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CVVH.ppt

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  • i am currently completing a poster on the use of cvvhdf, i was wondering if i could have permission to use this image in my work? i am assuming with the fact it can be shared and downloaded that this would be ok but wanted to check. thanks
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CVVH.ppt

  1. 1. Renal Replacement Therapy Children’s Healthcare of Atlanta
  2. 2. Renal Replacement Therapy <ul><li>What is it? </li></ul><ul><ul><li>The medical approach to providing the electrolyte balance, fluid balance, and toxin removal functions of the kidney. </li></ul></ul><ul><li>How does it work? </li></ul><ul><ul><li>Uses concentration and pressure gradients to remove solutes (K, Urea, etc…) and solvents (water) from the human body. </li></ul></ul>
  3. 3. Where did it come from? <ul><li>In Germany during 1979, Dr. Kramer inadvertently cannulated the femoral artery of a patient which led to a spontaneous experiment with CAVH (continuous arteriovenous hemofiltration) </li></ul><ul><ul><li>The patient's cardiac function alone is capable of driving the system </li></ul></ul><ul><ul><li>Large volumes of ultrafiltrate were produced through the highly permeable hemofilter </li></ul></ul><ul><ul><li>Continuous arteriovenous hemofiltration could provide complete renal replacement therapy in an anuric adult </li></ul></ul>
  4. 4. History of Pediatric Hemofiltration <ul><li>USA, 1985: Dr. Liebermann used SCUF (slow continuous ultrafiltration) to successfully support an anuric neonate with fluid overload </li></ul><ul><li>Italy, 1986: Dr. Ronco described the successful use of CAVH in four neonates </li></ul><ul><li>USA, 1987: Dr. Leone described CAVH in older children </li></ul><ul><li>1993: A general acceptance of pump-driven CVVH was seen as less problematic than CAVH </li></ul>
  5. 5. <ul><li>In 1984, Dr. Claudio Ronco, treated this child with CAVH in Vicenza, Italy. This is the first patient purposely treated with CAVH in the world. The patient survived. </li></ul>
  6. 6. Mechanisms of Action: Convection <ul><li>Hydrostatic pressure pushes solvent across a semi-permeable membrane </li></ul><ul><li>Solute is carried along with solvent by a process known as “solvent drag” </li></ul><ul><li>Membrane pore size limits molecular transfer </li></ul><ul><li>Efficient at removal of larger molecules compared with diffusion </li></ul> Pressure Na H 2 O H 2 O + Na
  7. 7. <ul><li>Solvent moves up a concentration gradient </li></ul><ul><li>Solute diffuses down an concentration gradient </li></ul><ul><ul><li>Solute movement occurs via Brownian motion </li></ul></ul><ul><ul><ul><li>The smaller the molecule (e.g. urea) the greater the kinetic energy </li></ul></ul></ul><ul><ul><ul><li>The larger the concentration gradient the more drive for movement </li></ul></ul></ul><ul><ul><ul><li>Therefore, smaller molecules with greater concentration gradients move more quickly across membrane </li></ul></ul></ul>Mechanisms of Action: Diffusion  Osmolarity H 2 O H 2 O  Osmolarity Urea Urea Uremia
