CVVH in SICUCVVH in SICU

外科加護病房 護理師外科加護病房 護理師蔡壁如蔡壁如

Hemodynamic instability duHemodynamic instability during different forms of dialyring different forms of dialysis therapy : Do we really knsis therapy : Do we really know why ?ow why ?

CRRT Program consideration and CRRT Program consideration and evaluationevaluationFactors effecting potential implementation of CRRT

Factors effecting performance of CRRT

•ICU beds•Dialysis patient/year•ARF patient on ICU/year

Clear delineation of nursing responsibilities(e.g.CRRT set-up, initiation, monitoring, trouble shooting)

Dialysis services (non-CRRT dialysis facilities, nephrological support, renal nurses)

Physician’s responsibilities and interaction

ICU staffing support (intensivists Vs nephrologists )

Formal and continuous instruction (lectures,“hands-on” training, skill assessment, patient care experience)

ICU staff training support Standardized and updated protocols

Level of intensive care unit Continuous identification of areas for improvement (e.g. new knowledge)

Which the renal replacement Which the renal replacement method of first choice in the method of first choice in the

ICU P’tICU P’t Simple to manage / low work-loadSimple to manage / low work-load Inexpensive Inexpensive Reliable and predictable ( solute and Reliable and predictable ( solute and

water removal)water removal) Optimal survival and complication Optimal survival and complication

profileprofile Optimal recovery of renal function Optimal recovery of renal function

Hybrid therapies in ICU Hybrid therapies in ICU

CRRT CRRT (Continuous Renal Replacement Therapy )(Continuous Renal Replacement Therapy ) EDD ( Extended daily dialysis )EDD ( Extended daily dialysis ) SLEDD ( Slow Low-efficient Daily Dialysis SLEDD ( Slow Low-efficient Daily Dialysis

)) SLEDD-f SLEDD-f (Sustained Low-Efficiency Daily Dia-filtrati(Sustained Low-Efficiency Daily Dia-filtrati

on ) on ) IHD ( Intermittent Hemo-dialysis ) IHD ( Intermittent Hemo-dialysis ) PlasmapheresisPlasmapheresis

Basic Principle of Basic Principle of RRenal enal RReplacement eplacement TTherapyherapy

Diffusion Diffusion Solute from higher concentration Solute from higher concentration to lower concentration to lower concentration

Ultra-Ultra-filtration filtration

Fluid trough semi-permeableFluid trough semi-permeable membrane driven by pressure membrane driven by pressure gradient gradient

ConvectionConvection Solute and fluid Solute and fluid (Depending on molecular (Depending on molecular

weight and size)weight and size) by ultra-filtration by ultra-filtration

Adsorption Adsorption Molecular adhesion to inner Molecular adhesion to inner surface of semi-membrane surface of semi-membrane

NEJM 336:1303-1309

血液透析的原理

脫水的原理

連續性血液過濾術 (CVVH) 原理

人工腎臟吸附毒素

CRRT

Dialysis

Introduction of Acute Renal Introduction of Acute Renal FailureFailure 17 ~ 25 % of ICU case develop 17 ~ 25 % of ICU case develop

ARFARF 5 ~ 10% of cases will require CRRT5 ~ 10% of cases will require CRRT Outcome is dependent upon the Outcome is dependent upon the

original cause of ARForiginal cause of ARF Mortality from underlying disease, Mortality from underlying disease,

and complication like sepsis and complication like sepsis

•Clinical care nephrology, 1998. P405-411

Acute renal failure

Intrinsic renal Post-renal

Nephrotoxic

Pre-renal

Absolute decrease in effective blood volume HaemorrhageVolume depletion

Relative decrease in blood Volume(ineffective arterial volume)Congestive heart failureDecompensated liver cirrhosis

Arterial occlusion or Stenosis of renal artery

Haemodynamic fromNSAIDsACE inhibitors or angiotensin-II receptorin renal- artery stenosisor congestive heart failure

VascularVasculitisMalignanthypertension

Acute glomerulo-nephritisPostinfectionsGlomerulonephrittis ,disease causedby antibody to glomerular basementmembrane

Acutetubularnecrosis

Obstruction of collecting system or extrarenal drainageBladder –outlet obstructionBilateral ureteral obstruction

Ischaemic

Exogenous Antibiotics(gentamicin)Radio contrast agents Cisplatin

EndogenousIntratubular pigments(haemoglobinuria,myoglobinuria)Intratubular proteins(myeloma)Intratublar crystals(uric acid,oxalate)

Classification ARF

Acute

Interstitial

nephritis

Drug-

associated

RIFLE CriteriaRIFLE Criteria

Crit Care Med 2006, Vol. 34 No 7

Acute Kidney Injury stage 3Acute Kidney Injury stage 3

Stage

Creatinine Criteria Urine Output Criteria

1 Serum creatinine of ≥ 0.3 mg/dL or to ≥ 150-200% from baseline

< 0.5 ml/kg/hr for > 6hrs

2 Serum creatinine to 200%-300% from baseline

< 0.5 ml/kg/hr for > 12hrs

3 Serum creatinine to >300% from baseline (or serum creatinine ≥ 4.0 mg/dL with an acute at least 0.5 mg/dL)

< 0.3 ml/kg/hr for x 24hrs or anuria x 12hr

Renal replacement therapy

CVVH IndicationCVVH Indication

CAVH in ECMO CAVH in ECMO Cerebral edemaCerebral edema ：： Mannitol ≧ q12hr Mannitol ≧ q12hr

in use frequencyin use frequency Prevention of post-dialytic “ rebounPrevention of post-dialytic “ reboun

d” intoxicationd” intoxication ：： lithium, tumor lyslithium, tumor lysis, rhabdomyolysis, tissue necrosisis, rhabdomyolysis, tissue necrosis

專有名詞專有名詞 CAVH, CAVHD, CAVHDFCAVH, CAVHD, CAVHDF CVVH, CVVHD, CVVHDFCVVH, CVVHD, CVVHDF IHD, EDD, SLEDD, SLEDDFIHD, EDD, SLEDD, SLEDDF RRTRRT

Renal Replacement TherapyRenal Replacement Therapy

Effects of different doses in continuous veno-venous Effects of different doses in continuous veno-venous hemofiltration on outcomes of acute renal failure : a hemofiltration on outcomes of acute renal failure : a

prospective randomized trialprospective randomized trial CVVH Ultrafiltration rate ? CVVH Ultrafiltration rate ? 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 outc start of treatment : improved outc

omeomeLancet 2000;355:26-30

脫水量愈多效果愈好 脫水量愈多效果愈好 ??

