A very simple yet comprehensive presentation to understand the concept of CRRT and its implementation in Intensive Care Unit. Intended for the very beginners in ICU. After going through the presentation you will be able to say "Now I know it!"
Renal Replacement Therapy: modes and evidenceMohd Saif Khan
Renal replacement therapy is a supportive care often required in critically ill patients who develop acute renal failure and its complications. Complexity arises when such patients become hemodynamically unstable and pose special challenge to critical care clinicians in ICU to carefully choose dialytic modality to tackle volume and solute overload. This presentation is about short description of modalities of RRT and current evidence regarding initiation, dose and type of modality.
Renal Replacement Therapy: modes and evidenceMohd Saif Khan
Renal replacement therapy is a supportive care often required in critically ill patients who develop acute renal failure and its complications. Complexity arises when such patients become hemodynamically unstable and pose special challenge to critical care clinicians in ICU to carefully choose dialytic modality to tackle volume and solute overload. This presentation is about short description of modalities of RRT and current evidence regarding initiation, dose and type of modality.
AKI in the ICU
Principles of RRT
Modes of RRT
Indications for RRT
Optimal timing: When to start
Optimal modality: What Modality and Where ??
Optimal dosing- How Much?
Summary and Conclusions
Hemodialysis is a treatment to filter wastes and water from your blood; In hemodialysis, the blood is cleaned outside the body using a dialysis machine and then sent back into the body.
Hemodialysis is a treatment to filter wastes and water from your blood, as your kidneys did when they were healthy. Hemodialysis helps control blood pressure and balance important minerals, such as potassium, sodium, and calcium, in your blood.
Hemodialysis is one way to treat advanced kidney failure and can help you carry on an active life despite failing kidneys.
Mechanism of Hemodialysis:
Hemodialysis is a procedure by which waste products and excess water are removed from a patient’s blood. This is done by directly removing blood from the patient’s circulation, passing it through the dialysis filter, and then returning it directly back into the circulation.
Apparatus needed:
Dialyzer or dialysis filter
Dialysate (dialysis solution)
Tubing for transport of blood and dialysate
Machine that powers and monitors the filtration
Hemodialysis has 5 main steps which are as follows:
1.Two sets of tubing are connected to the patient’s dialysis access:
Connected directly to central venous catheter
Two needles inserted into AVF/AVG and taped down
2. Azotemic blood pumped from patient into dialysis filter
3. Dialysis filter removes toxins primarily through diffusion:
Dialysis filter is a plastic cylinder filled with thousands of tiny individual tubes composed of the filtering material.
Blood flows through the inside of the tiny tubes in one direction.
Dialysis fluid (dialysate) flows on the outside of the tiny tubes (but still within the single plastic cylinder that contains them) in the opposite direction.
The opposing directions of blood and dialysate result in maximal concentration gradients that drive the diffusion of toxins:
Known as “countercurrent” mechanism
Also results in correction of electrolyte/acid–base abnormalities via diffusion.
4. Dialysis filter removes excess water from the blood through ultrafiltration.
Suction force is applied by the dialysis machine across the dialysis filter.
Water is pulled from the blood side into the dialysate side.
5. Clean blood and waste-filled dialysate exit the dialysis filter.
Clean blood is pumped back into the patient’s Circulation.
Waste-filled dialysate is disposed of (including the excess water from the patient’s body that was removed during ultrafiltration).
Chronic dialysis
3–4 hours each session
3 times a week (Monday/Wednesday/Friday or Tuesday/Thursday/Saturday)
Acute dialysis:
Treatment duration and daily schedule are
Variable.
Priscriptions: The nephrologist may control many variables within the dialysis procedure:
Duration of treatment
Ultrafiltration goal
Anticoagulation
Electrolyte composition of the dialysate
Speed of blood flow and dialysate flow
Presented by: Mohammadsaleh Moallem
A brief yet comprehensive coverage of ICU role in ECMO cases. Presentation has been prepared in order to help ICU fellows and registrars to understand the importance of their role and to know necessary actions they have to take in case of need.
A simplified description of basal ganglia stroke to help understand the clinical scenarios where patients present with neurological symptoms not clearly pointing towards possibility of stroke.
