crrt protocol continuous renal replacement therapy

CRRT ProtocolContinuous Renal Replacement Therapy

台大外科部護理師蔡壁如台大外科部護理師蔡壁如

Outline

History History Indication Indication CRRT Method CRRT Method Ultrafiltration rates Ultrafiltration rates Choice of replacement fluidChoice of replacement fluid Set-up protocol Set-up protocol

1861 Thomas Graham, etc. use a semi-permeable 1861 Thomas Graham, etc. use a semi-permeable membrane to diffuse ureamembrane to diffuse urea

1924 George Haas dialyse a patient during 15 minutes1924 George Haas dialyse a patient during 15 minutes 1927 Heparin,an anticoagulant, is available1927 Heparin,an anticoagulant, is available 1937 Production of cellophane for filters1937 Production of cellophane for filters 1943 Willem Kolff makes a rotating drum dialyser1943 Willem Kolff makes a rotating drum dialyser 1970 First artificial membrane1970 First artificial membrane 1975-1985 Development of new techniques, i.e. 1975-1985 Development of new techniques, i.e.

adsorption, plasma exchange, filtration …adsorption, plasma exchange, filtration …

History

Extracorporeal depuration in ICU

1977 : Peter Kramer performs first arterio-venous 1977 : Peter Kramer performs first arterio-venous hemofiltration (CAVH)hemofiltration (CAVH)

1982 : FDA approves the CAVH1982 : FDA approves the CAVH 1984 : Blood pump circulated remove fluid 1984 : Blood pump circulated remove fluid 1994 : Clinical importance to control fluid balance 1994 : Clinical importance to control fluid balance 1994 The first « automatic » machine is available 1994 The first « automatic » machine is available 2000 : higher flows machines becomes available2000 : higher flows machines becomes available



1982 : FDA approves the CAVH1982 : FDA approves the CAVH 1984 : Blood pump circulated remove fluid1984 : Blood pump circulated remove fluid 1994 : Clinical importance to control fluid balance 1994 : Clinical importance to control fluid balance 1994 The first « automatic » machine is available 1994 The first « automatic » machine is available 2000 : higher flows machines becomes available2000 : higher flows machines becomes available



1982 : FDA approves the CAVH1982 : FDA approves the CAVH 1984 : Blood pump circulated remove fluid 1984 : Blood pump circulated remove fluid 1994 : Clinical importance to control fluid balance1994 : Clinical importance to control fluid balance 1994 The first « automatic » machine is available 1994 The first « automatic » machine is available 2000 : higher flows machines becomes available2000 : higher flows machines becomes available



1982 : FDA approves the CAVH1982 : FDA approves the CAVH 1984 : Blood pump circulated remove fluid 1984 : Blood pump circulated remove fluid 1994 : Clinical importance to control fluid balance 1994 : Clinical importance to control fluid balance 1994 The first « automatic » machine is available1994 The first « automatic » machine is available 2000 : higher flows machines becomes available2000 : higher flows machines becomes available

Automatic CRRT

Objectives of extracorporeal depuration in the Intensive Care Units (ICU)

With acute renal failure (ARF)•function to control patient fluid, acid-base balances

• to correct electrolytic disorders

• to remove urea and creatinine

• to maintain sufficient nutrition

• to preserve the potential to recover renal

Without acute renal failure• to reduce the fluid overload to improve cardiac and brain status

• to remove lactate of major lactic acidosis

extracorporeal depuration in NTUH SICU

CVS ICU CVS ICU GS ICU GS ICU

CVVH CVVH 6.2% 6.2% 3.83%3.83%

H/D H/D 5.0%5.0% 2.97%2.97%

C.R.R.T. 適應症 1. 1. 急性腎衰竭急性腎衰竭 2. 2. 急性肺水腫急性肺水腫 3. 3. 在心臟手術進行期間，避免過量鉀及水份在心臟手術進行期間，避免過量鉀及水份 (( 利用體外血液利用體外血液