  8. 8. Semi-permeable Membranes <ul><ul><li>Urea </li></ul></ul><ul><ul><li>Creatinine </li></ul></ul><ul><ul><li>Uric acid </li></ul></ul><ul><ul><li>Sodium </li></ul></ul><ul><ul><li>Potassium </li></ul></ul><ul><ul><li>Ionized calcium </li></ul></ul><ul><ul><li>Phosphate </li></ul></ul><ul><ul><li>Almost all drugs not bound to plasma proteins </li></ul></ul><ul><ul><li>Bicarbonate </li></ul></ul><ul><ul><li>Interleukin-1 </li></ul></ul><ul><ul><li>Interleukin-6 </li></ul></ul><ul><ul><li>Endotoxin </li></ul></ul><ul><ul><li>Vancomycin </li></ul></ul><ul><ul><li>Heparin </li></ul></ul><ul><ul><li>Pesticides </li></ul></ul><ul><ul><li>Ammonia </li></ul></ul><ul><li>Allow easy transfer of solutes less than 100 Daltons </li></ul><ul><li>Are impermeable to albumin and other solutes of greater than 50,000 Daltons </li></ul>
  9. 9. Semi-permeable Membranes <ul><li>Sieving Coefficient </li></ul><ul><ul><li>Defines amount (clearance) of molecule that crosses semi-permeable membrane </li></ul></ul><ul><li>Sieving Coefficient is “1” for molecules that easily pass through the membrane and “0” for those that do not </li></ul>
  10. 10. Semi-permeable Membranes <ul><li>Continuous hemofiltration membranes consist of relatively straight channels of ever-increasing diameter that offer little resistance to fluid flow </li></ul><ul><li>Intermittent hemodialysis membranes contain long, tortuous inter-connecting channels that result in high resistance to fluid flow </li></ul>
  11. 11. How is it done? <ul><li>Peritoneal Dialysis </li></ul><ul><li>Hemodialysis </li></ul><ul><li>Hemofiltration </li></ul><ul><li>The choice of which modality to use depends on </li></ul><ul><ul><li>Patient’s clinical status </li></ul></ul><ul><ul><li>Resources available </li></ul></ul>
  12. 12. Peritoneal Dialysis <ul><li>Fluid placed into peritoneal cavity by catheter </li></ul><ul><li>Glucose provides solvent gradient for fluid removal from body </li></ul><ul><li>Can vary concentration of electrolytes to control hyperkalemia </li></ul><ul><li>Can remove urea and metabolic products </li></ul><ul><li>Can be intermittent or continuously cycled </li></ul>
  13. 13. Peritoneal dialysis <ul><li>Simple to set up & perform </li></ul><ul><li>Easy to use in infants </li></ul><ul><li>Hemodynamic stability </li></ul><ul><li>No anti-coagulation </li></ul><ul><li>Bedside peritoneal access </li></ul><ul><li>Treat severe hypothermia or hyperthermia </li></ul><ul><li>Unreliable ultrafiltration </li></ul><ul><li>Slow fluid & solute removal </li></ul><ul><li>Drainage failure & leakage </li></ul><ul><li>Catheter obstruction </li></ul><ul><li>Respiratory compromise </li></ul><ul><li>Hyperglycemia </li></ul><ul><li>Peritonitis </li></ul><ul><li>Not good for hyperammonemia or intoxication with dialyzable poisons </li></ul>Advantages Disadvantages
  14. 14. Intermittent Hemodialysis <ul><li>Maximum solute clearance of 3 modalities </li></ul><ul><li>Best therapy for severe hyperkalemia </li></ul><ul><li>Limited anti-coagulation time </li></ul><ul><li>Bedside vascular access can be used </li></ul><ul><li>Hemodynamic instability </li></ul><ul><li>Hypoxemia </li></ul><ul><li>Rapid fluid and electrolyte shifts </li></ul><ul><li>Complex equipment </li></ul><ul><li>Specialized personnel </li></ul><ul><li>Difficult in small infants </li></ul>Advantages Disadvantages