Vertebral artery pseudo-aneurysms and dissections are known to occur as a result of mechanical
manipulations of the cervical region, traumatic injury, spontaneously and iatrogenic injury because of central
venous catheterization. Central venous lines have become an integral part of patient care, but they are
not without complications. Vertebral artery injury (leading to pseudo-aneurysm and dissection) is one of
the rarer complications of central venous catheter placement. We report a case of inadvertent vertebral
artery catheterization during a dialysis catheter placement which subsequently demonstrated arterial
blood. Duplex ultrasound and computed tomographic (CT) scan confirmed vertebral artery catheterization.
It was successfully treated with open surgical technique by the vascular surgeon because of the size of
catheter and subsequent requirement of artery repair. There were no neurological sequelae. Open surgical
repair remains the gold standard of treatment. Endovascular repair of vertebral artery pseudo-aneurysms
has been described with promising outcomes, but long-term results are lacking. This case report describes
the rare iatrogenic event of vertebral artery injury and reviews its etiology, diagnosis, complications, and management.
From eye drops to icu, a case report of three side effects of ophthalmic timo...Muhammad Asim Rana
Timolol Maleate (also called Timolol) is a nonselective beta-adrenergic blocker and a class II antiarrhythmic drug, which is used
to treat intraocular hypertension. It has been reported to cause systemic side effects especially in elderly patients with other
comorbidities.These side effects are due to systemic absorption of the drug and it is known that Timolol is measurable in the serum
following ophthalmic use. Chances of life threatening side effects increase if these are coprescribed with other cardiodepressant
drugs like calcium channel or systemic beta blockers. We report a case where an elderly patient was admitted with three side
effects of Timolol and his condition required ICU admission with mechanical ventilation and temporary transvenous pacing.The
case emphasizes the need of raising awareness among physicians of such medications about the potential side effects and drug
interactions. A close liaison among patient’s physicians is suggested.
Congenitally absent Inferior Vena Cava: A rare cause of recurrent DVT and non...Muhammad Asim Rana
In search of a cause for the so-called idiopathic Deep Vein Thrombosis (DVT), researchers have
pointed towards association between recurrent DVT and absent IVC
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Corticosteroids are one of the most common medications that are used in the intensive care units (ICUs);
corticosteroids are used for a variety of indications, including septic shock, acute respiratory distress syndrome
(ARDS), bacterial meningitis, tuberculous meningitis, lupus nephritis, severe chronic obstructive pulmonary disease
(COPD) exacerbations and many others.
Corticosteroids are associated with many severe side effects that affect morbidity and mortality of the patients like
increased risk of infections, glucose intolerance, hypokalemia, sodium retention, edema, hypertension, myopathy
etc. In order to make the best use of these medications and to minimize the unwanted side effects we should follow
some particular protocol. Please keep in our mind that there is controversy about dosing and tapering of steroids, so
effort has been made to include the best available evidence.
This review discusses mainly the most common indications of corticosteroids in ICU, dosing of corticosteroids in
those indications and how to taper corticosteroids according to the best evidence that recommends their use.
Literature search was done using Medline, BMJ, Uptodate, Chochrane database, Google scholar and the best
evidence based guidelines in which steroids are recommended to treat ICU related disorders. Sex hormones are not
discussed in this review since its use is rare in the intensive care units.
A very effective, precise and focused presentation for Calcium abnormalities and approach towards management. Targeted to teach the to the point diagnosis and treatment.
It is requested to download the presentation to run the animation as it is a very interactive presentation
A detailed discussion and description on fungal diseases and management. The focus is kept on those facts which frequently come across an intensivist but it is also important for the Internist.
A simple presentation on hypokalemia. The most common electrolyte disorder in the Critical Care practice.The presentation is based on a mortality and morbidity case report and discussion. It covers all the basic aspects of understanding the causes of hypokalemia in ICU and its management. Target audience are residents ICU and ER but all health care workers can benefit.
A detailed discussion on a very much in demand topic. Covered all aspects of the procedure which are important for an Emergency, Medical and Intensive Care physician should know. Nurses can also benefit from the presentation as we have tried to keep it as simple and straight forward as possible.
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Multi drug resistant bacteria are a big problem in ICUs now a days. This is a successful case report where we treated an pleural infection b directly instilling the drug colistin in the pleura.
A simple description of a less understood topic in Intensive Care Medicine. Aim to make understanding and management easy for the residents and prevention steps for all ICU workers.
