure requiring dialysis...
Transcript of Continuous Renal Replacement Therapy current.pdf · Cost of acute renal failure requiring dialysis...
Continuous Renal Replacement Therapy
Jai Radhakrishnan, MD, MS
History of the CRRT program
1988Open heart programActive transplant programDeep dissatisfaction with peritoneal dialysis in hemodynamicallyunstable patients
Objectives
Physiologic principlesPatient Selection for CRRTModality SelectionPrescription VariablesFluid CompositionManagement of Fluid and Electrolyte problemsControversies
Basic Concepts
Pressure
Convection(Plasma water moves along pressure gradients)
•SCUF
•CVVH
•CVVHD
•CVVHDF
Continuous Renal Replacement Therapy
SCUF:Slow Continuous Ultra Filtration
Maximum Patient Fluid RemovalRate = 2000 ml/hr
Therapy Options
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CVVHContinuous Veno-Venous HemoFiltration
Maximum Patient Fluid Removal Rate = 1000 ml/hr
Therapy Options
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CVVHDContinuous Veno-Venous HemoDialysis
Maximum Patient Fluid Removal Rate = 1000 ml/hr
Therapy Options
Access
Return
Effluent
PRISMA
Dialysate
CVVHDFContinuous Veno-Venous HemoDiafiltration
Maximum Pt. fluidremoval rate = 1000 ml/hr
Therapy Options
Access
Return
Effluent
Replacement
PRISMA
Dialysate
A Case
35 year old female is s/p OHT, POD#1.Remains intubated, MAP 65 on Levo 20, Pit 3, Milrinone 0.25Urine output 10 ml.hour (Intake 150ml/h)PAD 20FiO2 0.60- ABG 7.45/35/102BMP 132/4.6/103/18/25/1.3 (Baseline 1.0)
Indications for Renal Replacement
Standard indications Volume overloadHyperkalemiaMetabolic AcidosisUremic Platelet DysfunctionUremic Encephalopathy
Modality Selection
SCUF
CVVHCVVHD
CVVHDF
CVVHDF
Volume only
Solutes +/- Volume
Hypercatabolic+/- Volume
Prescription Variables
Blood FlowUp to 180 ml/min
ReplacementUp to 4500 ml/hr
Dialysateup to 2500 ml/hr
Patient Fluid RemovalUp to 2000 ml/hr
Access
Return
Effluent
Replacement
PRISMA
Dialysate
Fluid Composition: Dialysate
Prismasate® 5000mLNa+ = 140 mEq/LK+ = 0 mEq/LCl- = 109.5 mEq/LCa2+ = 3.5 mEq/LMg2+ = 1 mEq/LLactate = 3 mEq/LHCO3 = 32 mEq/LGlucose = 0 mg/dL
Premixed Dialysate®
5000mL Na+ = 140 mEq/LK+ = 2.0 mEq/LCl- = 117 mEq/LCa2+ = 3.5 mEq/L Mg2+ = 1.5 mEq/LLactate = 30 mEq/LGlucose = 100 mg/dL
Peripheral Electrolyte Replacement
In the event of high volume Bicarbonate solutions, if Ca free:Peripheral CaCl2/MgSO4
In the event of high clearance:prn Na phosphate
Solutes: Azotemia
AzotemiaIncrease replacement fluid and/or dialysateflow rate
Solutes: Sodium
HyponatremiaAdd 3% NaCl to dialysate @70 cc/5L bag
HypernatremiaIncrease peripheral IV D5W (1L) or 1/2 NS
Solutes: K
HyperkalemiaZero K+, increase replacement and/or dialysate flow rate
1 L bag 5 L bag Serum Potassium
Add 0 mEq / Liter None None > 5.5 mEq / Liter
Add 3 mEq / Liter 7.5 mL 37.5 mL > 4.5 – 5.5 mEq / Liter
Add 4 mEq / Liter 10 mL 50 mL < 4.5 mEq / Liter
Solutes: pH
Metabolic AcidosisNaHCO3 (50%) 100 cc over 1 hour IVSS, prnChange replacement to D5W (1L) + 3 amps NaHCO3
Metabolic AlkalosisChange replacement solution to NS + sliding scale KCl
Solutes: Calcium
HypercalcemiaChange to HCO3 dialysate (Ca2+ free) Increase HCO3 dialysate or replacement flow rate
HypocalcemiaCaCl2 (10%) 10 cc/100 cc NS or D5W over one hour, prnPremixed calcium drip
Solute: Mg and Phospate
HypomagnesemiaMgSO4 (50%) 2 ml in 100 cc NS or D5W over one hour, prnPremixed magnesium drip
HypermagnesemiaSame as Rx for hypercalcemia
HypophosphatemiaNa Phosphate (3 mmol/ml) 5cc in 100cc NS IVSS over 2 hours, prn (repeat x 1 if PO4 <1.0 mg/dl)
HyperphosphatemiaSame as Rx for hypercalcemia
Anticoagulation
Heparin250 - 500 U/hr
HIT: Argatroban0.5 - 1 mg/hr
Bleeding risk:CitrateNo anticoagulation
Argatroban CRRT Anticoagulation Protocol
1. Call Hematology for approval.2. In a 20 cc syringe (1000 mcg/mL): 30 microgram/kg/hr (0.5 microgram/kg/min)
Rate: _____ microgram/hr = ____ mL / hr (Range 0.5 – 5 mL/hr)Use lower dose with liver failure. (15 mcg/kg/hr)
Disconnect: Flush lumen with _____ mL of 1000 microgram/mL argatroban in each port (use internal volume as stated on catheter).
