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CRRT options in the ICU
CRRT options in the ICU
CRRT options in the ICU
CRRT options in the ICU
CRRT options in the ICU
CRRT options in the ICU
CRRT options in the ICU
CRRT options in the ICU
CRRT options in the ICU
CRRT options in the ICU
CRRT options in the ICU
CRRT options in the ICU
CRRT options in the ICU
CRRT options in the ICU
CRRT options in the ICU
CRRT options in the ICU
CRRT options in the ICU
CRRT options in the ICU
CRRT options in the ICU
CRRT options in the ICU
CRRT options in the ICU
CRRT options in the ICU
CRRT options in the ICU
CRRT options in the ICU
CRRT options in the ICU
CRRT options in the ICU
CRRT options in the ICU
CRRT options in the ICU
CRRT options in the ICU
CRRT options in the ICU
CRRT options in the ICU
CRRT options in the ICU
CRRT options in the ICU
CRRT options in the ICU
CRRT options in the ICU
CRRT options in the ICU
CRRT options in the ICU
CRRT options in the ICU
CRRT options in the ICU
CRRT options in the ICU
CRRT options in the ICU
CRRT options in the ICU
CRRT options in the ICU
CRRT options in the ICU
CRRT options in the ICU
CRRT options in the ICU
CRRT options in the ICU
CRRT options in the ICU
CRRT options in the ICU
CRRT options in the ICU
CRRT options in the ICU
CRRT options in the ICU
CRRT options in the ICU
CRRT options in the ICU
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CRRT options in the ICU

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    • 1. It’s April…Your Patient has Acute Renal Failure…Now What? Critical Care Grand Rounds Jennifer Hancock, MD, FRCPC, CCM Jan 15, 2009
    • 2. Objectives <ul><li>Discuss the epidemiology of renal failure in the ICU according to the RIFLE criteria </li></ul><ul><li>Review the pathophysiology ATN </li></ul><ul><li>Discuss the practical aspects of CRRT including the different modes, timing, dosing and anticoagulation </li></ul><ul><li>Discuss future applications of RRT in the ICU setting </li></ul>
    • 3. Case 1 <ul><li>70 kg 80yr  post-op emergency AAA </li></ul><ul><li>Supra-renal x-clamp 60mins, massive transfusion </li></ul><ul><li>Post-op: </li></ul><ul><ul><li>FiO 2 100%, Sats 88%, CXR volume O/L </li></ul></ul><ul><ul><li>BP 100/60 on levo 0.2 ug/kg/min, CVP 18 </li></ul></ul><ul><ul><li>Aneuric despite a lasix trial </li></ul></ul><ul><ul><li>pH 7.12/28/55/10 K 5.3 </li></ul></ul><ul><li>Decision is made to start dialysis </li></ul>
    • 4. Case 2 <ul><li>45 year old male admitted with septic shock and MOF secondary to pneumonia. Treated with antibiotics, resuscitation, steroids, pressors and APC </li></ul><ul><li>By ICU Day 3: </li></ul><ul><ul><li>Intubated FiO2 60% sats 90% </li></ul></ul><ul><ul><li>CVP 14, levo 0.15ug/kg/min </li></ul></ul><ul><ul><li>pH 7.34, HCO3 18, K 4.3, Cr 325 </li></ul></ul><ul><ul><li>No uremic complications </li></ul></ul><ul><ul><li>Urine O/P ~10cc/hr, </li></ul></ul><ul><ul><li>Running balance +13L </li></ul></ul>
    • 5. Both patients have ARF presumed secondary to ATN… Now what????