循環系統循環系統 )) 4. 4. 嚴重性水腫如；心臟衰竭嚴重性水腫如；心臟衰竭 (Congestive cardiac failure ), (Congestive cardiac failure ), 腎腎

病綜合症病綜合症 ( Nephrotic syndrome )( Nephrotic syndrome ) 5. 5. 急性呼吸道病症急性呼吸道病症 ( ARDS )( ARDS ) 6. 6. 藥物中毒藥物中毒 7. 7. 嚴重乳酸鹽中毒嚴重乳酸鹽中毒 8. 8. 敗血病休克敗血病休克 ( Septic shock ) : ( Septic shock ) : 清除清除 CytokinesCytokines 和和 EndotoxinEndotoxin 9. 9. 體溫過高體溫過高 // 發熱發熱 (Hyperthermia )(Hyperthermia ) 10.10. 橫紋肌溶解橫紋肌溶解 ( Rhabdomyolisis )( Rhabdomyolisis ) 11. 11. 急性溶血急性溶血

急性腎衰竭治療的終極目標清除血液中的廢物清除血液中的廢物回復身體的酸鹼平衡回復身體的酸鹼平衡改正體內電解質不正常情況，特別是血改正體內電解質不正常情況，特別是血

鉀過高鉀過高免除體液過量，較高的體液清除能力，免除體液過量，較高的體液清除能力，

不能對心血管有太大的壓抑不能對心血管有太大的壓抑確保營養支持確保營養支持

Hemodialysis

anticoagulant

Art

eria

l flo

w

Ven

ous

flow

Fresh dialysate

FILTER

Blood flow : 200 ~ 250ml/minBlood flow : 200 ~ 250ml/min

Dialysate flow : 500 ml/minDialysate flow : 500 ml/min

Duration : 4hDuration : 4h

Weight loss : 2 ~ 4 LWeight loss : 2 ~ 4 L

Hemofiltration

Hemofiltration = filtration through a strainer

blood

ultrafiltrate

substitution

Filter including a semi-permeable membrane

What is renal replacement method of first choice for intensive care patients?

IHD ( IntermitIHD ( Intermittent hemodialysis )tent hemodialysis )

CRRT ( CCRRT ( Continuous renal replacement therapy )ontinuous renal replacement therapy )

SLEDD SLEDD ( ( SSlow low LLow-ow-eefficient fficient DDaily aily DDialysis )ialysis )

Journal of the American Society of Nephrology, 2001Journal of the American Society of Nephrology, 2001

Intermittent H/D

IHD compared with CRRT

IHDIHD CRRTCRRT

DiffusiveDiffusive ConvectiveConvective

Low-flux membraneLow-flux membrane High-flux membraneHigh-flux membrane

High dialysate flowHigh dialysate flow Low dialysate flowLow dialysate flow

A few hours per dayA few hours per day In theory continuouslyIn theory continuously

Technically demandingTechnically demanding Technically less demandingTechnically less demanding

Less labor intensiveLess labor intensive Labor intensiveLabor intensive

Journal of the American Society of Nephrology, 2001

Theoretical Advantage of CRRT

Hemodynamic StabilityHemodynamic Stability Recovery of renal functionRecovery of renal function Correction of metabolic acidosisCorrection of metabolic acidosis BiocompatibilityBiocompatibility Correction of malnutritionCorrection of malnutrition Better removal of cytokinesBetter removal of cytokines Solute removalSolute removal Overall outcomesOverall outcomes


Disadvantage of CRRT

Continuous anticoagulation Continuous anticoagulation Patient immobilityPatient immobility Intensive nursing requirementsIntensive nursing requirements Increased expenseIncreased expense