Reconnection: Aspirate 5 mL from each port before re-connecting.3. Write argatroban order separately.4. Check PTT q 12 hours
Citrate Regional Anticoagulation
Cointault O.. Nephrol Dial Transplant. 2004 Jan;19(1):171-8.
CRRT in LVAD circuit
LVAD
CRRT
CRRT- Controversial Issues
HCO3- vs lactate solutions
High vs standard delivered doseConvection vs diffusionCost of CRRT vs HD.Does CRRT improve outcome (vs HD)?CRRT to prevent contrast nephropathy
Lactate vs HCO3 Replacement
N=117Open-label trial randomized to Replacement Fluid:
HCO3
Lactate
Kidney International 58 (4), 1751-1757
Effects of different doses of CVVH on outcomes of ARF
425 patients with ARF.Patients were randomly assigned ultrafiltration at
• 20 mL/kg/h (Gr 1, n=146)• 35 mL/kg/h (Gr 2, n=139)
• 45 mL/kg/h (Gr 3, n=140).
Primary endpoint: survival at 15 days after stopping haemofiltration.
Lancet. 2000 Jul 1;356(9223):26-30
Intensity of Renal Support in Critically Ill Patients with Acute Kidney Injury
N Engl J Med. 2008 Jul 3;359(1):7-20
Diffusion vs. Convection
100
40
80
120
160
Molecular Weight
Cle
aran
ce (m
l/min
)
102 103 104 105 106 Urea, 60 DCreatinine, 113 DVit. B12, 1355 DInulin, 5200 DAlbumin, 55-60 kD
Diffusive transportConvective transport
Cost of acute renal failure requiring dialysis in the intensive care unit: clinical and resource implications of renal recovery.
DesignRetrospective cohort study Patients with ARF needing dialysis April 1, 1996, - March 31, 1999.
Setting: Two tertiary care intensive care units in Calgary, Canada.Patients: 261 critically ill patients.Outcomes:
in-hospital and subsequent survival and renal recoveryThe immediate and potential long-term costs
Manns: Crit Care Med, 31(2). 2003.449-455
Impact of dialytic modality on mortality (HD vs CRRT)
Am J Kidney Dis. 2002 Nov;40(5):875-85
Impact of dialytic modality on renal recovery.
Efficacy and cardiovascular tolerability of extended dialysis incritically ill patients: A randomized controlled study
Kielstein JT..Am J Kidney Dis. 2004 Feb;43(2):342-9.
Genius single-pass dialysis machine
Clearances
Hemodynamic Parameters
MAP HR
CO SVR
The Prevention of Radiocontrast-Agent–Induced Nephropathy by Hemofiltration
N Engl J Med 2003; 349:1333-1340,
•CVVH 1000 ml/h,
•4-8 hours pre and 18-24 hours after angiogram.
Outcome: Renal Function
Outcomes
OUTCOME CONTROLS CVVH
25% increase in Serum Creatinine
50% 5%
Renal replacement: (Oliganuriafor >48 h despite 1 g IV furosemide)
25% 3%
MortalityIn hospital One-year
14%30%
2%10%
Complications