    • 6. Why Worry About Acute Renal Failure? <ul><li>Common problem </li></ul><ul><ul><li>Reported incidence of 5-25% </li></ul></ul><ul><li>Serious problem </li></ul><ul><ul><li>Mortality ranges from 30-90% </li></ul></ul><ul><ul><li>Approaches 100% if 3 organ systems fail simultaneously </li></ul></ul><ul><ul><ul><ul><ul><li> </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li> Crit Care Med 2006;34:1913-1917 </li></ul></ul></ul></ul></ul>
    • 7. Acute Dialysis Quality Initiative: RIFLE Criteria GFR Criteria U/O Criteria Cr  1.5X N GFR  &gt;25% Cr  2X N GFR  &gt;50% Cr  3XN or &gt;354 GFR  &gt;75% &lt;0.5 cc/kg/hr X 6hr &lt;0.5 cc/kg/hr X 12hr &lt;0.3cc/kg/hr X 24hr Persistent loss &gt; 4wks ESRD &gt;3/12 R isk I njury F ailure L oss E SKD Crit Care Med 2004;8:204-212
    • 8. Validation of the RIFLE Criteria <ul><li>Incidence of ARF: </li></ul><ul><li>Risk: 9-10% </li></ul><ul><li>Injury: 4.5-5% </li></ul><ul><li>Failure: 3.7-3.4% </li></ul><ul><li>Mortality Rates: </li></ul><ul><li>Risk: 15-22% </li></ul><ul><li>Injury: 29-41% </li></ul><ul><li>Failure: 41-51% </li></ul>Australian study of 21,000 patients Crit Care Med 2006;34:1913-1917
    • 9. Acute Renal Failure in the ICU <ul><li>International multi-centered prospective study of 29269 patients </li></ul><ul><ul><li>5.7% developed ARF </li></ul></ul><ul><ul><li>52% ICU mortality, 60% Hospital mortality </li></ul></ul><ul><ul><li>13.8% of survivors needed RRT at discharge </li></ul></ul>
    • 10. What Has Happened to the Kidneys? <ul><li> MAP sensed by receptors </li></ul><ul><li> sympathetic tone, Renin/ATII, ADH </li></ul><ul><li>Renal vasoconstriction =  renal flow &amp; GFR =  pO2 of the medulla </li></ul><ul><li>?differences in sepsis </li></ul><ul><ul><li>RBF may  and tone  in sepsis </li></ul></ul><ul><ul><li>Inflammatory mediators </li></ul></ul><ul><ul><li>Microthrombi </li></ul></ul>NEJM 1995:332;647 Crit Care Med 2008:36;S198
    • 11. So What…How Do We Help? <ul><li>Diuretics </li></ul><ul><ul><li> pO 2 in medulla from 16 to 35 mmHg </li></ul></ul><ul><ul><li> urine O/P “flush out tubules” </li></ul></ul><ul><ul><li>Multiple studies show no benefit and potentially harm </li></ul></ul><ul><li>Fenoldapam/Dopamine </li></ul><ul><ul><li>No Benefit </li></ul></ul><ul><li>Dialysis </li></ul><ul><ul><li>IHD </li></ul></ul><ul><ul><li>CRRT </li></ul></ul><ul><ul><li>SLEDD </li></ul></ul>
    • 12. Acute Dialysis Options: What do we know? <ul><li>No difference in mortality outcomes regardless of mode of dialysis </li></ul><ul><li>Some patients do not tolerate IHD </li></ul><ul><ul><li>Symptomatic  BP occurs in 15-50% of IHD Am J Nephrol 1990;10(3):177-80 </li></ul></ul><ul><li>CRRT </li></ul><ul><ul><li>Enhanced hemodynamic stability </li></ul></ul><ul><ul><li>Increased net salt and water removal </li></ul></ul><ul><ul><li>Potentially improved renal recovery </li></ul></ul><ul><ul><li>Better preservation of cerebral perfusion </li></ul></ul>
    • 13. Timing of RRT <ul><li>Conventional indications </li></ul><ul><li>Observational studies suggest that “earlier initiation” may improve outcomes </li></ul><ul><li>Volume overload </li></ul><ul><ul><li>i </li></ul></ul><ul><ul><li>Surgical patients: </li></ul></ul><ul><ul><ul><li>Restricting fluids  anastomotic leaks, sepsis, bleeding, return to OR, dehiscence </li></ul></ul></ul>J Card Surg 2004:17 Clin J Am Soc Nephrol 2006;915  lung function  vent free days  ICU stay NEJM 2006:354;2564 Ann Surg 2003:238;641
    • 14. QEII CRRT Orders <ul><li>Filters </li></ul><ul><li>Mode of dialysis </li></ul><ul><li>Calculating dose </li></ul><ul><li>Anticoagulation </li></ul><ul><li>Replacement Solutions </li></ul>
