acute renal failre in icu

7/26/2019 Acute Renal Failre in ICU

1/51

cute Renal Failure in Intensive

Care Units

*High Mortality

* Mortality relates to severity of underlying condition

*Acute renal failure occurs as part of a complex of

multiple organ failure caused by infection sepsis

hypotension hypovolemia and drug therapy

*Fluid overload causes pulmonary edema

*Increase in interstitial !ater !ith "lea#y capillary"leading to impaired tissue perfusion

*Acid$base and electrolyte abnormalities

*%isseminated intravascular coagulation

*&oxic metabolites and drug accumulation*Fre'uently hemodynamic unstable

*Re'uired positive pressure ventilation


2/51

ropose r ter a or t e n t at on oRenal Replacement &herapy in Adult

Critically Ill (atients

1.Oliguria (urine output


3/51

Renal Replacement &herapy for

cute Renal Failure in Intensive

Care Units

*Intermittent therapies Intermittent

hemodialysis +IH%, extended daily

dialysis +-%%, slo! lo!$efficiency

dialysis +./-%,

*(eritoneal dialysis +(%,

*Continuous renal replacement therapy

+CRR&, .CUF C 0H C 0H% C 0H%F

C00H C00H% C00H%F


4/51

dvantages of CRR& Compared !ith

IH%

12CRR& maintains consistent homeostasis through slo!

gradual shifts in volume status and serum osmolality

32 CRR& avoids hypotensive or dyse'uilibrium episode

42CRR& permits continuous control of fluid balance and

reduces the need to restrict fluid administration

52CRR& re'uires a lo!er volume of blood to be

circulating outside the body

62CRR& has less effect on complement or leu#ocytes

72CRR& does not re'uire expensive e'uipment or extensive

training of personnel

82CRR& has greater clearance of mid$molecular !eight

solute


5/51

(rinciples of CRR&

%iffusion Movement ofsolute across asemipermeable membrne

from high concentration

to lo! concentration

Convection 9ater

affected by hydrostatic

pressure is transferred

across a membrane from

high pressure to lo!pressure2 Remove fluid

as !ell as solute

Adsorption affinity

gradient

%iffusion

Convection


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,on'etion '-. iu-ion


7/51

:perational Characteristics of CRR&Continuous Hemofiltration

* &ransport of solute is by convection based on a pressure gradient

Capacity of a solute to press through membrane expressed by sieving

coefficient +.,2

. ; Cufation

can influence sieving coefficient2

*Main determinant of . is extent of protein binding and for most

solutes e'uals the unbound fraction +a,2

* Convective clearance of solute ; Ultrafiltration rate

ClHF; ?f x . +a,


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:perational Characteristics of

CRR&

Continuous Hemodialysis

*.olute removal based on diffusion driven by concentration

gradient*/arge molecules more restricted and diffusive clearance

decreases !ith increasing molecular !eight

*In CRR& blood flo! rates exceed dialysate flo! rates thereby

resulting in complete e'uilibration bet!een blood and

dialysate*Capacity of solute to diffuse through membrane and saturation

dialysate is expressed as .d2

.d ; Cd


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&ypes of CRR& for &reating RF

(hysicochemical bases Urea

clearance +cc


10/51

Anticoagulation %uring CRR&*-fficacy of filter in fluid and solute removal

*:verall filter longevity

*:ptimum patient treatment

*Insufficiency filtration performance deteriorates

filter clot blood loss

*-xcessive bleeding complication* Modalities for anticoagulation

.aline solution Regional

citrate

Heparin

(rostacyclin

/M9 heparin afomostate

mesilate

Regional heparin o anticoagulant


11/51

.olution

*/actate RingerDs solution

*126E peritoneal dialysate solution

*icarbonate !ith dextrose

*icarbonate !ithout dextrose

ag A ag

1 liter =2GE aCl 1 liter =256E aCl

B= ml 8E aHC:4 1= ml 6E CaCl3

5 ml 16E Cl 5ml 1=E Mg.:5

ag A ag run 1 1

a 153 m-'


12/51

Important (arameter for CRR&Clinical data

* .#in turgor humidity of slin folds body !eight

* %etermination of total fluid loss

-stimate of fluid loss in !ound secretion and stool fluid

loss by perspiration insensiblities in relation to body

temperature respiration

* lood pressure pulse rate body temperature respiratory rate

* C0( (ulmonary capillary pressure

* Chest @$ray -J monitoring

Clinical chemistry

a Ca Mg ( Cl blood gas urea creatinine glucose

total protein albumin J:& J(& Al#$( cholesteroltriglyceride hemoglobin hematocrit leu#ocytes platelets

