Presentation on theme: "CRRT: It’s Not Just for Renal Failure Anymore"— Presentation transcript:
1CRRT: It’s Not Just for Renal Failure Anymore Presented by:Sue Fallone,MS,RN,CNNClinical Nurse SpecialistAdult and Pediatric DialysisAlbany Medical Center
2Objectives Define Heart Failure Define Sepsis Discuss medical management of heart failure and sepsisDescribe indications for CRRT for these disordersCase Study
3HEART FAILUREClinical syndrome that can result from any structural or functional cardiac disorder that impairs the ability of the ventricle to fill with or eject blood
4Incidence of Heart Failure More deaths from heart failure than from all forms of cancerNearly 1 millions people are admitted to the hospital with CHF and 30%-60% are readmittedContributed to 53,000 deaths in the U.S. each yearAbout 550,000 new cases per yearAffects men and women equallyRelated to the aging population, lower death rate from MI, and improved treatment for heart disease
5Causes of Heart Failure Main causesIschemic heart disease, Cardiomyopathy, Hypertension, DiabetesOther causes: Valvular heart disease, Congenital heartdisease, Alcohol and drugs, Hyperdynamic circulation(anemia, thyrotoxicosis, hemochromatosis, Paget'sdisease), Right heart failure (RV infarct, pulmonaryhypertension, pulmonary embolism, cor pulmonale(COPD)), Arrhythmia and Pericardial disease.
6Mechanisms Leading to Heart Failure Impaired cardiac contractility as in myocardial infarction and cardiomyopathyVentricular outflow obstruction (pressure overload) as in hypertension and aortic stenosisImpaired ventricular fillings as in mitral stenosis and constrictive pericarditisVolume overload as in mitral regurgitation
7Precipitating Factors InfectionsArrhythmiasPhysical, Dietary, Fluid, Environmental, and Emotional Excesses.Myocardial infarctionPulmonary embolismAnemiaThyrotoxicosis and pregnancyAggravation of hypertensionRheumatic, Viral, and Other Forms of MyocarditisInfective endocarditisDiabetes
9TYPES OF HEART FAILURELeft- sided or left ventricular (LV) heart failureis commonly caused by ischemic heart disease but can also occur with valvular heart disease and hypertension. 2 types of (LV) heart failurediastolic failure is a syndrome consisting of symptoms and signs of heart failure with preserved left ventricular ejection fraction above 45–50% and abnormal left ventricular relaxation assessed by echocardiographysystolic failure is when the left ventricle loses it’s ability to contract normally, can pump enough blood into the systemic circulationRight-sided or right ventricular (RV)heart failuremay be secondary to chronic( LV ) heart failure but can occur with primary and secondary pulmonary hypertension, right ventricular infarction.
10TYPES of HEART FAILURE Congestive Heart Failure- Blood flow out of the heart slows, blood returning to the heart through the veins backs up and congestion in the body’s tissuesWill see edema, SOB, can affect kidney function
11Symptoms & Signs OF Heart Failure Left heart failureSymptoms are predominantly fatigue,exertional dyspnea, orthopnea and PNDPhysical signs: Cardiomegaly, gallopfunctional mitral regurgitation and crackles a the lung bases.
12Right Heart FailureSymptoms (fatigue, breathlessness, anorexia and nausea) relate to distension and fluid accumulation in areas drained by the systemic veins.Physical signs are usually more prominent than the symptoms, with:jugular venous distensiontender smooth hepatic enlargementdependent pitting edemadevelopment of free abdominal fluid (ascites)Pleural effusion (commonly right-sided).Dilatation of the right ventricle produces cardiomegaly and may give rise to functional tricuspid regurgitation. Tachycardia and a right ventricular third heart sound are usual.
