1. CRRT Continue Renal Replacement Therapy
CVVH
CVVHD
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.

4. Anti-coagulation 的方式 STANDARD HEPARIN TYPICAL REGIMEN IN CRRT :
Priming of the circuit ( 5000 IU / L )
Initial Heparin Bolus : 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

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

6. 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

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

8. 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 , Cl , dextrose % , no Ca++ , no base )
CaCL2 (0.75%) by central I.V at ml/hr,
Maintain ionized Ca++ at mmol/L

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

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

14. 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 U  
 min
>2.5 min

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
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.

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

17. 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 U  
 min
>2.5 min

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

20. 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 U  
 min
>2.5 min

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
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.