(& A(&&


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Joals of Continuous &herapy

-lectrolyte balance

a Cl Ca Mg C:3

Fluid balance

Medication &( Colloids

A>otemia control

U .cr (CR (hosphorus

Cyto#ine maniputation

Factor maniputation


14/51

Applications for CRR&

Renal Applicationvs on$renal

Application

Renal Application + Renal replacement and Renal support,

*Acute renal failure + specifically complicated ARF

!ith multiple organ failure and cardiovascular

failure,*:ligouric ARF needs large amount of fluid or nutrition

*Acute renal failure !ith cerebral edema

*Acute renal failure !ith hypercatabolism

*An alternative to H% in the mass casualty situation

*-lectrolytes and acid base disturbance


15/51

Renal Application vs on$renal

Applicationon$renal Application

*Hepatic failure complicated !ith hepatic coma

*Congestive heart failure refractory to diuretics

*:verhydration during K after cardiac surgery + C( ,

* .epsis

*/ife$threatening hyperthermia

*/actic acidosis

*Cyto#ine removal cute respiratory distress syndrome

* &umor lysis syndrome

*Crush inLury

*Inborn errors of metabolism maple syrup disease

urea cycle disorder


16/51

.ystemic Complications of Fluid Resuscitation

* JI tract

Fluid flux in stomach and intestine

Jut edema and loss of protein

%ecreased motility diarrhea

&issue hypoxia

* Heart

Myocardial edema

%ecreased cardiac function

* (ulmonary edema

* .#in

-dema

(oor !ound healing

%ecreased tissue :3

* Central nervous system

Cerebral edema

* Increased mortality


17/51

CRR& Fluid Removal vs Fluid

Regulation

Fluid removal Fluid

Regulation

Ultrafiltration rate &o meet anticipated needs

Jreater than +UFR,

anticipated needs

Fluid management dLust UFR dLust

amount of

replacement fluid

Fluid balance ero or negative balance (ositive

negative

or >ero balance

0olume removed ased on physician estimate %riven by

patient

characteristics

pplication -asy similar to Re'uires


18/51

-ffects of in vitro hemofiltration +HF,

on levels of inflammatory mediatorsAuthors Membrane Adsorption Convection

of

arrera et al 1GG3 (A &F I/$1 minimal for &F K

I/$1

/onneman et al 1GG4 (A and (. &F I/$1

aga#i et al 1GG3 (A and (. &F minimal &F

Ronco et al 1GG6 (. I/$1 I/$B (AF no &F

ro!n et al 1GG5 (A &F I/$1

Joldfarb et al 1GG5 (A I/$1

van ommel et al 1GG6 (A &F I/$1

I/$7


19/51

ec s o n vo emo ra on+HF, on /evels of Inflammatory

Mediators

Author Membrane Adsorption of Convection oellum et al2 1GGB A7G &Fa I/7 I

1=

Hoffmanne et al 1GG6 (A C4a C6a I/$

Andreasson et al 1GG4 (A C4a C6a

Riegel et al 1GG6 (. and (A C4aC6a I/$7

Nournois et al 1GG7 (A C4a &F I/$

17B1=

Jasche et al 1GG7 (A factor %

van ommel et al 1GG6 (. and (A &Fminimal for &F

ellomo et al 1GG4 (A &F I/$1

&onnessen et al 1GG4 (. I/$1 not I/$

Millar et al 1GG4 (A I/$7

ellomo et al 1GG6 (A I/$7 I/$BHeidemann et al 1GG5 (. &x3


20/51

(ost Cardiac .urgery RF

O Intra$operative support and post$operative problems

O a2 :xygenator membranes and cyto#ine generation

O b2 lood tubing and extraction of plastici>ers

+%-H(,

O

c2 (rolonged by$pass time and hemodynamicconse'uences

O Application of aggressive ultrafiltration in the cardiac

support of children and outcome improvement

O %ialysis variants added to extracorporeal cardiacsupport system

O a2 0A% and support

O b2 -CM: and support

O c2 IA( and support


21/51

dvantage of CRR& for utritonal

.upport

*Fluid restrictions are removed

*-lectrolyte overload is avoided

*Hyperosmolar nutrition solutions are safe

