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Crrt
1. Introduction
• Main functions of the kidney:
maintenance of fluid balance
maintenance of acid base balance
elimination of waste products
• 20 –30 % of ICU patients develop AKI
• Many ICU are already on IHD
3. Intermittent Hemodialysis
• The gold standard
• Usually 2 –3 times a week for 3 –4 hours
• Involves a vascular access
• Pump, filter, dialysate& anticoagulation
5. Peritoneal Dialysis
• Simple and cheap, but …….
• Poor solute clearance
• Poor uremic control
• Risk of peritoneal infection
• Mechanical impedance
– Pulmonary and cardiovascular function
6. Continuous Renal Replacement Ther
• Concept-dialyze patients more physiolog
• Avoids the accumulation of waste produc
• Avoids the rapid shifts in volume & osmo
• Avoids disadvantages of Peritoneal Dialy
7. Advantages
• Precise volume control
• Very effective control of uremia and ↑ K⁺
• Rapid control of metabolic acidosis
• Suitable for hemodynamicallyunstable pt
• Improved nutritional support
– (no need for volume restriction)
8. Advantages
• Needs minimal training
• Safer for patients with TBI & CVS disorde
• May have an effect in sepsis
• Probable advantage in terms of renal rec
15. Ultrafiltration
• The passage of water through a membra
under a pressure gradient.
• Driving pressure can be
+ve(push fluid through the filter)
–ve(pull fluid to other side of filter)
• Pressure gradient is created by effluent p
17. Convection
• Movement of solutes through a membran
the force of water.
“solvent drag”
• The water pulls the molecules along with
it flows through the membrane.
• Can remove middle and large molecules,
well as large fluid volumes.
• Maximized by using replacement fluids.
21. Adsorption
• Adsorptionis the removal of solutes from
blood because they cling to the membra
– Think of an air filter. As the air passes throug
impurities cling to the filter itself.
– Eventually the impurities will clog the filter a
will need to be changed.
• The same is true in blood purification. Hi
levels of adsorptioncan cause filters to cl
and become ineffective
24. Replacement Fluids
• Used to increase the amount of convecti
solute removal in CRRT.
• Replacement fluids do not replace a
• Fluid removal rates are calculated
independently of replacement fluid rates
• The common replacement fluid is 0.9% s
• Can be pre or post filter.
26. Comparison Pre & Post Dilutio
PRE-FILTER
– Increases filter life
– Increases convective
transport
– Reduced solute clearance
– Some of delivered
replacement fluid lost by
hemofiltration
– Lower anticoagulation
requirements
– Higher UF required given
loss of replacement fluid
through filter
POST-FILTER
– No solute dilution,
improved diffusion and
solute clearance
– Increased
hemoconcentration
– Higher delivered dose
of hemofiltration
27. Indications
• Acidemia(pH <7.1)
• Electrolytes
– Hyperkalemia(K⁺ > 6.5 mEq/L)
– Severe dysnatremia(Na⁺ <115 or >160 mEq/L)
• Ingestions (Toxins, Drugs)
• Overload/ Oliguria(urine output <200 mL/12
• Uremia (urea >30 mg/dL)
– Uremic encephalopathy
– Uremic pericarditis
– Uremic neuro-myopathy
A E I O U
29. Timing
• Inadequate data available to answer this
• Observational data suggests better outco
are associated with early RRT initiation
Getting et al 1999
2
. Urea 15.2 vs33.7 conferred survival benefit.
Roncoet al 2000
3
and Saudanet al 2006
4
both dose/outcome studies suggested an early
start.
Liu et al 2006
5
observational PICARD study (Urea 27) suggested an early start
– RENAL study, NEJM 2009, 1508 pts.
– Demirkilic2004, Elahi2004, Piccini2006
31. • CRRT includes several treatment modalities
that use a veno-venous access.
• The choice will depend on the needs of the
patient and on the preference of the
physician.
CRRT Modalities
32. • Removal of ultrafiltrateat low rates
• without administration of a substitution solution.
• The purpose is to prevent or treat volume ove
• when waste product removal or pH correction isn’
necessary.
• Primary indication for SCUF -fluid overload
• Mechanism of water transport is Ultrafiltratio
• No dialysate or replacement fluid is used.
