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CRRT Continue Renal Replacement Therapy 1.CVVH 2.CVVHD 3.CVVHDF.

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Presentation on theme: "CRRT Continue Renal Replacement Therapy 1.CVVH 2.CVVHD 3.CVVHDF."— Presentation transcript:

1 CRRT Continue Renal Replacement Therapy 1.CVVH 2.CVVHD 3.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 1. Driving force : external pump 2.Circuit : Venovenous 3.Dialysis solutions : 1.5% PD solution 4.Replacement fluid : several types of replacement fluid can be used, depending on patient requirements, pre- dilution.

4 Anti-coagulation STANDARD HEPARIN TYPICAL REGIMEN IN CRRT : ñPriming of the circuit ( 5000 IU / L ) ñInitial Heparin Bolus : IU / kg ñInfuse 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 ïEasy to perform ïUseful method ïInexpensive DISADVANTAGES Occasional Thrombocytopenia ïHemorrhagic Risk with Bleeding patient

6 LOW MOLECULAR WEIGHT (LMW) HEPARIN TYPICAL REGIMEN IN CRRT : ïPriming of the circuit : 20 mg in 1 L ïMaintenance 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 ADVANTAGES ïDecreased Risk of Bleeding DISADVANTAGES ïExpensive ïSpecial and difficult monitoring ïWith low doses frequent filter clotting

8 Regional Citrate Anticoagulation TYPICAL REGIMEN : ïCitrate anticoagulation is always regional ïCitrate infusion (4%) at 170 ml/hr initially ïSpecial Dialysate at 1 liter/hr ( Na+ 117, K+ 4, Mg++ 1.5, Cl , dextrose %, no Ca++, no base ) ïCaCL2 (0.75%) by central I.V at ml/hr, ïMaintain ionized Ca++ at mmol/L

9 Citrate ADVANTAGES : ïNo Bleeding ïNo Thrombocytopenia ïImproved Filter Life and Efficacy DISADVANTAGES : ïComplex for the set up ïCa++ monitoring needed ïOccasional Alkalosis

10

11 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

12 Dialysis modalities in the ICU

13 CVVH CVVH Continuous Veno-Venous Hemofiltration CVVH, CVVH, 4500ml/hr 4500ml/hr

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

15 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 1 st bottle N/S 500cc + Sinca 1amp 2 nd bottle N/S 500cc + 10% MgSO4 4cc 3 rd bottle N/S 500cc 4 th 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.

16 CVVHD CVVHD Continuous Veno-Venous Hemodialysis PRISMAPRISMA S

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

18 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.

19 CVVHDF CVVHDF Continuous Veno-Venous Hemodiafiltration

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

21 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 1 st bottle N/S 500cc + Sinca 1amp 2 nd bottle N/S 500cc + 10% MgSO4 4cc 3 rd bottle N/S 500cc 4 th 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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