  15. 15. Continuous Hemofiltration <ul><li>Easy to use in PICU </li></ul><ul><li>Rapid electrolyte correction </li></ul><ul><li>Excellent solute clearances </li></ul><ul><li>Rapid acid/base correction </li></ul><ul><li>Controllable fluid balance </li></ul><ul><li>Tolerated by unstable patients </li></ul><ul><li>Early use of TPN </li></ul><ul><li>Bedside vascular access routine </li></ul><ul><li>Systemic anticoagulation (except citrate) </li></ul><ul><li>Frequent filter clotting </li></ul><ul><li>Vascular access in infants </li></ul>Advantages Disadvantages
  16. 16. SCUF:Slow Continuous Ultrafiltration Blood is pushed through a hemofilter Pressure generated within filter pushes solvent (serum) through semi-permeable membrane (convection) Solutes are carried through membrane by a process known as “solvent drag” Control rate of fluid removal Urea Creatinine K Na H 2 O Blood Ultrafiltrate  Pressure
  17. 17. SCUF:Slow Continuous Ultrafiltration <ul><li>Pros </li></ul><ul><ul><li>Filters blood effectively </li></ul></ul><ul><ul><li>Control fluid balance by regulating transmembrane pressures </li></ul></ul><ul><ul><li>No replacement fluid therefore less pharmacy cost </li></ul></ul><ul><li>Cons </li></ul><ul><ul><li>No replacement fluid given so electrolyte abnormalities can occur </li></ul></ul><ul><ul><li>Low ultrafiltration rates that keep electrolytes balanced do not remove urea effectively </li></ul></ul>
  18. 18. CVVH Blood is pushed through a hemofilter Pressure within filter (convection) Solvent Drag Replacement fluid given back to patient Urea Creatinine K Na H 2 O Ultrafiltrate Replacement Fluid Blood  Pressure
  19. 19. Continuous Venovenous Hemofiltration <ul><li>Filtration occurs by convection </li></ul><ul><li>Mimics physiology of the mammalian kidney </li></ul><ul><ul><li>Provides better removal of middle molecules (500-5000 Daltons) thought to be responsible clinical state of uremia </li></ul></ul><ul><li>Ultrafiltrate is replaced by a sterile solution (replacement solution) </li></ul><ul><li>Patient fluid loss (or gain) results from the difference between ultrafiltration and replacement rates </li></ul>
  20. 20. CVVHD Blood is pushed through a hemofilter Dialysis fluid flows counter- current to blood flow Water and Solutes move across concentration gradients (diffusion) Urea Creatinine K Na H 2 O Dialysate Blood Dialysis Fluid
  21. 21. Continuous Venovenous Hemodialysis <ul><li>Diffusion (predominantly) </li></ul><ul><ul><li>Some convection occurs due to transmembrane pressure created by roller-head pump </li></ul></ul><ul><li>Dialysate flow rate is slower than BFR and is the limiting factor to solute removal </li></ul><ul><ul><li>Therefore, solute removal is directly proportional to dialysate flow rate </li></ul></ul>
  22. 22. CVVHDF Blood is pushed through a hemofilter Dialysis fluid flows counter- current to blood flow Water and Solutes move across concentration gradients (diffusion) Pressure within filter (convection) Solvent Drag Replacement fluid given back to patient Urea Creatinine K Na H 2 O Replacement Fluid Blood Dialysis Fluid Dialysate  Pressure
  23. 23. Continuous Venovenous Hemodialysis with Ultrafiltration <ul><li>Pros </li></ul><ul><ul><li>Can provide both ultrafiltration (removal of medium size molecules) and dialysis (removal of small molecules) </li></ul></ul><ul><ul><li>Can remove toxins </li></ul></ul><ul><li>Cons </li></ul><ul><ul><li>Toxin removal is slow </li></ul></ul><ul><ul><li>Overly complicated to set-up for small clinical benefits </li></ul></ul>