33. • Other solutes are removed but are neglig
• The amount of fluid in the effluent bag is
same as the amount removed from the p
• Removal rates are closer to 100 ml/hour
35. Let’s Revise
• Primary therapeutic goal:
– Safe management of fluid
• Primary indications:
– Fluid overload without metabolic imbalance
• Principle used:
Ultrafiltration
• Therapy characteristics:
– No dialysateor substitution solutions
Fluid removal only
36. • Blood flow:
80 –200 ml/min
• Duration:
(as advised by the physician)
• Ultrafiltration:
20-100 ml/hr (or total volume)
• Anticoagulation…. Acc to physician
• Dialysate…….. NO
• Replacement fluid….. NO
37. • An extremely effective method of solute remov
is indicated for uremia or severe pH or electrol
imbalance with or without fluid overload.
• Particularly good at removal of large molecule
because CVVH removes solutes via convection
• Convective removal of waste products (small a
large molecules) utilizing a substitution solutio
• pH is affected with the buffer contained in the
substitution solution.
38. • Solutes can be removed in large quantiti
while easily maintaining a net zero or ev
positive fluid balance in the patient.
• The amount of fluid in the effluent bag is
equal to the amount of fluid removed fro
the patient plus the volume of replaceme
fluids administered.
• No dialysate is used.
40. Let’s Revise
• Primary therapeutic goal:
– Solute removal and safe fluid management
• Primary indications:
– Uremia, severe acid/base or electrolyte imbala
– Removal of larger mol wt substances
• Principle used:
convection
• Therapy characteristics:
– Substitution solution to drive
– No dialysatesolution
Effective at removing small and large molecules
41. • Blood flow:
80 –200 ml/min
• Duration:
As advised by physician
• Ultrafiltration:
20-100 ml/hr (or total volume)
• Replacement Fluid:
1000 –2000 ml/hr,preor post filter
• Anticoagulation
• Dialysate…. NO
Dosage:
30ml/kg/hr
70x30=2100ml
Replacement fluid
So
This Replacement can be
divided into pre & post filte
Depending upon physician
Ex, 500 pre and 1500ml po
(All can be pre or post)
42. • Effective for removal of small to medium sized m
• Solute removal occurs primarily due to diffusion
• No replacement fluid is used.
• Dialysateis run on the opposite side of the filter.
• Fluid in the effluent bag is equal to the amount o
removed from the patient plus the dialysate.
• Continuous diffusive removal of waste products
molecules) utilizing a dialysis solution.
• pH is also affected with the buffer contained in t
dialysate.
44. • Blood flow:
80 –200 ml/min
• Duration:
As advised by physician
• Ultrafiltration:
20 -100 ml/hr (or total volume)
• Anticoagulation:
• Dialysate:
600 –1800 ml/hr (up to 3 lit/hr).
• Replacement fluid….NO
Dosage:
45ml/kg/hr
70x45=3150ml
Dialysatefluid
So
Dialysatecan be 3 liters /
45. Let’s Revise
• Primary therapeutic goal:
– Solute removal and safe management of fluid volume
• Primary indications:
– Uremia, severe acid/base or electrolyte imbalance
• Principle used:
Diffusion
• Therapy characteristics:
– Requires dialysatesolution to drive diffusion
– No substitution solution
Effective at removing small to medium molecu
46. • The most flexible of all the therapies, an
combines the benefits of diffusionand
convectionfor solute removal.
• The use of replacement fluid allows adeq
solute removal even with zero or positiv
fluid balance for the patient.
47. • Amount of fluid in the effluent bag equals the fl
removed from the patient plus the dialysate an
replacement fluid.
• Dialysate on the opposite side of the filter and
replacement fluid either before or after the filte
• Continuous diffusive and convective removal o
waste products (small and large molecules)
• Utilizing both dialysate and substitution solutio
• pH is also affected with the buffer contained in
dialysate and substitution solution.
49. Let’s Revise
• Primary therapeutic goal:
– Solute removal and safe management of fluid volume
• Primary indications:
– Uremia, severe acid/base or electrolyte imbalance
– Removal of large molecular weight substances is required
– Unstable haemodunamics
• Principle used:
diffusion and convection
• Therapy characteristics:
– Requires dialysatefluid and substitution solution
drive diffusion and convection
• Effective at removing small, medium and la
molecules
50. • Blood flow:
80 –200 ml/min
• Duration:
As advised by the physician
• Ultrafiltration:
20-100 ml/hr (or total volume)
• Anticoagulation:
• Dialysate:
600 –1800 ml/hr (up to 3 lit/hr)
• Replacement fluid:
1000-2000 ml/hr, pre or post filter(up to 3 lit/hr)
Dosage:
45ml/kg/hr
70x45=3150ml
½ as Dialysate& ½ as
Replacement fluid
So
1500ml as Dialysate
1500ml as Replacement
be divided into pre & po
filter
Depending upon physicia
Ex, 500 pre and 1000ml p