14Classification of Heart Failure Functional Capacity Class I – patients with cardiac disease and no limitation of physical activityClass II- patients with cardiac disease slight limitation of physical activity results in fatigue, palpitation, dyspnea or anginaClass III-patients with cardiac disease marked limitation of physical activity comfortable at restClass IV-patients with cardiac disease inability to carry on any physical activity, symptoms of heart failure at rest
17If Resistant to Diuretics MAY NEED Ultrafiltration
18UNLOAD STUDYThe UNLOAD study was a randomized, multicenter study of 200 patients involving 28 hospitals and medical centers across the United States. UNLOAD compared the short and long-term safety and efficacy of an advanced form of ultrafiltration therapy(Aquapheresis) to the use of conventional diuretic drug therapy in fluid overloaded heart failure patients.The UNLOAD study was published in the February 13, issue of Journal of American College of Cardiology. (Costanzo MR et al. JACC 2007; 49(6): ).
19UNLOAD Study Results 28% with greater fluid loss with UF 43% reduction in patients being re-hospitalization for HF63% fewer hospital days for HF
20What is SIRS?The systemic inflammatory response syndrome is systemic level of acute inflammation, that may or may not be due to infection, and is generally manifested as a combination of vital sign abnormalities including fever or hypothermia, tachycardia, and tachypnea.
21DefinitionsSevere SIRS – SIRS in which at least 1 major organ system has failed.Sepsis – SIRS which is secondary to infection.Severe Sepsis – Severe SIRS which is secondary to infection.Septic Shock – Severe sepsis resulting in hypotensive cardiovascular failure.
22Systemic Inflammatory Reponse(SIRS) Can be triggered by infectious and non-infectious eventsInfectious causes bacteria or fungiNon infectious causes are prancreatitis,burns, traumaSIRS is the term used for noninfectious causes
23Criteria for SIRSRequires 2 of the following 4 features to be present:Temp >38.3° or <36.0° CTachypnea (RR>20 or MV>10L)Tachycardia (HR>90, in the absence of intrinsic heart disease)WBC > 10,000/mm3 or <4,000/mm3 or>10% band forms on differential
24Criteria for Severe SIRS Must meet criteria for SIRS, plus 1 of the following:Altered mental statusSBP<90mmHg or fall of >40mmHg from baselineImpaired gas exchangeMetabolic acidosis (pH<7.30 & lactate > 1.5 x upper limit of normal)Oliguria (<0.5mL/kg/hr) or renal failureHyperbilirubinemiaCoagulopathy (platelets < 80, ,000/mm3, INR >2.0, PTT >1.5 x control, or elevated fibrin degredation products)
25Pathophysiology of Sepsis Overwhelming inflammatory responseIncreased production of proimflamatory cytokines and decreased production of cytokines( which inhibit inflammation)Clotting cascade activatedPeripheral Vasodilatation systemic vascular resistance
26Pathophysiology of Sepsis continued C/O decreasesIntravascular fluid lossDecreased pre load-hypotensionATN-renal hypoperfusion and ischemic injuryMODSMOF
32Risk Factors for SIRS/Sepsis AgeIndwelling lines/cathetersImmunocompromised statesMalnutritionAlcoholismMalignancyDiabetesCirrhosisMale sexGenetic predisposition?
33PrognosisOverall mortality from SIRS/sepsis in the U.S. is approximately 20%. Mortality is roughly linearly related to the number of organ failures, with each additional organ failure raising the mortality rate by 15%. Hypothermia is one of the worst prognostic signs. Patients presenting with SIRS and hypothermia have an overall mortality of ~80%.
34Treatment Fluid Resuscitation Vasopressors Antibiotics Eradication of infectionVentilatory support, activated protein C, steroids, glycemic control, nutritionCRRT
36CRRT Definition CRRT = Continuous Renal Replacement Therapy Defined as “Any 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 /day.” ** Bellomo R., Ronco C., Mehta R, Nomenclature for Continuous Renal Replacement Therapies, AJKD, Vol 28, No. 5, Suppl 3, November 1996CRRT is the blanket term which encompasses all continuous therapies. It has been defined as ……read the slide. Make sure to note the proof source.
37Introduction to CRRT Why continuous therapies? Continuous therapies closely mimic the native kidney in treating ARF and fluid overloadSlow & gentleRemove fluid and waste products over timeTolerated well by the hemodynamically unstable patientThe continuous therapies provide a slow, gentle treatment of ARF and fluid overload very much like the native kidney.CRRT is generally well tolerated by critically ill, hemodynamically unstable patients. Moreover, control of azotemia, acid-base balance and fluid volume can easily be achieved with CRRT.