  24. 24. Is there a “Best” Method? <ul><li>The greatest difference between modalities is most likely related to the membrane utilized and their specific characteristics. </li></ul><ul><li>There are no data available assessing patient outcomes using diffusive (CVVHD) and convective (CVVH) therapies </li></ul>
  25. 25. Indications for Renal Replacement Therapy <ul><li>Intractable acidosis </li></ul><ul><li>Fluid overload or pulmonary edema </li></ul><ul><li>BUN > 150 mg/dL </li></ul><ul><li>Symptomatic uremia (encephalopathy, pericarditis) </li></ul><ul><li>Hyperkalemia (serum K > 7 mEq/L) </li></ul><ul><li>Hyperammonemia </li></ul><ul><li>Ultrafiltration for nutritional support or excessive transfusions </li></ul><ul><li>Exogenous toxin removal </li></ul><ul><li>Hyponatremia or hypernatremia </li></ul>Adapted From Rogers’ Textbook of Pediatric Intensive Care, Table 38.7
  26. 26. Indicators of Circuit Function
  27. 27. Filtration Fraction <ul><li>The degree of blood dehydration can be estimated by determining the filtration fraction (FF) </li></ul><ul><ul><li>The fraction of plasma water removed by ultrafiltration </li></ul></ul><ul><li>FF(%) = (UFR x 100) / QP </li></ul><ul><ul><li>where QP is the filter plasma flow rate in ml/min </li></ul></ul><ul><li>QP = BFR* x (1-Hct) </li></ul><ul><li>*BFR: blood flow rate </li></ul>
  28. 28. Ultrafiltrate Rate <ul><li>FF(%) = (UFR x 100) / QP </li></ul><ul><li>QP = BFR x (1-Hct) </li></ul><ul><li>For example... </li></ul><ul><ul><li>When BFR = 100 ml/min & Hct = 0.30 (i.e. 30%), the QP = 70 ml/min </li></ul></ul><ul><ul><li>A filtration fraction > 30% promotes filter clotting </li></ul></ul><ul><ul><li>In this example, when the maximum allowable FF is set at 30%, a BFR of 100 ml/min yields a UFR = 21 ml/min </li></ul></ul><ul><li>QP: the filter plasma flow rate in ml/min </li></ul>
  29. 29. Blood Flow Rate & Clearance <ul><li>A child with body surface area = 1.0 m 2 , BFR = 100 ml/min and FF = 30% </li></ul><ul><ul><li>Small solute clearance is 36.3 ml/min/1.73 m 2 </li></ul></ul><ul><ul><ul><li>(About one third of normal renal small solute clearance) </li></ul></ul></ul><ul><li>Target CVVH clearance of at least 15 ml/min/1.73 m 2 </li></ul><ul><ul><li>For small children, BFR > 100 ml/min is usually unnecessary </li></ul></ul><ul><ul><li>High BFR may contribute to increased hemolysis within the CVVH circuit </li></ul></ul>
  30. 30. Pediatric CRRT Vascular Access: Performance = Blood Flow!!! <ul><li>Minimum 30 to 50 ml/min to minimize access and filter clotting </li></ul><ul><li>Maximum rate of 400 ml/min/1.73m 2 or </li></ul><ul><ul><li>10-12 ml/kg/min in neonates and infants </li></ul></ul><ul><ul><li>4-6 ml/kg/min in children </li></ul></ul><ul><ul><li>2-4 ml/kg/min in adolescents </li></ul></ul>
  31. 31. Urea Clearance <ul><li>Urea clearance (C urea) in hemofiltration, adjusted for the patient's body surface area (BSA), can be calculated as follows: </li></ul><ul><li>C urea =   UF [urea] x UFR x 1.73 </li></ul><ul><li> BUN pt’s BSA </li></ul><ul><li>In CVVH, ultrafiltrate urea concentration and BUN are the same, canceling out of the equation, which becomes: </li></ul><ul><li>C urea = UFR x 1.73 </li></ul><ul><li> pt’s BSA </li></ul><ul><li>C urea: (ml/min/1.73 m 2 BSA) </li></ul>