    • 15. CRRT Filters <ul><li>ST100 is an AN69 membrane </li></ul><ul><ul><li>Increased risk of anaphylactoid reactions in patients taking an ACE inhibitor </li></ul></ul><ul><li>HF1000 is a PAES membrane </li></ul>
    • 16. CRRT Mode <ul><li>CVVHD </li></ul><ul><ul><li>Continuous Venovenous Hemodialysis </li></ul></ul><ul><li>CVVH </li></ul><ul><ul><li>Continuous Venovenous Hemofiltration </li></ul></ul><ul><li>CVVHDF </li></ul><ul><ul><li>Continuous Venovenous Hemodiafiltration </li></ul></ul><ul><li>SCUF </li></ul><ul><ul><li>Slow Continuous Ultrafiltration </li></ul></ul>
    • 17. CVVHD - Hemodialysis <ul><li>Diffusion of solutes passively down a concentration gradient </li></ul><ul><ul><li>Na, Urea, Creatinine move from blood to dialysate </li></ul></ul><ul><ul><li>HCO 3 , Ca move from dialysate to blood </li></ul></ul>Blood from patient Blood to patient Dialysate flow
    • 18. CVVH - Hemofiltration <ul><li>The hydrostatic pressure gradient induces convection of water across the membrane. The frictional forces between the solutes and water results in transport of small and middle weight molecules. </li></ul>Blood from patient Blood to patient High Pressure Low Pressure Replacement Fluid
    • 19. CVVHDF - HemoDiafiltration <ul><li>A combination of both CVVH and CVVHD </li></ul>Blood from patient Blood to patient Dialysate flow High Pressure Low Pressure Replacement Fluid High Concentration Low Concentration
    • 20. CRRT Practice Patterns Crit Care Resus 2008: 10; 225
    • 21. Dosing in All Causes of ARF <ul><li>ATN Study </li></ul><ul><ul><li>Intensive therapy (CVVHDF 35 ml/kg/hr) vs. less intensive therapy (CVVHDF 20 ml/kg/hr) </li></ul></ul><ul><ul><li>&gt;50 % of patients ARF related to sepsis </li></ul></ul><ul><ul><li>Average APACHE II 26 </li></ul></ul>NEJM 2008:359;E1
    • 22. Determining Dose in CVVHDF <ul><li>Dialysis Dosing = Effluent Rate </li></ul><ul><li>Effluent Rate = Dialysate flow + Replacement Rate </li></ul><ul><li>For a 70 kg person at 20ml/kg/hr </li></ul><ul><ul><li>= 1400 ml/hr </li></ul></ul><ul><ul><li>= 700 ml/hr dialysate flow &amp; 700 ml/hr replacement rate </li></ul></ul>
    • 23. Dialysis Dosing at the QEII
    • 24. Sepsis, Dosing &amp; Hemofiltration <ul><li>High volume hemofiltration is aimed at non-selectively removing both pro and anti-inflammatory mediators </li></ul><ul><ul><li>Prospective study of 15 septic patients receiving HVHF (85 ml/kg/hr X 6 hr) then 35 ml/kg/hr </li></ul></ul><ul><ul><li>Mortality 48% vs. predicted mortality of 72% APACHEII and 69% SAPS </li></ul></ul>Semin Dial 2006:19;69
    • 25. Sepsis, Dosing &amp; Hemofiltration <ul><li>Pilot study of 20 septic patients </li></ul><ul><ul><li>Randomized to HVHF (65 ml/kg/hr) or LVHF (35ml/kg/hr) </li></ul></ul><ul><ul><ul><li>HVHF  norepi dose and  urine O/P </li></ul></ul></ul><ul><ul><ul><li>No mortality difference </li></ul></ul></ul><ul><li>IVOIRE study </li></ul><ul><ul><li>Randomized multi-centered European study </li></ul></ul><ul><ul><li>Septic patients to HVHF (70 ml/kg/hr) vs. LVHF (35 ml/kg/hr) </li></ul></ul><ul><ul><li>Recruitment due to end Dec 2008 </li></ul></ul>Intensive Care Med 2008: 34; 1646
    • 26. Anticoagulation <ul><li>Clotting and the CRRT circuit </li></ul><ul><ul><li>Multifactorial: </li></ul></ul><ul><ul><ul><li>Patients with hypercoaguable states </li></ul></ul></ul><ul><ul><ul><li>Procoagulation effect of the circuit </li></ul></ul></ul><ul><ul><ul><li>Low blood flow rates </li></ul></ul></ul><ul><ul><ul><li>High convective transfer with CVVH or CVVHDF </li></ul></ul></ul><ul><ul><ul><li>Time responding to machine alarms </li></ul></ul></ul><ul><ul><li>Effects: </li></ul></ul><ul><ul><ul><li>Less effective dialysis </li></ul></ul></ul><ul><ul><ul><li>Loss of blood in the circuit </li></ul></ul></ul><ul><ul><ul><li>Increased costs </li></ul></ul></ul>