38Circulating Blood Volume Three Compartment Model2Intra-cellular SpaceExtra-cellular SpaceIntra-Vascular SpaceCirculating Blood VolumeToxinsFluidDialyzer23 L 17 L 40 Liters5 Liters
39Indications for Therapy Acute kidney injury- preferred in the critically ill patientFluid overload- can removed large amounts of fluid slowlyHemodynamically unstable- continuous therapy allow for slow hourly fluid removal which allows the intravascular spaces to refill
40Indications continued Highly catabolic patients who need increased clearance ratesPatients needing large molecular weight substances removedSepsis
43SCUF/Ultrafiltration Primary therapeutic goal:Safe management of fluid removalPatient UF rate ranges up to 2 L/HrNo dialysate;No replacement fluidsNo molecule removalLarge fluid removal via ultrafiltrationBlood Flow rates = ml/minSCUF…read the slide. Note that when using this therapy, significant amounts of fluid are removed from the patient. No dialysate or replacement fluid are used to increase solute removal. Ultrafiltration can be adjusted to cause dramatic fluid shifts. This therapy is best suited to severely hypervolemic patients (i.e. post OHS, post resuscitation, etc.) and is not generally employed for lengthy periods of time. It is not uncommon to remove fluid from the patient over a short (8-12 hr.) time period and then to D/C the treatment.
44Slow Continuous UltraFiltration SCUF/ULTRAFILTRATION Access Return EffluentSCUF/ULTRAFILTRATIONSlowContinuousUltraFiltrationAs this slide shows, the circuit for SCUF is a simple one. Blood enters the extracorporeal circuit through an access line, passes through the hemofilter, and returns to the patient circulation via the return line. As the blood passes through the filter, ultrafiltration takes place and effluent goes down the effluent waste line. Pumps control blood flow and fluid removal rates.
45UltrafiltrationParticles move through a semi-permeable membrane by use of HYDROSTATIC pressure. The separation of particles from a suspension by passage through a filter. The separation is accomplished by convective transport.
46Convection – Step 1 Filter Action Red CellNaKNaNaNaH2OH2OUH2ONaUNaNaURed CellH2OKH2OH2OKH2ORed CellUUNaNaURed CellH2ONaNaNaKNaUKH2OH2OKUH2OKH2OUNaNaNaH2OOn the left represents the filter with blood coming from the patient through the red tubes and yello represent the plasma water being filtered out of the patient. The figure on the right represents one of the red tubes and the action with the filter. Note the blood concentration of solutes (electrolytes) within the inner portion (blood) of the filter and concentration of solutes (electrolytes). With convection the plasma water is shifted from the patient to the outside of the filter, during this action the solutes (electrolytes) are dragged along with the plasma water. Of note: with convection, there’s a large amount of plasma water shifted or removed. See the next slide.UNaKKH2ORed CellUNaKH2ONaNaUK
47Solute Removal by Convection To illustrate convection, we go back to the use of the cups. The cup now has a concentrated solution on one side of the semipermeable membrane. As fluid moves (by ultrafiltration), solutes small enough to pass through the pores of the membrane move along with the fluid. Change in blood concentration of a specific solute is dependent on the fluid volume removed.Convection: The movement of solutes with a water-flow, “solvent drag”, e.g... the movement of membrane-permeable solutes with water across the semipermeable membrane
48Continuous Veno-Venous Hemofiltration Replacement(pre or post dilution)AccessReturnEffluentCVVHContinuous Veno-Venous HemofiltrationThis schematic represents a CVVH circuit. As I stated earlier, note that the replacement fluids (indicated by the dotted lines) can be delivered either pre or post filter. In the past replacement fluids were used to control patient’s fluid volume. No equipment was available to provide precise volume control and it was the nurse’s responsibility to calculate total patient intake and output every hour and compare that to the MD’s prescription. Invariably the doctor’s prescribed fluid removal and the actual volume removed were not equal, requiring either the addition of fluid to the patient or trying not to increase fluid removal for the next hour. More often than not, “catch up” was played and this volume infused was referred to as the replacement fluid. With the advent of precise control systems, integrated pumps are used to take the mystery out of fluid management. Solute removal is accomplished by convection. Note that the effluent waste line not only contains UF from the patient, but also the replacement fluid volume.