  32. 32. Urea Clearance <ul><li>When target urea clearance (C urea) is set at 15 ml/min/1.73 m2, the equation can be solved for UFR </li></ul><ul><li>15 = UFR x 1.73 / pt’s BSA </li></ul><ul><li>UFR = 15 / 1.73 = 8.7 ml/min </li></ul><ul><li>Thus, in a child with body surface area = 1.0 m 2 , a C urea of about 15 ml/min/1.73 m 2 is obtained when UFR = 8.7 ml/min or 520 ml/hr. </li></ul><ul><li>This same clearance can be achieved in the 1.73 m 2 adolescent with a UFR = 900 ml/hr. </li></ul>
  33. 33. Solute Molecular Weight and Clearance <ul><li>Solute (MW) Convective Coefficient Diffusion Coefficient </li></ul><ul><li>Urea (60) 1.01 ± 0.05 1.01 ± 0.07 </li></ul><ul><li>Creatinine (113) 1.00 ± 0.09 1.01 ± 0.06 </li></ul><ul><li>Uric Acid (168) 1.01 ± 0.04 0.97 ± 0.04 </li></ul><ul><li>Vancomycin (1448) 0.84 ± 0.10 0.74 ± 0.04 </li></ul><ul><li>Cytokines (large) adsorbed minimal clearance </li></ul><ul><li>Drug therapy can be adjusted by using frequent blood level determinations or by using tables that provide dosage adjustments in patients with altered renal function </li></ul>
  34. 34. Fluid Balance <ul><li>Precise fluid balance is one of the most useful features of CVVH </li></ul><ul><li>Each hour, the volume of filtration replacement fluid (FRF) is adjusted to yield the desired fluid balance. </li></ul>
  35. 35. Replacement Fluids <ul><li>Ultrafiltrate can be replaced with a combination of: </li></ul><ul><ul><li>Custom physiologic solutions </li></ul></ul><ul><ul><li>Ringer’s lactate </li></ul></ul><ul><ul><li>Total parenteral nutrition solutions </li></ul></ul><ul><li>In patients with fluid overload, a portion of the ultrafiltrate volume is simply not replaced, resulting in predictable and controllable negative fluid balance. </li></ul>
  36. 36. Physiologic Replacement Fluid <ul><li>Na 135-145 mEq/L </li></ul><ul><li>K 2.5-4.5 mEq/L </li></ul><ul><li>HCO 3 25-35 mEq/l </li></ul><ul><li>Cl Balance </li></ul><ul><li>Ca 2.5 mEq/L </li></ul><ul><li>Mg 1.5 mEq/L </li></ul><ul><li>Glucose 100 mg/dL </li></ul>
  37. 37. Anticoagulation <ul><li>To prevent clotting within the CVVH circuit, active anti-coagulation is often needed </li></ul><ul><ul><li>Heparin </li></ul></ul><ul><ul><li>Citrate </li></ul></ul><ul><ul><li>Local vs. systemic </li></ul></ul>
  38. 38. Mechanisms of Filter Thrombosis CONTACT PHASE XII activation XI IX TISSUE FACTOR TF:VIIa THROMBIN fibrinogen prothrombin Xa Va VIIIa Ca ++ platelets CLOT monocytes / platelets / macrophages FIBRINOLYSIS ACTIVATION FIBRINOLYSIS INHIBITION NATURAL ANTICOAGULANTS (APC, ATIII) X Phospholipid surface Ca ++ Ca ++ Ca ++ Ca ++ Ca ++ Ca ++
  39. 39. Sites of Action of Heparin CONTACT PHASE XII activation XI IX TISSUE FACTOR TF:VIIa THROMBIN fibrinogen prothrombin Xa Va VIIIa Ca ++ platelets CLOT monocytes platelets macrophages FIBRINOLYSIS ACTIVATION FIBRINOLYSIS INHIBITION NATURAL ANTICOAGULANTS (APC, ATIII) X Phospholipid surface UF HEPARIN ATIII Ca ++ Ca ++ Ca ++ Ca ++ Ca ++ Ca ++
  40. 40. Heparin - Problems <ul><li>Bleeding </li></ul><ul><li>Unable to inhibit thrombin bound to clot </li></ul><ul><li>Unable to inhibit Xa bound to clot </li></ul><ul><li>Ongoing thrombin generation </li></ul><ul><li>Direct activation of platelets </li></ul><ul><li>Thrombocytopenia </li></ul><ul><li>Extrinsic pathway unaffected </li></ul>
  41. 41. No Heparin Systemically Heparinized NO surface - no heparin NO surface - heparinized Compliments of Dr. Gail Annich, University of Michigan
  42. 42. Unfractionated Heparin Hoffbauer R et al. Kidney Int. 1999;56:1578-1583.
