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Continuous Renal Replacement Therapy Basic Therapy Principles
© Is an extracorporeal blood purification therapy intended to substitute for impaired renal function over an extended period of time and applied for or aimed at being applied for 24 hours a day. * Bellomo R., Ronco C., Mehta R, Nomenclature for Continuous Renal Replacement Therapies, AJKD, Vol 28, No. 5, Suppl 3, November 1996 Continuous Renal Replacement Therapy (CRRT)
© CRRT Goals Mimic the functions and physiology of the native organ Qualitative and quantitative blood purification Restore and maintain of homeostasis Avoid complications and good clinical tolerance Provide conditions favoring recovery of renal function
© Requirements for CRRT CRRT requires: A central double-lumen veno-venous hemodialysis catheter An extracorporeal circuit and a hemofilter A blood pump and a effluent pump. With specific CRRT therapies dialysate and/or replacement pumps are required.
© CRRT Modalities SCUF- Slow Continuous Ultrafiltration Ultrafiltration CVVH- Continuous Veno-Venous Hemofiltration Convection CVVHD- Continuous Veno-Venous Hemodialysis Diffusion CVVHDF- Continuous Veno-Venous Hemodiafiltration Diffusion and Convection
© SCUF-Ultrafiltration Slow continuous ultrafiltration: Requires a blood and an effluent pump. No dialysate or replacement solution. Fluid removal up to 2 liters/hr can be achieved. Primary Goal Safe management of fluid removal Large fluid removal via ultrafiltration
© Transport mechanism: Ultrafiltration The movement of fluid through a semi- permeable membrane driven by a pressure gradient (hydrostatic pressure). The effluent pump forces plasma water and solutes across the membrane in the filter. This transport mechanism is used in SCUF, CVVH, CVVHD, and CVVHDF.
SCUF Syringe pump Return Pressure Air Detector Blood Pump Access Pressure Filter Pressure BLD Hemofilter Patient Effluent Pump Return Clamp Pre Blood Pump Effluent Pressure
© CVVH-Convection Continuous veno-venous hemofiltration Requires blood, effluent and replacement pumps. Dialysate is not required. Plasma water and solutes are removed by convection and ultrafiltration.
© Transport Mechanism: Convection Removal of solutes, especially middle and large molecules, by convection of relatively large volumes of fluid and simultaneous. This transport mechanism is used: CVVH CVVHDF
© Replacement Fluids Physician Rx and adjusted based on pt. clinical need. Sterile replacement solutions may be: Bicarbonate-based or Lactate-based solutions Electrolyte solutions Must be sterile and labeled for IV Use Higher rates increase convective clearances You are what you replace
© CVVH Return Pressure Air Detector Return Clamp Patient Access Pressure Effluent Pump Syringe Pump Filter Pressure Hemofilter Pre Post Replacement Pump Pre Blood Pump Effluent Pressure
© CVVHD-Diffusion Continuous veno-venous hemodialysis Requires the use of blood, effluent and dialysis pumps. Replacement solution is not required. Plasma water and solutes are removed by diffusion and ultrafiltration.
© Transport Mechanisms: Diffusion Removal of small molecules by diffusion through the addition of dialysate to the fluid side of the filter. Dialysate is used to create a concentration gradient across a semi permeable membrane Dialysis uses a semi permeable membrane for selected diffusion This transport mechanism is used in: CVVHD CVVHDF
© Dialysate Solutions Through diffusion, dialysate corrects underlying metabolic problems Dialysate is dependent on buffering agent, electrolytes, and glucose Dialysate formulas should reflect normal plasma values to achieve homeostasis
© CVVHD Return Pressure Air Detector Return Clamp Access Pressure Blood Pump Syringe Pump Filter Pressure Hemofilter Patient Effluent Pump Dialysate Pump Pre Blood Pump BLD Effluent Pressure
© Bicarbonate Based Solution Bicarbonate based solutions are physiologic and replace lost bicarbonate immediately. Effective tool to correct acidosis Concentration of 30-35mEq/L corrects acidosis in 24 to 48 hours.
© Bicarbonate Based Solution Preferred buffer for patients with compromised liver function. Mean arterial pressure remains stable Superior buffer in normalizing acidosis without the risk of alkalosis Improved hemodynamic stability, and fewer cardiovascular events.