A brief yet comprehensive description of a very common problem faced in KSA especially during hajj season. It is meant to enhance the awareness among ER and ICU physicians.
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CLASS 11 CBSE B.St Project AIDS TO TRADE - INSURANCE
Basics of Continuous Renal Replacement Therapy
1. Continuous Renal Replacement Therapy
(CRRT)
Muhammad Asim Rana
MBBS, MRCP, SF-CCM, EDIC, FCCP
Critical Care Medicine
King Saud Medical City
Riyadh, Saudi Arabia
2. Dedication
• Today’s presentation is dedicated to
• Dr Mohammed Odat
• Dr Waleed Tharwat Hasim
• Being the PIONEERS in KSMC ICU to start
lectures on CRRT
3. Case 1
•
•
•
•
•
•
•
•
•
35 yrs male pt, involved in RTA
Massive crush injury to legs
Severe Rhabdomyolysis, AKI Creat 250
Trauma to liver and spleen post laparotomy
Received 15 Blood transfusions in OR
Severe DIC, metabolic acidemia pH 7.0
TRALI…ARDS FiO2 100%, Sat O2 80%
Shocked on 2 inotropes moderate doses
Seen by ICU consultant decided.. CRRT
4. Case 2
• 75 yrs female pt, DM, IHD, mild renal
impairment
• Admitted with SOB with high BP
• CXR showed B/L infiltration “BAT Wing”
• ECHO… EF 45%
• Diagnosed as acute pulmonary edema
• Lasix trial failed, pt intubated for worsening
dyspnea and hypoxia
5. Case 3
•
•
•
•
•
•
•
45 yrs male pt, known drug addict
Admitted with decreased LOC
ABGs showed severe metabolic acidemia
Creatinin 180, BUN 10
Urine positive for oxalate
Papilloedema
Rx ………..CRRT
6. Case 4
•
•
•
•
•
•
•
•
56 yrs male pt, no past medical hx
Admitted with bilateral pneumonia
Ventilted developed MOF, Septic Shock
ABGs showed severe metabolic acidemia
Creatinin 300, BUN 29
Urine out put 10 ml/hr
Fluid Balance +13L
Rx ………..CRRT
7. Objectives
•
•
•
•
•
To understand the theory of CRRT
To appreciate the difference b/w IHD & CRRT
Understanding the modes of CRRT
To learn the indications and timing of CRRT
Dosage writing
8. Introduction
• Main functions of the kidney:
maintenance of fluid balance
maintenance of acid base balance
elimination of waste products
• 20 – 30 % of ICU patients develop AKI
• Many ICU are already on IHD
11. Advantages/Disadvantages
• Very efficient
• Hemodynamic instability in ≤ 30 % of patients
• Causes rapid shifts in osmolarity
– (Disequilibrium syndrome)
• It is “Intermittent”
12. Peritoneal Dialysis
•
•
•
•
•
Simple and cheap, but …….
Poor solute clearance
Poor uremic control
Risk of peritoneal infection
Mechanical impedance
– Pulmonary and cardiovascular function
13. Continuous Renal Replacement Therapy
• Concept- dialyze patients more physiologically
• Avoids the accumulation of waste products
• Avoids the rapid shifts in volume & osmolarity
• Avoids disadvantages of Peritoneal Dialysis
14. Advantages
•
•
•
•
•
Precise volume control
Very effective control of uremia and ↑ K⁺
Rapid control of metabolic acidosis
Suitable for hemodynamically unstable pts
Improved nutritional support
– (no need for volume restriction)
23. Ultrafiltration
• The passage of water through a membrane
under a pressure gradient.
• Driving pressure can be
+ve (push fluid through the filter)
–ve (pull fluid to other side of filter)
• Pressure gradient is created by effluent pump
25. Convection
• Movement of solutes through a membrane by
the force of water.
“solvent drag”
• The water pulls the molecules along with it as
it flows through the membrane.
• Can remove middle and large molecules, as
well as large fluid volumes.
• Maximized by using replacement fluids.
29. Adsorption
• Adsorption is the removal of solutes from the
blood because they cling to the membrane.
– Think of an air filter. As the air passes through it,
impurities cling to the filter itself.
– Eventually the impurities will clog the filter and it
will need to be changed.