SLEDD ( Slow Low-efficient Daily

Dialysis ) Fresenius 2008H delivery systemFresenius 2008H delivery system Toray model 2.0 dialyzerToray model 2.0 dialyzer Double lumenDouble lumen Duration : 6 ~ 8 hrsDuration : 6 ~ 8 hrs Blood flow : 200 ml/minBlood flow : 200 ml/min Dialysate flow rate : 300 ml/minDialysate flow rate : 300 ml/min Dialysate bicarbonate concentration : 30 ~ 3Dialysate bicarbonate concentration : 30 ~ 3

5meq/L5meq/L

American Journal of Kidney Disease, 2000

SLEDD as an Alternative

Low blood flowLow blood flow Low dialysate flow ratesLow dialysate flow rates Prolong period of time Prolong period of time

( 6 ~ 12hrs)( 6 ~ 12hrs)

Compared with IHDCompared with IHD Hemodynamic stability Hemodynamic stability Better correction of hypeBetter correction of hype

rvolemia rvolemia Adequate solute removalAdequate solute removal Cost lower than CRRTCost lower than CRRT


Advantage of SLEDD

Less cumbersome techniqueLess cumbersome technique Patient mobilityPatient mobility Decreased requirements for anticoagulationDecreased requirements for anticoagulation Providing similar hemodynamic stability anProviding similar hemodynamic stability an

d volume controld volume control

American Journal of Kidney Disease, 2000

CVVHD

P/D Solution : Dialysate solutionP/D Solution : Dialysate solution 35 ~ 45% infused dextrose absorbed throug35 ~ 45% infused dextrose absorbed throug

h the hemodiafilterh the hemodiafilter Glucose delivery 5.8 g/hr (P/D 1.5%, rate 1Glucose delivery 5.8 g/hr (P/D 1.5%, rate 1

L/hr)L/hr) Impact nitrogen and carbohydrate balanceImpact nitrogen and carbohydrate balance

Intensive Care Med. 1991, 1995

CVVHDContinuous Veno-Venous hemodiafiltration

Blood Flow, 200 ml/min

ultrafiltration

P/D solutiondialysate V

CVVHD Glucose dynamics during continuous hemodiafiltrationGlucose dynamics during continuous hemodiafiltration

Lipogenesis in the liverLipogenesis in the liver Excessive carbon dioxide productionExcessive carbon dioxide production MV (minute ventilation)MV (minute ventilation) HyperglycemiaHyperglycemia

• Preventing glucose overloadPreventing glucose overload• Dextrose free dialysateDextrose free dialysate• Glucose load from dialysateGlucose load from dialysate

ConclusionConclusion Dextrose free : loss is small and predictableDextrose free : loss is small and predictable

Intensive Care Med. 1995

Ultrafiltration rates ?

Recommend 2L per hour or moreRecommend 2L per hour or more 20 ml/hr/kg : 41% 20 ml/hr/kg : 41% (survival rate)(survival rate)

35ml/hr/kg : 57% 35ml/hr/kg : 57% 45ml/hr/kg : 58% 45ml/hr/kg : 58%

High treatment doses might be difficultHigh treatment doses might be difficult EarlyEarly start of treatment : improved outcome start of treatment : improved outcome

Lancet 2000;355:26-30

Early and Intensive Continuous Hemofiltration for severe renal failure after cardiac surgery

EarlyEarly : 2.8 days post-op: 2.8 days post-op Too late in the post-opToo late in the post-op

Leading prolonged and poorly controlled uremiaLeading prolonged and poorly controlled uremiaRestricted nutritionRestricted nutritionVolume overloadVolume overload

IntensiveIntensive : 2 L/hr urtrafiltration rate: 2 L/hr urtrafiltration rate Limited intensity leading to inferior uremic control Limited intensity leading to inferior uremic control

with its attendant sequel with its attendant sequel Actual mortality : 40% vs 66%Actual mortality : 40% vs 66%

Ann Thorac Surg 2001

Hemofiltration withpredilution or postdilution

ultrafiltrate

PostdilutionPredilution antic

oagu

lant

FILTRE

Art

eria

l flo

w

Ven

ous

flow

Predilution : Injection before the filter

Postdilution : Injection after the filter

Double lumen : Re-circulation rate

250cc/min blood flow250cc/min blood flow Subclavian , internal jugular vein < 3%Subclavian , internal jugular vein < 3% Catheter length Catheter length