  43. 43. Sites of Action of Citrate CONTACT PHASE XII activation XI IX TISSUE FACTOR TF:VIIa THROMBIN fibrinogen prothrombin Xa Va VIIIa Ca ++ platelets CLOT monocytes / platelets / macrophages FIBRINOLYSIS ACTIVATION FIBRINOLYSIS INHIBITION NATURAL ANTICOAGULANTS (APC, ATIII) X Phospholipid surface CITRATE Ca ++ Ca ++ Ca ++ Ca ++ Ca ++ Ca ++
  44. 44. Anticoagulation: Citrate <ul><li>Citrate regional anticoagulation of the CVVH circuit may be employed when systemic (i.e., patient) anticoagulation is contraindicated for any reason (usually, when a severe coagulopathy pre-exists). </li></ul><ul><li>CVVH-D helps prevent inducing hypernatremia with the trisodium citrate solution </li></ul>
  45. 45. Anticoagulation: citrate <ul><li>Citrate regional anticoagulation of the CVVH circuit: </li></ul><ul><ul><li>4% trisodium citrate ‘pre-filter’ </li></ul></ul><ul><ul><li>Replacement fluid: normal saline </li></ul></ul><ul><ul><li>Calcium infusion: 8% CaCl in NS through a distal site </li></ul></ul><ul><li>Ionized calcium in the circuit will drop to < 0.3, while the systemic calcium concentration is maintained by the infusion. </li></ul>
  46. 46. Citrate Hoffbauer R et al. Kidney Int. 1999;56:1578-1583.
  47. 47. Citrate: Problems <ul><li>Metabolic alkalosis </li></ul><ul><ul><li>metabolized in liver / skeletal muscle / other tissues </li></ul></ul><ul><li>Electrolyte disorders </li></ul><ul><ul><li>Hypernatremia </li></ul></ul><ul><ul><li>Hypocalcemia </li></ul></ul><ul><ul><li>Hypomagnesemia </li></ul></ul><ul><li>May not be able to use in </li></ul><ul><ul><li>Congenital metabolic diseases </li></ul></ul><ul><ul><li>Severe liver disease / hepatic failure </li></ul></ul><ul><li>May be issue with massive blood transfusions </li></ul>
  48. 48. Experimental: High Flow <ul><li>High-volume CVVH might… </li></ul><ul><ul><li>Improve hemodynamics </li></ul></ul><ul><ul><li>Increase organ blood flow </li></ul></ul><ul><ul><li>Decrease blood lactate and nitrite/nitrate concentrations. </li></ul></ul>
  49. 49. Ronco et al. Lancet 2000; 351: 26-30 35 mL/kg/hr ~ 40 cc/min/1.73 m 2
  50. 50. Ronco et al. Lancet 2000; 351: 26-30 <ul><li>Conclusions: </li></ul><ul><ul><li>Minimum UF rates should reach at least 35 ml/kg/hr (40 mL/min/1.73 m 2 ) </li></ul></ul><ul><ul><li>Survivors in all their groups had lower BUNs than non-survivors prior to commencement of hemofiltration </li></ul></ul>
  51. 51. Experimental: septic shock <ul><li>Zero balance ultrafiltration (ZBUF) performed </li></ul><ul><ul><li>3L ultrafiltrate/h for 150 min then 6 L/h for an additional 150 min. </li></ul></ul><ul><ul><li>Rogers et al: Effects of CVVH on regional blood flow and nitric oxide production in canine endotoxic shock. </li></ul></ul>
  52. 52. What are the targets? <ul><li>Most known mediators are water soluble </li></ul><ul><li>Possible contenders </li></ul><ul><ul><li>500-60,000D (“middle molecules”) </li></ul></ul><ul><ul><ul><li>cytokines </li></ul></ul></ul><ul><ul><ul><li>anti/pro-coagulants </li></ul></ul></ul><ul><ul><li>Other molecules </li></ul></ul><ul><ul><ul><li>complement </li></ul></ul></ul><ul><ul><ul><li>phospholipase A-2 dependent products </li></ul></ul></ul><ul><li>Likely many unknown contenders </li></ul>