• The same is true in blood purification. High
levels of adsorption can cause filters to clog
and become ineffective
31. Dialysate
Dialysate is any fluid used on the opposite side of the filter from
the blood during blood purification.
32. Replacement Fluids
• Used to increase the amount of convective
solute removal in CRRT.
• Replacement fluids do not replace anything.
• Fluid removal rates are calculated
independently of replacement fluid rates.
• The common replacement fluid is 0.9% saline
• Can be pre or post filter.
34. Comparison Pre & Post Dilution
PRE-FILTER
–
–
–
–
–
–
Increases filter life
Increases convective
transport
Reduced solute clearance
Some of delivered
replacement fluid lost by
hemofiltration
Lower anticoagulation
requirements
Higher UF required given
loss of replacement fluid
through filter
POST-FILTER
– No solute dilution,
improved diffusion and
solute clearance
– Increased
hemoconcentration
– Higher delivered dose
of hemofiltration
36. Dialysable or Not
Dialysable
Barbiturates
Lithium
Alcohols, Amglcoside
Salicylates
Theophyllin
Penicillins,
Carbapenems, Cephalo
PC-B L A S T
Non-Dialysable
Digoxin
Tricyclic
Antidepressents
Phenytoin
Benzodiazepines
B-blockers
(atenolol is removed)
Metformin
37. Timing
• Inadequate data available to answer this Q
• Observational data suggests better outcomes
are associated with early RRT initiation
2
Getting et al 1999 . Urea 15.2 vs 33.7 conferred survival benefit.
3
4
Ronco et al 2000 and Saudan et al 2006 both dose/outcome studies suggested an early
start.
5
Liu et al 2006 observational PICARD study (Urea 27) suggested an early start
– RENAL study, NEJM 2009, 1508 pts.
– Demirkilic 2004, Elahi 2004, Piccini 2006
39. CRRT Modalities
• CRRT includes several treatment modalities
that use a veno-venous access.
• The choice will depend on the needs of the
patient and on the preference of the
physician.
40. • Removal of ultrafiltrate at low rates
• without administration of a substitution solution.
• The purpose is to prevent or treat volume overload
• when waste product removal or pH correction isn’t
necessary.
• Primary indication for SCUF - fluid overload
• Mechanism of water transport is Ultrafiltration.
• No dialysate or replacement fluid is used.
41. • Other solutes are removed but are negligible
• The amount of fluid in the effluent bag is the
same as the amount removed from the pt.
• Removal rates are closer to 100 ml/hour.
43. Let’s Revise
• Primary therapeutic goal:
– Safe management of fluid
• Primary indications:
– Fluid overload without metabolic imbalance
• Principle used:
Ultrafiltration
• Therapy characteristics:
– No dialysate or substitution solutions
Fluid removal only
44. • Blood flow:
80 – 200 ml/min
• Duration:
(as advised by the physician)
• Ultrafiltration:
20-100 ml/hr (or total volume)
• Anticoagulation…. Acc to physician
• Dialysate …….. NO
• Replacement fluid….. NO
45. Effects of different doses in CVVH on outcome of ARF
Ronco & Bellomo study. Lancet . july 00
•
Prospective study on 425 patients - 3 groups:
•
Study:
– survival after 15 days of HF stop
– recovery of renal function
46. Effects of different doses in CVVH on outcome of ARF - Ronco
& Bellomo study. Lancet . july 00
100
p < 0.001
90
Survival (%)
80
70
p < 0.001
p n..s.
60
50
40
30
20
41 %
57 %
58 %
10
0
Group 1(n=146)
Group 3 (n=140)
(Uf = 20 ml/h/Kg)
306100135
Group 2 (n=139)
(Uf = 35 ml/h/Kg)
(Uf = 45 ml/h/Kg)
47. • An extremely effective method of solute removal and
is indicated for uremia or severe pH or electrolyte
imbalance with or without fluid overload.
• Particularly good at removal of large molecules,
because CVVH removes solutes via convection.
• Convective removal of waste products (small and
large molecules) utilizing a substitution solution.
• pH is affected with the buffer contained in the
substitution solution.
48. • Solutes can be removed in large quantities
while easily maintaining a net zero or even a
positive fluid balance in the patient.