    • 27. Types of Anticoagulation <ul><li>Systemic </li></ul><ul><ul><li>Heparin </li></ul></ul><ul><ul><ul><li> Antithrombin III activity  s Xa and IIa activity </li></ul></ul></ul><ul><ul><ul><li>Problem if high bleeding risk </li></ul></ul></ul><ul><ul><ul><li>Risk of HITT </li></ul></ul></ul><ul><ul><li>Reports of use of APC and argactaban </li></ul></ul><ul><li>Regional </li></ul><ul><ul><li>Citrate </li></ul></ul><ul><ul><li>Prostacyclin </li></ul></ul>
    • 28. Prostacyclin <ul><li>Prostacyclin and prostaglandin E1 inhibits platelet activation </li></ul><ul><li>Short acting </li></ul><ul><li>Systemic hypotension, H/A, flushing </li></ul><ul><li>Filter life without any additional heparin only ~15 hours </li></ul><ul><li>Very expensive! </li></ul>Crit Care 2007:11;218
    • 29. Regional Citrate <ul><li>Citrate chelates Ca </li></ul><ul><li>iCa &lt; 0.35 inhibits coagulation </li></ul><ul><li>Citrate clearance </li></ul><ul><ul><li>Partially diffusion and convection </li></ul></ul><ul><ul><li>Partially enters circulation </li></ul></ul><ul><li>1 citrate metabolized by the liver and skeletal muscle to 3 HCO 3 </li></ul>
    • 30. Citrate Anticoagulation Filter Effluent Waste Citrate Ca Replacement Fluid
    • 31. Citrate Anticoagulation <ul><li>Pros </li></ul><ul><ul><li>No systemic anticoagulation </li></ul></ul><ul><ul><li>Can be used with suspected HITT patients </li></ul></ul><ul><ul><li>Possibly longer filter life </li></ul></ul><ul><ul><ul><li>Heparin ~48hr </li></ul></ul></ul><ul><ul><ul><li>Citrate ~72 hr </li></ul></ul></ul><ul><li>Cons </li></ul><ul><ul><li>More complicated system </li></ul></ul><ul><ul><ul><li>Citrate and calcium infusions </li></ul></ul></ul><ul><ul><li>Needs close monitoring </li></ul></ul><ul><ul><ul><li>Especially in liver patients! </li></ul></ul></ul><ul><ul><ul><li>Hypo/hyper calcemia </li></ul></ul></ul><ul><ul><ul><li>Metabolic Alkalosis </li></ul></ul></ul><ul><ul><ul><li>Metabolic Acidosis </li></ul></ul></ul>Crit Care 2007:11;218
    • 32. Citrate Toxicity &amp; the Citrate Ratio <ul><li>Citrate accumulation may occur if: </li></ul><ul><ul><li>Unintentional citrate over infusion </li></ul></ul><ul><ul><li>Decreasing liver function </li></ul></ul><ul><ul><li>Decreasing function of the filter </li></ul></ul><ul><li>Results in: </li></ul><ul><ul><li>Hypocalcemia </li></ul></ul><ul><ul><li>Metabolic Acidosis </li></ul></ul><ul><li>Citrate Ratio: [Total Ca2+]/[ iCa2+] </li></ul><ul><ul><li>Measured q12h </li></ul></ul><ul><ul><li>Ratio &gt; 2.5 stop citrate anticoagulation! </li></ul></ul>
    • 33. Anticoagulation at the QEII <ul><li>Two options: </li></ul><ul><ul><li>Citrate anticoagulation </li></ul></ul><ul><ul><ul><li>Citrate infusion pre-printed orders </li></ul></ul></ul><ul><ul><ul><ul><li>Post filter iCa 0.25-0.35 mmol/L </li></ul></ul></ul></ul><ul><ul><ul><li>Calcium infusion pre-printed orders </li></ul></ul></ul><ul><ul><ul><ul><li>Systemic iCa 1.0-1.35 mmol/L </li></ul></ul></ul></ul><ul><ul><li>No anticoagulation </li></ul></ul><ul><ul><ul><li>Use if patient on systemic anticoagulation for other reasons </li></ul></ul></ul><ul><ul><ul><li>Severe liver disease </li></ul></ul></ul>
    • 34. Replacement Solutions <ul><li>Prismocal </li></ul><ul><ul><li>Calcium 0 mmol/L </li></ul></ul><ul><ul><li>Mg 0.5 mmol/L </li></ul></ul><ul><ul><li>Cl 106 mmol/L </li></ul></ul><ul><ul><li>Na 140 mmol/L </li></ul></ul><ul><ul><li>Lactate 3 mmol/L </li></ul></ul><ul><ul><li>Bicarb 32 mmol/L </li></ul></ul>
