Crrt domyat-final

1. Dr. Osama El-Shahat
Consultant Nephrologist
Head of Nephrology Department
New Mansoura General Hospital (international)
ISN Educational Ambassador

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 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 Extended time 24 -72 h.
Bellomo R., Ronco C., Mehta R, Nomenclature for Continuous Renal Replacement Therapies, AJKD, Vol 28, No. 5, Suppl 3, November 1996

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Renal Indications
Life-threatening
indications
Hyperkalemia
Metabolic Acidosis
Pulmonary edema
Uremic complications
Non Renal Indications
Fluid removal in congestive
heart failure& Fluid
management in multiorgan
failure
Cytokine manipulation in
sepsis
Treatment of drug overdose
Nutrition support

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Mode of
therapy
Principle method of
solute clearance
CVVH Convection
CVVHD Diffusion
CVVHDF Convection & Diffusion
SCUF Ultrafiltration (fluids)

13. SCUF
Syringe pump
Return Pressure Air Detector
Blood Pump
Access PressureFilter Pressure
BLD
Hemofilter
Patient
Effluent Pump
Return Clamp
Pre Blood Pump
Effluent Pressure

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CVVHF
Return Pressure Air Detector
Return Clamp
Patient
Access Pressure
Syringe Pump
Hemofilter
Post
Replacement Pump Pre Blood Pump
Replacement Pump
Pre
Effluent Pump
Effluent Pressure
Filter Pressure

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CVVHD
Return Pressure Air Detector
Return Clamp
Access Pressure
Blood PumpSyringe Pump
Filter Pressure
Hemofilter
Patient
Effluent Pump Pre Blood Pump
BLD
Effluent Pressure
Dialysate Pump

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CVVHDF
Return Pressure Air Detector
Return Clamp
Patient
Access Pressure
Syringe Pump
Hemofilter
Pre Blood Pump
Replacement Pump
Pre
Effluent Pump
Effluent Pressure
Filter Pressure
Dialysate Pump

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Ronco C et al Kidney Int 56 ( suppl 72 ) s-8-s-14 , 1999

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 5.6.2: We suggest using CRRT, rather than standard
intermittent RRT, for hemodynamically unstable patients. (2B)
 5.6.1: Use continuous and intermittent RRT as complementary
therapies in AKI patients. (Not Graded

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 5.4.1: We suggest initiating RRT in patients with AKI via an uncuffed
nontunneled dialysis catheter, rather than a tunneled catheter. (2D)
 5.4.2: When choosing a vein for insertion of a dialysis catheter in
patients with AKI, consider these preferences (Not Graded):
 First choice: right jugular vein;
 Second choice: femoral vein;
 Third choice: left jugular vein;
 Last choice: subclavian vein with preference for the dominant side.
Vascular access
KDIGO® AKI Guideline March 2012

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• 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
Vascular access

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• 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 aware what you replace

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Bicarbonate versus lactatebased fluid replacement in CVVH
Prospective, randomized study
Results
 Serum lactate concentration was
significantly higher and the
bicarbonate was lower in patients
treated with lactatebased solutions
 Increased incidence of CVS events in
pts ttt with lactate solution
◦ Hypotension
◦ Increased dose of inotropic support
barenborck and colleague
Barenbrock M et al; Kidney Int (2000
Replacement Fluids

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 5.5.1: We suggest to use dialyzers with a biocompatible membrane
for IHD and CRRT in patients with AKI. (2C)
 High Flux membrane , synthetic , biocompatable ,
acting by providing both methods of detoxications:
A. Diffusion : for low molecular weight toxins.
B. Convection : for large molecules.
KDIGO® AKI Guideline March 2012

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Modality Advantages Disadvantages
Heparin Good anticoagulation Thrombocytopenia bleeding
LMWH Less thrombocytopenia bleeding
Citrate Lowest risk of bleeding
Metabolic alkalosis,
hypocalcemia special dialysate
Regional Heparin Reduced bleeding Complex management
Saline flushes No bleeding risk Poor efficacy
Prostacycline Reduced bleeding risk Hypotension poor efficacy

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• 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

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• 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

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• 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

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◦ 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

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ESNT-CNE 2nd Course, Cairo Jan 2-5, 2013
Mr. Smith, 60 kg, ARF
Required dose: 35ml/kg BW/hr CVVHDF
◦Pre: 30%
◦Post:70%
◦Pt., fluid removal: 100 ml/hr
◦Dialysate: ?????
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Calculation: 60kg x 35 ml/kg/h = 2100 ml/h
Flow rates
1000 ml Dialysate
1000 ml Replacement
700 ml Post-Replacement
300 ml Pre-Dilution (PBP)

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ESNT-CNE 2nd Course, Cairo Jan 2-5, 2013
Mrs. Jones, 100 kg, Polytrauma with Rhabdo
Required dose: 35ml/kg BW/hr
Mode: CVVHDF
◦Pre-Replacement : 50% Post 50%
◦Pt. fluid removal: 200 ml/hr
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Calculation: 100kg x 35 ml/kg/h = 3500 ml/h
Flow rates:
1650ml Dialysate
1600ml Replacement
800 ml Post-Replacement
800 ml Pre-Replacemnt

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ESNT-CNE 2nd Course, Cairo Jan 2-5, 2013
TYPICAL REGIMEN IN CRRT :
o Priming of the circuit ( 5000 IU / L )
o Initial Heparin Bolus : 5 - 8 IU / kg
o 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
AKI: Renal Replacement Therapy (RRT)
CRRT: Anticoagulation
STANDARD HEPARIN

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Acute Renal Failure Sepsis Rhabdomyolyse
Dose (ml/kg/BW/hr) 35 50 35
Blood flow (ml/min) 150-350 250-450 > 150
Patient 60 kg
Dialysate
Replacement Post
Replacement Pre = PBP
60 x 35 = 2100 ml
900 ml
400 ml
800 ml
60 x 50 = 3000 ml
1200 ml
600 ml
1200 ml
60 x 35 = 2100 ml
500 ml
550 ml
1050 ml
Patient 70 kg
Dialysate
Replacement Post
Replacement Pre = PBP
70 x 35 = 2450 ml
1000 ml
450 ml
1000 ml
70 x 50 = 3500 ml
1300 ml
700 ml
1400 ml
70 x 35 = 2450 ml
500 ml
650 ml
1300 ml
Patient 80 kg
Dialysate
Replacement Post
Replacement Pre = PBP
80 x 35 = 2800 ml
1000 ml
600 ml
1200 ml
80 x 50 = 4000 ml
1400 ml
900 ml
1800 ml
80 x 35 = 2800
500 ml
750 ml
1550 ml
Patient 90 kg
Dialysate
Replacement Post
Replacement Pre = PBP
90 x 35 = 3150 ml
1050 ml
700 ml
1400 ml
90 x 50 = 4500 ml
1500 ml
1000 ml
2000 ml
90 x 35 = 3150
500 ml
900 ml
1750 ml