Acute Renal Failure ICU Grand Rounds

It’s April…Your Patient has Acute Renal Failure…Now What? Critical Care Grand Rounds Jennifer Hancock, MD, FRCPC, CCM Jan 15, 2009

Objectives ,[object Object],[object Object],[object Object],[object Object]

Case 1 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Case 2 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Both patients have ARF presumed secondary to ATN… Now what????

Why Worry About Acute Renal Failure? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Acute Dialysis Quality Initiative: RIFLE Criteria GFR Criteria U/O Criteria Cr  1.5X N GFR  >25% Cr  2X N GFR  >50% Cr  3XN or >354 GFR  >75% <0.5 cc/kg/hr X 6hr <0.5 cc/kg/hr X 12hr <0.3cc/kg/hr X 24hr Persistent loss > 4wks ESRD >3/12 R isk I njury F ailure L oss E SKD Crit Care Med 2004;8:204-212

Validation of the RIFLE Criteria ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Australian study of 21,000 patients Crit Care Med 2006;34:1913-1917

Acute Renal Failure in the ICU ,[object Object],[object Object],[object Object],[object Object]

What Has Happened to the Kidneys? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],NEJM 1995:332;647 Crit Care Med 2008:36;S198

So What…How Do We Help? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Acute Dialysis Options: What do we know? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Timing of RRT ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],J Card Surg 2004:17 Clin J Am Soc Nephrol 2006;915  lung function  vent free days  ICU stay NEJM 2006:354;2564 Ann Surg 2003:238;641

QEII CRRT Orders ,[object Object],[object Object],[object Object],[object Object],[object Object]

CRRT Filters ,[object Object],[object Object],[object Object]

CRRT Mode ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

CVVHD - Hemodialysis ,[object Object],[object Object],[object Object],Blood from patient Blood to patient Dialysate flow

CVVH - Hemofiltration ,[object Object],Blood from patient Blood to patient High Pressure Low Pressure Replacement Fluid

CVVHDF - HemoDiafiltration ,[object Object],Blood from patient Blood to patient Dialysate flow High Pressure Low Pressure Replacement Fluid High Concentration Low Concentration

CRRT Practice Patterns Crit Care Resus 2008: 10; 225

Dosing in All Causes of ARF ,[object Object],[object Object],[object Object],[object Object],NEJM 2008:359;E1

Determining Dose in CVVHDF ,[object Object],[object Object],[object Object],[object Object],[object Object]

Sepsis, Dosing & Hemofiltration ,[object Object],[object Object],[object Object],Semin Dial 2006:19;69

Sepsis, Dosing & Hemofiltration ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Intensive Care Med 2008: 34; 1646

Anticoagulation ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Types of Anticoagulation ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Prostacyclin ,[object Object],[object Object],[object Object],[object Object],[object Object],Crit Care 2007:11;218

Regional Citrate ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Citrate Anticoagulation Filter Effluent Waste Citrate Ca Replacement Fluid

Citrate Anticoagulation ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Crit Care 2007:11;218

Citrate Toxicity & the Citrate Ratio ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Anticoagulation at the QEII ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Replacement Solutions ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Starting someone on CRRT at the QEII ,[object Object],[object Object],[object Object],[object Object],[object Object]

Starting someone on CRRT at the QEII ,[object Object],[object Object],[object Object],[object Object]

Starting someone on CRRT at the the QEII ,[object Object],[object Object],[object Object],[object Object]

Putting it Together ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Remember: Dose = Replacement + Dialysate Dose = 70kg x 20ml/kg/hr =1.4 L/hr 1/2 given as replacement and dialysate

Putting it together…. ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Remember: Dose = Replacement + Dialysate Dose = 85kg x 20ml/kg/hr =1.7 L/hr 1/2 given as replacement and dialysate

Drugs and Dialysis ,[object Object],[object Object],[object Object],[object Object],[object Object],Sieving Coefficient Protein Binding Membrane Type Ultrafiltration Rate Molecular Size

Future Directions ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Acute Renal Failure ICU Grand Rounds

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Acute Renal Failure ICU Grand Rounds