    • 35. QEII Citrate Orders
    • 36. No Anticoagulation Orders
    • 37. Starting someone on CRRT at the QEII <ul><li>Joint process between both the Division of Critical Care and the Division of Nephrology </li></ul><ul><li>ICU must contact nephrology before starting any patient on CRRT </li></ul><ul><ul><li>This may be in the form of a phone consultation </li></ul></ul><ul><li>Lines to be inserted by ICU </li></ul><ul><li>Orders can be written by either ICU or Nephrology </li></ul>
    • 38. Starting someone on CRRT at the QEII <ul><li>Indications </li></ul><ul><ul><li>Hemodynamically unstable (defined as already requiring vasopressors or inotropes to maintain blood pressure) </li></ul></ul><ul><ul><li>The patient became hemodynamically unstable (requiring vasopressors of inotropes to maintain blood pressure) during a previous IHD or SLEDD run </li></ul></ul><ul><li>In the initial implementation stages of CRRT at the QEII only 1 patient per unit will be on CRRT at a time, even if there is another patient hemodynamically unstable who requires dialysis. </li></ul>
    • 39. Starting someone on CRRT at the the QEII <ul><li>Also during the implementation stages, CRRT will be the preferred mode of dialysis provided to unstable patients (over SLEDD) </li></ul><ul><li>Patients would not be a candidate for CRRT regardless of their hemodynamic status if: </li></ul><ul><ul><li>The patient has taken an overdose that requires dialysis </li></ul></ul><ul><ul><li>The patient is presenting with acute hyperkalemia refractory to medical management </li></ul></ul>
    • 40. Putting it Together <ul><li>Case 1 </li></ul><ul><ul><li>70 kg 80 yr female </li></ul></ul><ul><ul><li>Volume overload </li></ul></ul><ul><ul><li>Poor oxygenation </li></ul></ul><ul><ul><li>MA - HCO3 10 </li></ul></ul><ul><ul><li>K - 5.5 </li></ul></ul><ul><ul><li>No reason to avoid citrate </li></ul></ul>
    • 41. &nbsp;
    • 42. &nbsp;
    • 43. Remember: Dose = Replacement + Dialysate Dose = 70kg x 20ml/kg/hr =1.4 L/hr 1/2 given as replacement and dialysate
    • 44. &nbsp;
    • 45. &nbsp;
    • 46. Putting it together…. <ul><li>Case 2 </li></ul><ul><li>85 kg 45 year old male with sepsis induced acute renal failure on APC </li></ul><ul><ul><li>No conventional indications for dialysis </li></ul></ul><ul><ul><ul><li>Sats ok on 60% </li></ul></ul></ul><ul><ul><ul><li>Metabolically stable </li></ul></ul></ul><ul><ul><ul><li>No uremic changes </li></ul></ul></ul><ul><ul><li>However 12.5L +ve cumulative balance, no renal recovery and acute lung injury </li></ul></ul><ul><ul><li>Temp: 39.2 </li></ul></ul>
    • 47. &nbsp;
    • 48. &nbsp;
    • 49. Remember: Dose = Replacement + Dialysate Dose = 85kg x 20ml/kg/hr =1.7 L/hr 1/2 given as replacement and dialysate
    • 50. &nbsp;
    • 51. Drugs and Dialysis <ul><li>Not Straight Forward! </li></ul><ul><ul><li>CVVH clearance </li></ul></ul><ul><ul><li>CVVHD clearance </li></ul></ul><ul><li>Will need much input from pharmacy </li></ul><ul><li>Loading doses shouldn’t be altered…it’s the maintenance that will need adjustment </li></ul>Sieving Coefficient Protein Binding Membrane Type Ultrafiltration Rate Molecular Size
    • 52. Future Directions <ul><li>Plasma Exchange </li></ul><ul><li>High Volume CVVH in septic patients?? </li></ul><ul><ul><li>Waiting results of the IVOIRE study </li></ul></ul><ul><li>Liver dialysis? </li></ul><ul><ul><li>Molecular Adsorbents Recirculating System (MARS) </li></ul></ul><ul><ul><li>Albumen dialysis </li></ul></ul><ul><ul><li>Small studies suggest improved encephalopathy </li></ul></ul>
    • 53. &nbsp;
    • 54. &nbsp;

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