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CRRT Continue Renal Replacement Therapy

CRRT Continue Renal Replacement Therapy. CVVH CVVHD CVVHDF. Indications. In critically ill patients with renal failure and hemodynaemic instability

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CRRT Continue Renal Replacement Therapy

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  1. CRRTContinue Renal Replacement Therapy • CVVH • CVVHD • CVVHDF

  2. Indications • In critically ill patients with renal failure and hemodynaemic instability • For patients in whom continuous removal of volume or toxic substance is desirable ( as in septic shock , AMI , severe GI bleeding ,ARDS or condition with or at risk for cerebral edema ….)

  3. Procedure共同處 • Driving force : external pump • Circuit : Venovenous • Dialysis solutions :一般使用1.5% PD solution • Replacement fluid : several types of replacement fluid can be used , depending on patient requirements ,一般使用 pre-dilution 方式.

  4. Anti-coagulation 的方式 • STANDARD HEPARIN • TYPICAL REGIMEN IN CRRT : • Priming of the circuit ( 5000 IU / L ) • Initial Heparin Bolus : 5 - 8 IU / kg • 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

  5. STANDARD HEPARIN • ADVANTAGES • Easy to perform • Useful method • Inexpensive • DISADVANTAGES • Occasional Thrombocytopenia • Hemorrhagic Risk with Bleeding patient

  6. LOW MOLECULAR WEIGHT (LMW) HEPARIN • TYPICAL REGIMEN IN CRRT : • Priming of the circuit : 20 mg in 1 L • Maintenance dose : 10 to 40 mg q6 hrs • Monitor anti- factor Xa (aXa) units . Adjust between 0.1 and 0.4 µ/ml • Different Dosages for LMW heparin

  7. LOW MOLECULAR WEIGHT (LMW) HEPARIN • DISADVANTAGES • Expensive • Special and difficult monitoring • With low doses frequent filter clotting • ADVANTAGES • Decreased Risk of Bleeding

  8. Regional Citrate Anticoagulation • TYPICAL REGIMEN : • Citrate anticoagulation is always regional • Citrate infusion (4%) at 170 ml/hr initially • Special Dialysate at 1 liter/hr ( Na+ 117 , K+ 4 , Mg++ 1.5 , Cl- 121.5 , dextrose 0.5- 2.5% , no Ca++ , no base ) • CaCL2 (0.75%) by central I.V at 40-60 ml/hr, • Maintain ionized Ca++ at 0.96- 1.20 mmol/L

  9. Citrate • ADVANTAGES : • No Bleeding • No Thrombocytopenia • Improved Filter Life and Efficacy • DISADVANTAGES : • Complex for the set up • Ca++ monitoring needed • Occasional Alkalosis

  10. Heparin- free methos • Normal saline flush • Used in patients with 1. Severe liver disease 2. Acitve or recent bleeding 3. Heparine-induced thrombocytopenia 4. Post-op patients

  11. Dialysis modalities in the ICU

  12. P R I S M A CVVH配置簡圖 CVVHContinuous Veno-Venous Hemofiltration CVVH 模式下, 置換液流速 最高可達4500ml/hr

  13. CVVH order lPrepare Heparin 2cc + N/S 3cc, then inject 1.6cc into each femoral cath. lFor AK priming: (GAMBRO, Polyarylethersulfone, 6S) *1st N/S 1000cc. *2nd Heparin 2,500U. *3rd N/S 500cc. l*Prepare Heparin 25,000U + N/S 500cc IVD 10cc/hr with pump to keep aPPT 1.5-2 and adjust as followed: aPPT bolus hold dose(cc/hr) <1.0 2000U - +4 1.0-1.5 - - +2 1.5-2.0 - - - 2.0-2.5 - 30min -2 >2.5 - 60min -4

  14. CVVH order • If non-heparin , N/S 200cc q ½ hr to rinse the AK • Predilution run 500cc/hr alternately as followed via artery end 1st bottle N/S 500cc + Sinca 1amp 2nd bottle N/S 500cc + 10% MgSO4 4cc 3rd bottle N/S 500cc 4th bottle D5W 500cc + NaHCO3 5amp • Warm dialysate to 37C • Record I/O and BP q1hr • UF target I-O ( ) cc/hr • Check BUN,Crea,Na,K,Cl,aPPT q6hr for 1 day & then q8hr. • Check Ca,P,Mg qd.

  15. P R I S M A S CVVHD配置簡圖 CVVHDContinuous Veno-Venous Hemodialysis

  16. CVVHD order lPrepare Heparin 2cc + N/S 3cc, then inject 1.6cc into each femoral cath. lFor AK priming: (GAMBRO, Polyarylethersulfone, 6S) *1st N/S 1000cc. *2nd Heparin 2,500U. *3rd N/S 500cc. l*Prepare Heparin 25,000U + N/S 500cc IVD 10cc/hr with pump to keep aPPT 1.5-2 and adjust as followed: aPPT bolus hold dose(cc/hr) <1.0 2000U - +4 1.0-1.5 - - +2 1.5-2.0 - - - 2.0-2.5 - 30min -2 >2.5 - 60min -4

  17. CVVHD order • If non-heparin , N/S 200cc q ½ hr to rinse the AK • 1.5% PD solution 500cc/hr run as dailysate • Warm dialysate to 37C • Record I/O and BP q1hr • UF target I-O ( ) cc/hr • Check BUN,Crea,Na,K,Cl,aPPT q6hr for 1 day & then q8hr. • Check Ca,P,Mg qd.

  18. P R I S M A S CVVHDF配置簡圖 CVVHDFContinuous Veno-Venous Hemodiafiltration

  19. CVVHDF order lPrepare Heparin 2cc + N/S 3cc, then inject 1.6cc into each femoral cath. lFor AK priming: (GAMBRO, Polyarylethersulfone, 6S) *1st N/S 1000cc. *2nd Heparin 2,500U. *3rd N/S 500cc. l*Prepare Heparin 25,000U + N/S 500cc IVD 10cc/hr with pump to keep aPPT 1.5-2 and adjust as followed: aPPT bolus hold dose(cc/hr) <1.0 2000U - +4 1.0-1.5 - - +2 1.5-2.0 - - - 2.0-2.5 - 30min -2 >2.5 - 60min -4

  20. CVVHDF order • If non-heparin , N/S 200cc q ½ hr to rinse the AK • Predilution run 500cc/hr alternately as followed via artery end 1st bottle N/S 500cc + Sinca 1amp 2nd bottle N/S 500cc + 10% MgSO4 4cc 3rd bottle N/S 500cc 4th bottle D5W 500cc + NaHCO3 5amp • 1.5% PD solution 500cc/hr run as dailysate • Warm predilution and dialysate to 37C • Record I/O and BP q1hr • UF target I-O ( ) cc/hr • Check BUN,Crea,Na,K,Cl,aPPT q6hr for 1 day & then q8hr. • Check Ca,P,Mg qd.

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