49Molecular Transport Mechanisms Convection - The movement of solutes with a water-flow, “solvent drag”, the movement of membrane-permeable solutes with water across the semipermeable membraneThere are a number of key scientific principles used to accomplish the goals of CRRT. They are listed here and before we discuss the individual therapies, I would like to review them. Understanding the principles of diffusion, ultrafiltration and convection will clarify which therapy will best produce the desired outcome whether used alone or in combination.
50Convection – Step 1 Filter Action Red CellNaKNaNaNaH2OH2OUH2ONaUNaNaURed CellH2OKH2OH2OKH2ORed CellUUNaNaURed CellH2ONaNaNaKNaUKH2OH2OKUH2OKH2OUNaNaNaH2OOn the left represents the filter with blood coming from the patient through the red tubes and yello represent the plasma water being filtered out of the patient. The figure on the right represents one of the red tubes and the action with the filter. Note the blood concentration of solutes (electrolytes) within the inner portion (blood) of the filter and concentration of solutes (electrolytes). With convection the plasma water is shifted from the patient to the outside of the filter, during this action the solutes (electrolytes) are dragged along with the plasma water. Of note: with convection, there’s a large amount of plasma water shifted or removed. See the next slide.UNaKKH2ORed CellUNaKH2ONaNaUK
51Solute Removal by Convection To illustrate convection, we go back to the use of the cups. The cup now has a concentrated solution on one side of the semipermeable membrane. As fluid moves (by ultrafiltration), solutes small enough to pass through the pores of the membrane move along with the fluid. Change in blood concentration of a specific solute is dependent on the fluid volume removed.Convection: The movement of solutes with a water-flow, “solvent drag”, e.g... the movement of membrane-permeable solutes with water across the semipermeable membrane
52CVVHD - Continuous VV Hemodialysis Primary therapeutic goal:Solute removal by diffusionSafe fluid volume management by ultrafiltrationRequires Dialysate solutionPatient UF rate ranges 2-7 L/24 hours (~300 ml/hr)Dialysate Flow rate = ml/min (~2 L/hr)Blood Flow rate = ml/minNo replacement solutionSolute removal determined by Dialysate Flow rate.The next therapy for discussion is CVVHD - continuous veno-venous hemodialysis. This therapy uses a dialysate on the fluid side of the filter to increase solute exchange by diffusion. Replacement fluid is not administered with this therapy. Dialysate is infused at ml/min (1-3 L/ hour). The blood flow rate is maintained between ml/min. This compares to intermittent HD that uses typical blood flow rates of ml/min and dialysate flow rates of ml/min.
53Diffusion – Filter Action NaNaKMgMgNaH2OUNaNaNaNaUH2OH2OUNaNaKKUNaMgH2OKH2ONaUNaUH2OKUH2OKH2OH2OUNaNaMgOn the left represents the filter with blood coming from the patient through the red tubes with the dialysate being infused to the outer portion of the filter in the opposite direction. The figure on the right represents one of the red tubes and the action with the filter. Note the blood concentration of solutes (electrolytes) within the inner portion (blood) of the filter and concentration of solutes (electrolytes). With diffusion the solutes will move from a high concentration to a low concentration until there’s equilibrium; the dialysate controls the amount of movement of solutes. Of note: with diffusion, minimal plasma water is shifted or removed.UNaUKH2ONaH2OUNaH2ONaKUKNaNaMgK
54Vascular Access Depending on the device used lumen size matters If using AquaDex FlexFlow Fluid Removal System midline catheters can be usedIf using CRRT devices hemodialysis type catheters need to be placed.