© Plasma PrismaSate BK0/3.5 PrismaSate BGK2/0 Calcium Ca 2+ (mEq/L) Magnesium Mg 2+ (mEq/L) Sodium Na + (mEq/L) Potassium K + (mEq/L) Chloride Cl - (mEq/L) Lactate (mEq/L) Bicarbonate HCO 3 - (mEq/L) Glucose (mg/dL) Osmolarity (mOsm/L) pH ~ 7.40 PrismaSate Solution
© Lactate-based Solution Metabolized into bicarbonate providing its under normal conditions. Lactate is converted in the liver on a 1:1 basis to bicarbonate and can sufficiently correct acidemia.
© Lactate Based Solution Non physiologic pH value of 5.4 Is a powerful peripheral vasodilator Further acidemia for patients in: Hypoxia Liver impairment Pre-existing lactic acidemia can result in worsening of lactic acidemia
© CVVHDF Continuous veno-venous hemodiafiltration Requires the use of a blood, effluent, dialysate and replacement pumps. Both dialysate and replacement solutions are used. Plasma water and solutes are removed by diffusion, convection and ultrafiltration.
© Transport Mechanisms: Diffusion and Convection Removal of small molecules by diffusion through the addition of dialysate solution. Removal of middle to large molecules by convection through the addition of replacement solution. This transport mechanism is used in: CVVHDF
© CRRT Transport Mechanisms Adsorption Molecular adherence to the surface or interior of the membrane This mechanism is used in: SCUF CVVH CVVHD or CVVHD with ultrafiltration CVVHDF
© Principles of CRRT clearance CRRT clearance of solute is dependent on the following: The molecule size of the solute The pore size of the semi-permeable membrane The higher the ultrafiltration rate (UFR), the greater the solute clearance.
© Principles of CRRT clearance Small molecules easily pass through a membrane driven by diffusion and convection. Middle and large size molecules are cleared primarily by convection. Semi-permeable membrane remove solutes with a molecular weight of up to 50,000 Daltons. Plasma proteins or substances highly protein bound will not be cleared.
© Principles of CRRT clearance Sieving Coefficient The ability of a substance to pass through a membrane from the blood compartment of the hemofilter to the fluid compartment. A sieving coefficient of 1 will allow free passage of a substance; but at a coefficient of 0, the substance is unable to pass..94 Na+ 1.0 K+ 1.0 Cr 0 albumin will not pass
© Vascular Access A veno-venous double lumen hemodialysis catheter or two single lumen venous hemodialysis catheters may be used.
© Access Location Internal Jugular Vein Primary site of choice due to lower associated risk of complication and simplicity of catheter insertion. Femoral Vein Patient immobilized, the femoral vein is optimal and constitutes the easiest site for insertion. Subclavin Vein The least preferred site given its higher risk of pneumo/hemothorax and its association with central venous stenosis.
© Choosing the right catheter The length of the catheter chosen will depend upon the site used Size of the catheter is important in the pediatric population. The following are suggested guidelines for the different sites: RIJ= 15 cm French LIJ= 20 cm French Femoral= 25 cm French
© Membrane types and characteristics Hemofilter membrane are composed of: High flux material Synthetic/biocompatible material Structural design is characterized by: High fluid removal Molecular cut-off weight of 30, ,000 Daltons.