Femoral vein 24cm : 10% Femoral vein 24cm : 10% 15cm : 18% 15cm : 18%

400 c.c/min blood flow400 c.c/min blood flow38% in the femoral vein38% in the femoral vein

American Journal of Kidney disease , 1996

Double lumen : Re-circulation rate

298 c.c/min blood flow 298 c.c/min blood flow Femoral vs Subclavian : 16.1Femoral vs Subclavian : 16.1%% vs 4.1 vs 4.1%% Femoral cath 13.5 cm vs 19.5 cm : Femoral cath 13.5 cm vs 19.5 cm :

22.8 22.8 ±3.0%±3.0% vs12.6 vs12.6 ±1.7%±1.7%

American Journal of Kidney disease, 1996

Choice of replacement fluid Acetate-Based fluidsAcetate-Based fluids

HyperacetatemiaHyperacetatemiaperipheral vasodilator, myocperipheral vasodilator, myocardial depressant effectardial depressant effect

Acetate metabolism Acetate metabolism oxygen consumptionoxygen consumption Bicarbonate-Based fluidBicarbonate-Based fluid

SVR, SVR, CICI Lactate-Based fluidLactate-Based fluid

lactate : lactate : protein catabolism protein catabolism ADP level and impair oxygen delivery and venADP level and impair oxygen delivery and ven

tricular function (myocardial depression)tricular function (myocardial depression) Excessive accumulation of D-lactate Excessive accumulation of D-lactate IICPIICP

American Journal of Kidney disease, 1996

Effects of bicarbonate and lactate-buffered replacement fluids on cardiovascular

outcome in CRRT patients

Bicarbonate Replacement Fluid :Bicarbonate Replacement Fluid : recomme recommended in patients with lactic acidemia and sevended in patients with lactic acidemia and severe liver failurere liver failure

Improve cardiovascular outcome in critically ill Improve cardiovascular outcome in critically ill patients with acute renal failurepatients with acute renal failure

International Society of Nephrology 2000International Society of Nephrology 2000

CVVH Solution Formula

品名品名 NaNa++ CaCa++++ MgMg++++ ClCl-- SOSO44

== HCO3HCO3--

CVVH”A”CVVH”A” 73.673.6 2.62.6 1.431.43 76.276.2 1.431.43

CVVH”B”CVVH”B” 68.7568.75 35.435.4 —— 33.3333.33

MixtureMixture 142.35142.35 2.62.6 1.431.43 111.62111.62 4.134.13 33.3333.33

Replacement Fluid : A, B Solution

Anticoagulation

Heparin free : flush 50 ~ 100 cc N/S Q1hHeparin free : flush 50 ~ 100 cc N/S Q1h CitrateCitrate Heparin : PTT 45 ~ 65 secHeparin : PTT 45 ~ 65 sec

SICU CVVH Protocol

Double : R’t Jugular > Femoral Double : R’t Jugular > Femoral Blood Flow : 150 ~ 200 c.c/minBlood Flow : 150 ~ 200 c.c/min UF rate : 1L/hr ~ 2L/hr UF rate : 1L/hr ~ 2L/hr 視病患而定視病患而定

Blood Flow : 150 c.c /min 1L/hrBlood Flow : 150 c.c /min 1L/hr Blood Flow : 200 c.c /min 2L/hrBlood Flow : 200 c.c /min 2L/hr

Replacement Fluid : Replacement Fluid : 視脫水多少而定視脫水多少而定

Roller pump

PowerBlood flow

加熱袋

主機

A

B C D

arteryvein

Blood pump

Blood flow

A,B solution 接頭

Air chamber

接 IV set

CRRT 圖解分析

Automatic CRRT

crrt protocol continuous renal replacement therapy

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