The Third International Course on Critical Care Nephrology held in Vicenza, Italy in June 2004

答案是 : 病患的 indication

增加護理人力

血流速相對要提高

電解質的的監控 : K+ loss

Vascular Vascular accessaccess

Grade C : avoided subclavian in adultsGrade C : avoided subclavian in adults Grade D : avoided femoral vein in neonates and yGrade D : avoided femoral vein in neonates and y

oung (femoral vein thrombosis is a significant prooung (femoral vein thrombosis is a significant problem)blem)

Grade C : Internal jugular vein Grade C : Internal jugular vein Level II and III studies : Ultrasound guidanceLevel II and III studies : Ultrasound guidance Re-circulation is likely to be significant for blood fRe-circulation is likely to be significant for blood f

low in excess of 200 c.c/min, but depending on calow in excess of 200 c.c/min, but depending on catheter design and locationtheter design and location

•The first international consensus conference on CRRT, 2002

Double lumen : Re-circulation rateDouble lumen : Re-circulation rate不是血流速愈高愈好不是血流速愈高愈好 :: 看導管大小看導管大小 位 位置置

under 250cc/min blood flowunder 250cc/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%

Blood flowBlood flow– 400 cc/min : 38% in the femoral vein400 cc/min : 38% in the femoral vein

American Journal of Kidney disease , 1996

Double lumen : Re-circulation Double lumen : Re-circulation raterate

Blood flow : 298 cc/minBlood flow : 298 cc/min Femoral vs Subclavian:Femoral vs Subclavian:16.116.1±1.8%±1.8% vs 4.1 ±0.7 vs 4.1 ±0.7

%%

Femoral cath 13.5 cm vs 19.5 cm : 22.Femoral cath 13.5 cm vs 19.5 cm : 22.8 ±3.0% vs12.6 ±1.7%8 ±3.0% vs12.6 ±1.7%

台大台大 SICU Double lumenSICU Double lumen 準備時要注意準備時要注意– 14Fr 20cm (Femoral )14Fr 20cm (Femoral )– 14Fr 16cm (Neck )14Fr 16cm (Neck )

American Journal of Kidney disease, 1996

AnticoagulationAnticoagulation

Grade E : priming solution: 2000 U/1000c.c Grade E : priming solution: 2000 U/1000c.c Grade E : avoided systemic heparin in high risGrade E : avoided systemic heparin in high ris

k bleeding p’t k bleeding p’t Grade D : without any anticoagulation, circuit Grade D : without any anticoagulation, circuit

life may be less than 24hrlife may be less than 24hr Grade E : anticoagulation monitoring , ACT(acGrade E : anticoagulation monitoring , ACT(ac

tivated clotting times) or PTT(partial thrtivated clotting times) or PTT(partial thromboplastin time)omboplastin time)

•The first international consensus conference on CRRT, 200

AnticoagulationAnticoagulation

Standard protocolStandard protocol Initial bolus 10-30 unit/kg of heparinInitial bolus 10-30 unit/kg of heparin Infusion 10-30 unit/kg to targetInfusion 10-30 unit/kg to target

ACT :170-220 seconds orACT :170-220 seconds orPTT: 2 XPTT: 2 X

N.J.Maxvold, T.E. Bunchman/Crit Care Clin 2003 19(2),563-575N.J.Maxvold, T.E. Bunchman/Crit Care Clin 2003 19(2),563-575

Automatic CRRT

優點 :

全自動計算

可加熱

缺點 :

太敏感

機器不穩定

Fresenius machineFresenius machine

優點 :

容易操作

缺點 :

沒有加熱器 溫度散失厲害

外掛的輸液機不穩定

Replacement Fluid A, B Solution

CVVH Solution FormulaCVVH Solution Formula

品名品名 NaNa++ CaCa++++ MgMg++++ ClCl-- SOSO44== HCO3HCO3

--

CVVH ACVVH A 73.673.6 2.62.6 1.431.43 76.276.2 1.431.43

CVVH BCVVH 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 33.3333.331. B solution + 250c.c Rolikan

2. A B 溶液單獨進入體內 :Ca+HCO3 會沉澱

3. 溶液內沒有 K離子，注意電解質問題

4. 若要加鉀離子， A液一袋加一支 (20Meq )

WallthicknesWallthicknes

ss

35 µm35 µm

Inner Inner

lumen 220 lumen 220

µmµm

220 µm220 µm

35 µm35 µm

CVVH 人工腎臟特性

The membrane geometry was adapted to meet the specific needs in CRRT

Increased inner lumen: Decreased wall thickness:

200 µm200 µm

40 µm40 µm

WallthicknesWallthicknes

ss

40 µm40 µm

Inner Inner

lumen 200 lumen 200

µmµm

血液透析之人工腎臟

Fresenius Polysulfone® :Fibre structure No pores filling agent Not wettable: no swelling Consistency of fibre geometry

40

1

Dialysate side

Blood side