CRRT Continue Renal Replacement Therapy CVVH CVVHD CVVHDF

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 ….)

Procedure共同處 Driving force : external pump Circuit : Venovenous Dialysis solutions :一般使用1.5% PD solution Replacement fluid : several types of replacement fluid can be used , depending on patient requirements ,一般使用 pre-dilution 方式.

Anti-coagulation 的方式 STANDARD HEPARIN TYPICAL REGIMEN IN CRRT : Priming of the circuit ( 5000 IU / L ) Initial Heparin Bolus : 5 - 8 IU / kg Infuse Heparin at : 5 to 12 IU / kg / hr ACT on post filter : Adjust heparin rate to keep ACT between 1.5 & 2.0 times

STANDARD HEPARIN ADVANTAGES Easy to perform Useful method Inexpensive DISADVANTAGES Occasional Thrombocytopenia Hemorrhagic Risk with Bleeding patient

LOW MOLECULAR WEIGHT (LMW) HEPARIN TYPICAL REGIMEN IN CRRT : Priming of the circuit : 20 mg in 1 L Maintenance 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

LOW MOLECULAR WEIGHT (LMW) HEPARIN DISADVANTAGES Expensive Special and difficult monitoring With low doses frequent filter clotting ADVANTAGES Decreased Risk of Bleeding

Regional Citrate Anticoagulation TYPICAL REGIMEN : Citrate anticoagulation is always regional Citrate infusion (4%) at 170 ml/hr initially Special Dialysate at 1 liter/hr ( Na+ 117 , K+ 4 , Mg++ 1.5 , Cl- 121.5 , dextrose 0.5- 2.5% , no Ca++ , no base ) CaCL2 (0.75%) by central I.V at 40-60 ml/hr, Maintain ionized Ca++ at 0.96- 1.20 mmol/L

Citrate ADVANTAGES : No Bleeding No Thrombocytopenia Improved Filter Life and Efficacy DISADVANTAGES : Complex for the set up Ca++ monitoring needed Occasional Alkalosis

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

Dialysis modalities in the ICU

CVVH配置簡圖 CVVH Continuous Veno-Venous Hemofiltration CVVH 模式下, 置換液流速 P R I S M A CVVH Continuous Veno-Venous Hemofiltration CVVH 模式下, 置換液流速 最高可達4500ml/hr

CVVH order l    Prepare Heparin 2cc + N/S 3cc, then inject 1.6cc into each femoral cath. l  For AK priming: (GAMBRO, Polyarylethersulfone, 6S) *1st N/S 1000cc. *2nd Heparin 2,500U. *3rd N/S 500cc. l     *Prepare Heparin 25,000U + N/S 500cc IVD 10cc/hr with pump to keep aPPT 1.5-2 and adjust as followed: aPPT bolus hold dose(cc/hr) <1.0 2000U - +4 1.0-1.5 - - +2 1.5-2.0 - - - 2.0-2.5 - 30min -2 >2.5 - 60min -4

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

CVVHD配置簡圖 CVVHD Continuous Veno-Venous Hemodialysis P R I S M A

CVVHD order l    Prepare Heparin 2cc + N/S 3cc, then inject 1.6cc into each femoral cath. l  For AK priming: (GAMBRO, Polyarylethersulfone, 6S) *1st N/S 1000cc. *2nd Heparin 2,500U. *3rd N/S 500cc. l     *Prepare Heparin 25,000U + N/S 500cc IVD 10cc/hr with pump to keep aPPT 1.5-2 and adjust as followed: aPPT bolus hold dose(cc/hr) <1.0 2000U - +4 1.0-1.5 - - +2 1.5-2.0 - - - 2.0-2.5 - 30min -2 >2.5 - 60min -4

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.

CVVHDF配置簡圖 P R I S M A CVVHDF Continuous Veno-Venous Hemodiafiltration

CVVHDF order l    Prepare Heparin 2cc + N/S 3cc, then inject 1.6cc into each femoral cath. l  For AK priming: (GAMBRO, Polyarylethersulfone, 6S) *1st N/S 1000cc. *2nd Heparin 2,500U. *3rd N/S 500cc. l     *Prepare Heparin 25,000U + N/S 500cc IVD 10cc/hr with pump to keep aPPT 1.5-2 and adjust as followed: aPPT bolus hold dose(cc/hr) <1.0 2000U - +4 1.0-1.5 - - +2 1.5-2.0 - - - 2.0-2.5 - 30min -2 >2.5 - 60min -4

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