*CRR& result in a cumulative t

!ith the avoidance of repeatedly high pea# serum nitrogen

values

+ Clar# 9R et al2 N2 m2 .oc2 ephrol2 1GG5,


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Reasons for CRR&

6ehta et al. 7 Am 8 ephrol 1


23/51

(otential Complications !ith CRR&

&echnical Clinical

0ascular access leeding malfunction Hematomas

Circuit clotting &hrombosis

Circuit explosion Infection and

sepsisCatheter and circuit #in#ing Allergic

reactions

Insufficient blood flo! Hypothermia

/ine$catheter disconnection utrient losses

Fluid balance errors Insufficient

blood

purification

/oss of efficiency


24/51

omp ca ons o recor e n a o a

of 313 patients

Complication o

E

leeding 1BB25

Haematoma B

428

Access Malfunction 1

=25

/ine disconnection 18

B2=

Fre'uent filter clotting 6

324

&reatment$induced hypotension 8

424

Cannulation site infection 3

=2G

Hypothermia 5=2G


25/51

Recommendation for Initial

%ialysis Modality for ARF

Indication Clinical condition (referred

&herapy

Uncomplicated RF ntibiotic nephrotoxicity IH% (%

Fluid removal Cardiogenic shoc# CRR&

C( bypass

Uremia Complicated RF in ICU CRR&

IH%

Increased

intracranial pressure .ubarachnoid hemorrhage CRR&

) hepatorenal syndrome

).hoc# .epsis R%. CRR&

utrition urns CRR&


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ey (layers in CRR& (rogram

Administration

ICU physician

ephrologistICU nurses

Hemodialysis nurses

(harmacistsutritionists

&echnicians


27/51

,99: an Outome- in ,ritial

;llne--


28/51

99: '-. no 99: in the ;,

For RRT: Hyperkalemia kills

Pulmonary edemakills

Experience before

RRT available

Visible effects of

uremia

Against RRT Costs money

No RCT it makesany difference

Side effects


29/51

'- -tanar ;H

PD: Hemodynamic

stability Continuous therapy

Standard IHD: etter clearances

No !lycemic s"in!s No abdominal leaks

No splintin! of

diaphra!m

#ecreased risk of

infection


30/51

=ioompatile '-.

ioinompatile ialy-i-

Biocompatible: iolo!ic rationale

T"o RCTs sho"in!clinical advanta!e

Non issue if

convective CRRT

used

Bioincompatible: Cheaper

Some ne!ative RCTs

$po"er limitations%


31/51

&tanar ;H '-. ,99:

Standard IHD: cheaper in some parts

of the "orld $&S'%

CRRT: better volume control

hemodynamic stability

better a(otemic control

better nutrition

no cerebral edema

better renal recovery same cost in )elbourne


32/51

,hange- in [urea"7 ,99: '-. ;H

05

10

15

20

25

30

35

40

45

50

0 1 2 3 4 5 6

CRRT

IHD

van ommel et al* 'm + Nephrol ,--.

urea

$mmol/0%

p12*2.

#ays


33/51

,hange- in [reatinine"7

,99: '- ;H

0100

200

300

400

500

600

700

800

0 1 2 3 4 5 6

CRRT

IHD

3creat4

$mcmol/0%

p12*2.

#ays

van ommel 'm + Nephrol ,--.


34/51

Ahie'ing lui goal-7

,99: '-. ;H

0

5

10

15

20

25

30

ol!me

con"#ol

CRRT

IHD5 of patients

p12*2.

)ehta e al* +'SN ,--6 $abstract%


35/51

Ai>a-e homeo-ta-i-7 ,99: '-.

;H

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

$H

CRRT

IHD

Chan!e in pHafter 78 h of treatment p12*2.

ellomo et al* lood Purif ,--8


36/51

#ays of Treatment

)etabolic acidosis durin! RRT

3HC9:;4mmol/0

2

.

,2

,.

72

7.

:2

:.

82

HC9;2

HC9;,

HC9;7

HC9;:

HC9;8

HC9;.

HC9;6

HC9;;,

>;7

>;:

>;8

>;.

>;6

>;;=

>;-

>;,2

>;,,

>;,7

>;,:

Normali(ation of serum potassium durin! RRT

3>?4mmol/0

#ays of Treatment

p


38/51

,,.

,72

,7.

,:2

,:.

,82

,8.

,.2

,..

,62

Na;2

Na;,

Na;7

Na;:

Na;8

Na;.

Na;6

Na;

acute renal failre in icu

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