© Semi-permeable Membrane The semi-permeable membrane provides: An interface between the blood and dialysate compartment. Biocompatibility minimizes: Severe patient reactions Decreases the complement activation
© Complications Vascular access Vascular spasm(initial BFR too high) Movement of catheter against vessel wall Improper length of hemodialysis catheter inserted Fluid volume deficit Excessive fluid removal without appropriate fluid replenishment
© Complications Hypotension Intravascular volume depletion Underlying cardiac dysfunction Electrolyte imbalances High ultrafiltration rates (high clearance) Inadequate replenishment of electrolytes by intravenous infusion, Inadequate replenishment of bicarbonate loss during CRRT
© Acid/base imbalance Renal dysfunction Respiratory compromise Blood loss Ineffective anticoagulation therapy Clotting of hemofilter Inadvertent disconnection in the CRRT system Hemorrhage due to over-anticoagulation Blood filter leaks Complications
© Complications Air embolus Leaks or faulty connections in tubing Line separation. Cardiac arrest Hypotension/hypertension Hemolysis Air embolism Circulatory overload Arrhythmias
© Clinical Conditions to Consider ARF and need for fluid management related to: SIRS Unstable on IHD Organ transplants CHF /volume overload Post CV surgery Post trauma patients Severe Burns
© Fluid Management in CRRT Goal of Fluid Management The patient will achieve and maintain fluid volume balance within planned or anticipated goals (ANNA Standards of Clinical Practice for Continuous Renal Replacement Therapy) Considerations Intakes and outputs (I&O)
© I & O Formula Net fluid removal hourly (physician order) + Nonprisma intake (IV, TPN, etc.) - Nonprisma output (urine, etc.) = Patient Fluid Removal Rate (set in prisma)
© Hypothermia in CRRT Causes Patients blood in extracorporeal circuit at room temperature Administration of large volumes of room temperature fluids (replacement and dialysate) Signs and Symptoms Hemodynamic instability Chilling, shivering Skin pallor, coolness and cyanosis
© Hypothermia Treatment measures Warming blankets Prismatherm II Blood Warmer Prismaflo ® Blood Warmer
© Initiation of Therapy Assess and record the patients vital signs and hemodynamic parameters prior to initiation of therapy. Review physician orders and lab data Prepare vascular access using unit protocol. Set fluid removal, dialysate and replacement solution flow rates as prescribed. Administer anticoagulant and initiate infusion if applicable. Document patients hemodynamic stability with initiation of therapy.
© Intratherapy Monitoring The critical care nurse must continuously monitor the following parameters during CRRT Blood pressure Patency of circuit Hemodynamic stability Level of consciousness Acid/base balance Electrolyte balance Hematological status Infection Nutritional status Air embolus Blood flow rate Ultrafiltration flow rate Dialysate/replacement flow rate Alarms and responses Color of ultrafiltrate/filter blood leak Color of CRRT circuit
© Termination of Therapy The decision to terminate CRRT is made by the nephrologist or an intensivist based on the patients renal recovery or the patients status-recovery or decision of the patient and family. Extracorporeal circuit will be discontinued as per established protocol. Vascular access care administered as per unit protocol
Current Research FAQs
How much replacement and dialysate do you use? Roncos research
© 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
© Group 1(n=146) (Uf = = 20 ml/h/Kg) Group 2 (n=139) (Uf= 35 ml/h/Kg) Group 3 (n=140) (Uf= 45 ml/h/Kg) 41 % 57 % 58 % p < 0.001p n..s. p < Survival (%) Effects of different doses in CVVH on outcome of ARF - Ronco & Bellomo study. Lancet. july 00
© Effect of BUN at CVVH Initiation on Survival Group 1Group 2Group 3 Survivors Non Survivors p < 0.01 Blood Urea Nitrogen (mg/dl) p < 0.01 Effects of different doses in CVVH on outcome of ARF - Ronco & Bellomo study. Lancet. july 00
© RIFLE Criteria
© RIFLE Stratification in Patients Treated with CRRT Bell et al, Nephrol Dial Transplant 2005
© Conclusions: An increased treatment dose from 20 ml/h/kg to 35 ml/h/kg significantly improved survival. A delivery of 45ml/kg/hr did not result in further benefit in terms of survival, but in the septic patient an improvement was observed. Our data suggest an early initiation of treatment and a minimum dose delivery of 35 ml/h/kg (ex. 70 kg patient = 2450 ml/h) improve patient survival rate. Effects of different doses in CVVH on outcome of ARF - Ronco & Bellomo study. Lancet. july 00
Renal Recovery? CRRT does affect resumption of function.
© By avoiding hypotensive episodes, the risk of further kidney damage is reduced and the chance for renal recovery is enhanced
© IRRT CRRT days Recovery from Dialysis Dependence: BEST Kidney Data Recovery from dialysis dependence Manuscript under review Leading the way…
© CRRT vs. IHD in Renal Recovery Recent studies suggest that CRRT is superior to IHD with respect to recovery of renal function Implications go far beyond just hard endpoint of renal recovery Need for chronic dialysis impairs quality of life If length of stay (LOS) in ICU can be reduced this will have a major impact on hospital budget Patients dependent on chronic dialysis will consume significant health care resources and have an impact on the community health care budget Leading the way…
Continuous Renal Replacement Therapy. Why continuous Therapies? Continuous therapies closely mimic the GFR of native kidneys Large amounts of fluid.
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