• The amount of fluid in the effluent bag is
equal to the amount of fluid removed from
the patient plus the volume of replacement
fluids administered.
• No dialysate is used.
50. Let’s Revise
• Primary therapeutic goal:
– Solute removal and safe fluid management
• Primary indications:
– Uremia, severe acid/base or electrolyte imbalance
– Removal of larger mol wt substances
• Principle used:
convection
• Therapy characteristics:
– Substitution solution to drive
– No dialysate solution
Effective at removing small and large molecules
51. •
•
•
•
•
•
Blood flow:
80 – 200 ml/min
Duration:
As advised by physician
Ultrafiltration:
20-100 ml/hr (or total volume)
Replacement Fluid:
1000 – 2000 ml/hr,pre or post filter
Anticoagulation
Dialysate…. NO
Dosage:
30ml/kg/hr
70x30=2100ml
Replacement fluid
So
This Replacement can be
divided into pre & post filter
Depending upon physician
Ex, 500 pre and 1500ml post
(All can be pre or post)
52. •
•
•
•
•
Effective for removal of small to medium sized molecules.
Solute removal occurs primarily due to diffusion.
No replacement fluid is used.
Dialysate is run on the opposite side of the filter.
Fluid in the effluent bag is equal to the amount of fluid
removed from the patient plus the dialysate.
• Continuous diffusive removal of waste products (small
molecules) utilizing a dialysis solution.
• pH is also affected with the buffer contained in the
dialysate.
54. •
•
•
•
•
•
Blood flow:
80 – 200 ml/min
Duration:
Dosage:
As advised by physician
45ml/kg/hr
70x45=3150ml
Ultrafiltration:
Dialysatefluid
20 -100 ml/hr (or total volume)
So
Dialysate can be 3 liters /hr
Anticoagulation:
Dialysate:
600 – 1800 ml/hr (up to 3 lit/hr).
Replacement fluid….NO
55. Let’s Revise
• Primary therapeutic goal:
– Solute removal and safe management of fluid volume
• Primary indications:
– Uremia, severe acid/base or electrolyte imbalance
• Principle used:
Diffusion
• Therapy characteristics:
– Requires dialysate solution to drive diffusion
– No substitution solution
Effective at removing small to medium molecules
56. • The most flexible of all the therapies, and
combines the benefits of diffusion and
convection for solute removal.
• The use of replacement fluid allows adequate
solute removal even with zero or positive net
fluid balance for the patient.
57. • Amount of fluid in the effluent bag equals the fluid
removed from the patient plus the dialysate and the
replacement fluid.
• Dialysate on the opposite side of the filter and
replacement fluid either before or after the filter.
• Continuous diffusive and convective removal of
waste products (small and large molecules)
• Utilizing both dialysate and substitution solution.
• pH is also affected with the buffer contained in the
dialysate and substitution solution.
59. Let’s Revise
• Primary therapeutic goal:
– Solute removal and safe management of fluid volume
• Primary indications:
– Uremia, severe acid/base or electrolyte imbalance
– Removal of large molecular weight substances is required
– Unstable haemodunamics
• Principle used:
diffusion and convection
• Therapy characteristics:
– Requires dialysate fluid and substitution solution to
drive diffusion and convection
• Effective at removing small, medium and large
molecules
60. •
Blood flow:
Dosage:
80 – 200 ml/min
45ml/kg/hr
• Duration:
70x45=3150ml
½ as Dialysate& ½ as
As advised by the physician
Replacement fluid
• Ultrafiltration:
So
1500ml as Dialysate
20-100 ml/hr (or total volume)
1500ml as Replacement can
• Anticoagulation:
be divided into pre & post
filter
• Dialysate:
600 – 1800 ml/hr (up to 3 lit/hr) Depending upon physician
Ex, 500 pre and 1000ml post
• Replacement fluid:
1000-2000 ml/hr, pre or post filter (up to 3 lit/hr)
Not a homogenous group, not one shoe fits all and use of different modalities may confer different survival and benefits. But certainly in ARF with no hx CKD and an unlikely quick recovery would all suggest early initiation would be wise. No negative outcomes demonstrated. Concurred by the recent recommendation by the ICS jan 2009.
Dose is strictly speaking solute clearance. This is difficult to measure so dose is usually described as the amount of effluent fluid in mls/kg/h: