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Continuous Renal Replacement Therapy

Jai Radhakrishnan, MD, MS

History of the CRRT program1988 Open heart program Active transplant program Deep dissatisfaction with peritoneal dialysis in hemodynamically unstable patients

ObjectivesPhysiologic principles Patient Selection for CRRT Modality Selection Prescription Variables Fluid Composition Management of Fluid and Electrolyte problems Controversies

Basic Concepts

Pressure

Convection(Plasma water moves along pressure gradients)

Continuous Renal Replacement TherapySCUF CVVH CVVHD CVVHDF

Therapy OptionsAccess

Return

SCUF:Slow Continuous Ultra FiltrationP R I S M A

Maximum Patient Fluid Removal Rate = 2000 ml/hr

Effluent

Therapy OptionsAccess Return

CVVHContinuous Veno-Venous HemoFiltrationP R I S M A

Replacement

Effluent

Maximum Patient Fluid Removal Rate = 1000 ml/hr

Therapy OptionsAccess Dialysate Return

CVVHDContinuous Veno-Venous HemoDialysisMaximum Patient Fluid Removal Rate = 1000 ml/hrP R I S M A

Effluent

Therapy OptionsAccess Dialysate Return

CVVHDFContinuous Veno-Venous HemoDiafiltrationMaximum Pt. fluid removal rate = 1000 ml/hr

P R I S M A

Replacement

Effluent

A Case35 year old female is s/p OHT, POD#1. Remains intubated, MAP 65 on Levo 20, Pit 3, Milrinone 0.25 Urine output 10 ml.hour (Intake 150ml/h) PAD 20 FiO2 0.60- ABG 7.45/35/102 BMP 132/4.6/103/18/25/1.3 (Baseline 1.0)

Indications for Renal ReplacementStandard indicationsVolume overload Hyperkalemia Metabolic Acidosis Uremic Platelet Dysfunction Uremic Encephalopathy

Modality Selection

Volume only

SCUF CVVH CVVHD CVVHDF CVVHDF

Solutes +/- Volume

Hypercatabolic +/- Volume

Prescription VariablesDialysate Access

Blood Flow Up to 180 ml/min Replacement Up to 4500 ml/hr Dialysate up to 2500 ml/hr Patient Fluid Removal Up to 2000 ml/hrP R I S M A

Return

Replacement

Effluent

Fluid Composition: DialysatePrismasate 5000mL Na+ = 140 mEq/L K+ = 0 mEq/L Cl- = 109.5 mEq/L Ca2+ = 3.5 mEq/L Mg2+ = 1 mEq/L Lactate = 3 mEq/L HCO3 = 32 mEq/L Glucose = 0 mg/dL

Premixed Dialysate 5000mL Na+ = 140 mEq/L K+ = 2.0 mEq/L Cl- = 117 mEq/L Ca2+ = 3.5 mEq/L Mg2+ = 1.5 mEq/L Lactate = 30 mEq/L Glucose = 100 mg/dL

Peripheral Electrolyte ReplacementIn the event of high volume Bicarbonate solutions, if Ca free:Peripheral CaCl2/MgSO4

In the event of high clearance:prn Na phosphate

Solutes: AzotemiaAzotemiaIncrease replacement fluid and/or dialysate flow rate

Solutes: SodiumHyponatremiaAdd 3% NaCl to dialysate @70 cc/5L bag

HypernatremiaIncrease peripheral IV D5W (1L) or 1/2 NS

Solutes: K1 L bag Add 0 mEq / Liter Add 3 mEq / Liter Add 4 mEq / Liter None 7.5 mL 10 mL 5 L bag None 37.5 mL 50 mL Serum Potassium > 5.5 mEq / Liter > 4.5 5.5 mEq / Liter < 4.5 mEq / Liter

Hyperkalemia Zero K+, increase replacement and/or dialysate flow rate

Solutes: pHMetabolic AcidosisNaHCO3 (50%) 100 cc over 1 hour IVSS, prn Change replacement to D5W (1L) + 3 amps NaHCO3

Metabolic AlkalosisChange replacement solution to NS + sliding scale KCl

Solutes: CalciumHypercalcemiaChange to HCO3 dialysate (Ca2+ free) Increase HCO3 dialysate or replacement flow rate

HypocalcemiaCaCl2 (10%) 10 cc/100 cc NS or D5W over one hour, prn Premixed calcium drip

Solute: Mg and PhospateHypomagnesemiaMgSO4 (50%) 2 ml in 100 cc NS or D5W over one hour, prn Premixed magnesium drip

HypermagnesemiaSame as Rx for hypercalcemia

HypophosphatemiaNa Phosphate (3 mmol/ml) 5cc in 100cc NS IVSS over 2 hours, prn (repeat x 1 if PO4 48 h despite 1 g IV furosemide)

CONTROLS50%

CVVH5%

25%

3%

Mortality In hospital One-year

14% 30%

2% 10%

Complications