  53. 53. Unknowns of Hemofiltration for Sepsis <ul><li>Interaction of immune system with foreign surface of the circuit? </li></ul><ul><ul><li>Complement activation </li></ul></ul><ul><ul><li>Bradykinin generation </li></ul></ul><ul><ul><li>Leukocyte adhesion </li></ul></ul><ul><li>Clearance of anti-inflammatory mediators? </li></ul><ul><li>Clearance of unknown good mediators? </li></ul><ul><li>What do plasma levels of mediators really mean? </li></ul><ul><li>Is animal sepsis clinically applicable to human sepsis? </li></ul>
  54. 54. Clinical Applications in Pediatric ARF: Disease and Survival Bunchman TE et al: Ped Neph 16:1067-1071, 2001
  55. 55. Clinical Applications in Pediatric ARF: Disease and Survival <ul><li>Patient survival on pressors (35%) lower survival than without pressors (89%) (p<0.01) </li></ul><ul><li>Lower survival seen in CRRT than in patients who received HD for all disease states </li></ul>Bunchman TE et al: Ped Neph 16:1067-1071, 2001
  56. 56. Pediatric CRRT in the PICU <ul><li>22 pt (12 male/10 female) received 23 courses (3028 hrs) of CVVH (n=10) or CVVHD (n=12) over study period. </li></ul><ul><li>Overall survival was 41% (9/22). </li></ul><ul><li>Survival in septic patients was 45% (5/11). </li></ul><ul><li>PRISM scores at ICU admission and CVVH initiation were 13.5 +/- 5.7 and 15.7 +/- 9.0, respectively (p=NS). </li></ul><ul><li>Conditions leading to CVVH (D) </li></ul><ul><ul><li>Sepsis (11) </li></ul></ul><ul><ul><li>Cardiogenic shock (4) </li></ul></ul><ul><ul><li>Hypovolemic ATN (2) </li></ul></ul><ul><ul><li>End Stage Heart Disease (2) </li></ul></ul><ul><ul><li>Hepatic necrosis, viral pneumonia, bowel obstruction and End-Stage Lung Disease (1 each) </li></ul></ul>Goldstein SL et al: Pediatrics 2001 Jun;107(6):1309-12
  57. 57. Percent Fluid Overload Calculation % FO at CVVH initiation = [ Fluid In - Fluid Out ICU Admit Weight ] * 100% Goldstein SL et al: Pediatrics 2001 Jun;107(6):1309-12
  58. 58. Renal Replacement Therapy in the PICU Pediatric Literature <ul><li>Lesser % FO at CVVH (D) initiation was associated with improved outcome (p=0.03) </li></ul><ul><li>Lesser % FO at CVVH (D) initiation was also associated with improved outcome when sample was adjusted for severity of illness (p=0.03; multiple regression analysis) </li></ul>Goldstein SL et al: Pediatrics 2001 Jun;107(6):1309-12
  59. 59. PRISM at CRRT Initiation and Outcome P < 0.0005
  60. 60. Fluid Overload and Outcome: Renal Failure Only P < 0.05
  61. 61. Final Thoughts on Hemofiltration <ul><li>Medical Therapy that can perform the functions of the kidney and provide precise electrolyte and fluid balance </li></ul><ul><li>Unknown which method (CVVH vs. CVVHD vs. CVVHDF) is best </li></ul><ul><li>Many applications in the PICU </li></ul><ul><li>No perfect method of coagulation </li></ul><ul><li>High flow replacement fluids may be beneficial in sepsis </li></ul><ul><li>Earlier use in fluid overloaded patients with lower PRISM scores may improve mortality </li></ul>
  62. 62. These slides created from presentations by... <ul><li>Joseph DiCarlo, MD </li></ul><ul><li>Stanford University </li></ul><ul><li>Steven Alexander, MD </li></ul><ul><li>Stanford University </li></ul><ul><li>Catherine Headrick, RN </li></ul><ul><li>Children’s Medical Center Dallas </li></ul><ul><li>Patrick D. Brophy, MD </li></ul><ul><li>University of Michigan </li></ul><ul><li>Peter Skippen, MD </li></ul><ul><li>British Columbia Children’s Hospital </li></ul><ul><li>Stuart L. Goldstein, MD </li></ul><ul><li>Baylor College of Medicine </li></ul><ul><li>Timothy E. Bunchman, MD </li></ul><ul><li>University of Alabama </li></ul>

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