55Catheter Size Adults Children (weight based) 12.5 to 14 french Length will vary 16,19,24,cmFemoral placement least preferredChildren (weight based)5 french single catheter 7 fr dual lumen8 fr dual lumen10 fr dual lumen11 fr dual lumenLength9 cm, 10 cm, 12 cm, 15 cm
57Case Study #1Mr. G is a 60 year old man with CAD s/p MI and PTCA to LAD in 1997, dyslipidemia, and tobacco use who called 911 for severe chest pain on 11/01/10. This pain was similar in nature to his previous MI.
59HistoryIn the ambulance en route to the emergency room, the patient developed two episodes of ventricular fibrillation which both successfully responded to DC cardioversion. After arrival to the cath lab, the patient developed cardiogenic shock and recurrent ventricular fibrillation requiring multiple shocks (he was shocked 11 times in the cath lab prior to intervention) and intubation with mechanical ventilation.
60Cath Lab Course Coronary angiography showed: Totally occluded mid LAD with thrombusMild diffuse atherosclerosis of left circumflex and right coronary arteriesSoon after the first injection there was proximal propagation of the LAD thrombus which occluded the left main coronary arteryA wire was passed to the distal LAD and an AngioJet thrombectomy device was used which re-established flow
61Cath Lab CourseAfter the Impella device was placed, the patient had no further episodes of ventricular fibrillation
62Immediately Post CathPatient admitted to the CCU on IV Epinephrine, Dobutamine, and Dopamine continuous infusionsEchocardiogram the next day showed severe anterior wall hypokinesis with EF 25%The patient was placed on CVVH then on SCUF to remove excess fluid
63Hospital Course Hospital day 3: Impella device was removed Hospital Day 6: Repeat echocardiogram, EF 50-55%Hospital Day 8: Extubated, neurologically intactHospital Day 16: Discharged to home
64Case Study #2Alan is a 20 year old admitted to a cardiology unit with CHF and Situs Inversus. He had SOB , anascara, arrythmias. His blood pressure was 110/60 mm Hg. He has a serum creatinine of 1.5 mg/dl. He is in need of a pacemaker but first needs 10 liters of fluid removed before placement of a pacemaker.He is started on furosemide 80 mg every 8 hours and metolazone 10mg/d for 2 days. On day three he is given mannitol 25 g every eight hours.He is putting out 3L of urine a day but has only decreased his net fluid loss by 3 L due to lack of adherance to his fluid restriciton
65Case Study ContinuedBecause of his need for a pacemaker, the decision was made to place the patient on SCUF.After three days of therapy the patient was at his dry weight and stable and was able to receive his pacemakerConsideration has to be given related to rate of fluid removal and his overall renal functionPatient was discharged to home with a follow up to a nephrologist
66Case Study #3Mrs. D was admitted to MICU for sepsis. She had been hypotensive that required vasopressors. During the course of her stay in MICU, she developed AKI. To manage her fluid and electrolytes, she was started on CRRT. She seemed to tolerate CRRT well.On her 5th day of therapy, her Serum Creatinine was down to 1.2 from 6.9 and her electrolytes were stable, her BP was borderline with MAP > 60 mmHg and < 70 mmHg.CRRT was discontinued and only to be restarted after 2 days when the patient became hypotensive again that regular HD was not possible given her hemodynamic parameters.Patient was started on phenylephrine at 200 mcg/min and nor- epinephrine at 10 mcg/min. On the 3rd day of the 2nd therapy, the patient had the following data:
67Patient Data Time BP CVP I and O Balance 2/15 2200 125/60 14 Off -100 VasopressorI and OBalance2/125/6014Off-1002/110/6512-2502/73/856ON-11002/108/5510-500
68Questions What happened in this scenario? What should have been considered in setting the net fluid removal rate?How would we assess for the intravascular vs extra-vascular fluid status?When will be the right time to advocate for discontinuance of CRRT?
69CRRT IS NOT JUST FOR RENAL FAILURE ConclusionCRRT therapies can be applied to many clinical situationsThe patient goals/outcomes can be enhanced with early initiation of this therapyCRRT IS NOT JUST FORRENAL FAILURE