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CRRTContinue Renal Replacement Therapy
1. CVVH
2. CVVHD
3. CVVHDF
Indications
• In critically ill patients with renal failure and hemodynaemic instability
• For patients in whom continuous removal of volume or toxic substance is desirable ( as in septic shock , AMI , severe GI bleeding ,ARDS or condition with or at risk for cerebral edema ….)
Procedure 共同處
1. Driving force : external pump2. Circuit : Venovenous3. Dialysis solutions : 一般使用 1.5% PD so
lution4. Replacement fluid : several types of replac
ement fluid can be used , depending on patient requirements , 一般使用 pre-dilution 方式 .
Anti-coagulation 的方式• STANDARD HEPARIN
• TYPICAL REGIMEN IN CRRT :Priming of the circuit ( 5000 IU / L )Initial Heparin Bolus : 5 - 8 IU / kg Infuse Heparin at : 5 to 12 IU / kg / hrACT on post filter : Adjust heparin rate to
keep ACT between 1.5 & 2.0 times
STANDARD HEPARIN
• ADVANTAGESEasy to performUseful methodInexpensive
DISADVANTAGES• Occasional
ThrombocytopeniaHemorrhagic Risk
with Bleeding patient
LOW MOLECULAR WEIGHT (LMW) HEPARIN
• TYPICAL REGIMEN IN CRRT :Priming of the circuit : 20 mg in 1 LMaintenance dose : 10 to 40 mg q6 hrs
Monitor anti- factor Xa (aXa) units . Adjust between 0.1 and 0.4 µ/ml
Different Dosages for LMW heparin
LOW MOLECULAR WEIGHT (LMW) HEPARIN
• ADVANTAGESDecreased Risk
of Bleeding
• DISADVANTAGESExpensiveSpecial and difficult
monitoringWith low doses
frequent filter clotting
Regional Citrate Anticoagulation
• TYPICAL REGIMEN :Citrate anticoagulation is always regional Citrate infusion (4%) at 170 ml/hr initiallySpecial Dialysate at 1 liter/hr ( Na+ 117 ,
K+ 4 , Mg++ 1.5 , Cl- 121.5 , dextrose 0.5- 2.5% , no Ca++ , no base )
CaCL2 (0.75%) by central I.V at 40-60 ml/hr,Maintain ionized Ca++ at 0.96- 1.20 mmol/L
Citrate
• ADVANTAGES :No BleedingNo
ThrombocytopeniaImproved Filter
Life and Efficacy
• DISADVANTAGES :Complex for the set upCa++ monitoring neededOccasional Alkalosis
Heparin- free methos
• Normal saline flush
• Used in patients with
1. Severe liver disease
2. Acitve or recent bleeding
3. Heparine-induced thrombocytopenia
4. Post-op patients
Dialysis modalities in the ICU
CVVH 配置簡圖
CVVHContinuous Veno-Venous Hemofiltration
PRISMA
CVVH CVVH 模式下模式下 , , 置換液流置換液流速速最高可達最高可達 4500ml/hr4500ml/hr
CVVH order Prepare Heparin 2cc + N/S 3cc, then inject 1.6cc into each femoral
cath. For AK priming: (GAMBRO, Polyarylethersulfone, 6S) *1st N/S 1000cc. *2nd Heparin 2,500U. *3rd N/S 500cc. *Prepare Heparin 25,000U + N/S 500cc IVD 10cc/hr with pump to
keep aPPT 1.5-2 and adjust as followed: aPPT bolus hold dose(cc/hr) <1.0 2000U - +4 1.0-1.5 - - +2 1.5-2.0 - - - 2.0-2.5 - 30min -2 >2.5 - 60min -4
CVVH order• If non-heparin , N/S 200cc q ½ hr to rinse the AK• Predilution run 500cc/hr alternately as followed via artery e
nd 1st bottle N/S 500cc + Sinca 1amp
2nd bottle N/S 500cc + 10% MgSO4 4cc 3rd bottle N/S 500cc 4th bottle D5W 500cc + NaHCO3 5amp • Warm dialysate to 37C• Record I/O and BP q1hr• UF target I-O ( ) cc/hr• Check BUN,Crea,Na,K,Cl,aPPT q6hr for 1 day & then q8hr.• Check Ca,P,Mg qd.
CVVHD 配置簡圖CVVHD
Continuous Veno-Venous Hemodialysis
PRISMA
S
CVVHD order
Prepare Heparin 2cc + N/S 3cc, then inject 1.6cc into each femoral cath.
For AK priming: (GAMBRO, Polyarylethersulfone, 6S) *1st N/S 1000cc. *2nd Heparin 2,500U. *3rd N/S 500cc. *Prepare Heparin 25,000U + N/S 500cc IVD 10cc/hr with pump to
keep aPPT 1.5-2 and adjust as followed: aPPT bolus hold dose(cc/hr) <1.0 2000U - +4 1.0-1.5 - - +2 1.5-2.0 - - - 2.0-2.5 - 30min -2 >2.5 - 60min -4
CVVHD order
• If non-heparin , N/S 200cc q ½ hr to rinse the AK• 1.5% PD solution 500cc/hr run as dailysate• Warm dialysate to 37C• Record I/O and BP q1hr• UF target I-O ( ) cc/hr• Check BUN,Crea,Na,K,Cl,aPPT q6hr for 1 day &
then q8hr.• Check Ca,P,Mg qd.
CVVHDF 配置簡圖
CVVHDFContinuous
Veno-Venous Hemodiafiltration P
RISMA
S
CVVHDF order
Prepare Heparin 2cc + N/S 3cc, then inject 1.6cc into each femoral cath.
For AK priming: (GAMBRO, Polyarylethersulfone, 6S) *1st N/S 1000cc. *2nd Heparin 2,500U. *3rd N/S 500cc. *Prepare Heparin 25,000U + N/S 500cc IVD 10cc/hr with pump to
keep aPPT 1.5-2 and adjust as followed: aPPT bolus hold dose(cc/hr) <1.0 2000U - +4 1.0-1.5 - - +2 1.5-2.0 - - - 2.0-2.5 - 30min -2 >2.5 - 60min -4
CVVHDF order• If non-heparin , N/S 200cc q ½ hr to rinse the AK• Predilution run 500cc/hr alternately as followed via artery
end 1st bottle N/S 500cc + Sinca 1amp
2nd bottle N/S 500cc + 10% MgSO4 4cc 3rd bottle N/S 500cc 4th bottle D5W 500cc + NaHCO3 5amp • 1.5% PD solution 500cc/hr run as dailysate• Warm predilution and dialysate to 37C• Record I/O and BP q1hr• UF target I-O ( ) cc/hr• Check BUN,Crea,Na,K,Cl,aPPT q6hr for 1 day & then q8
hr.• Check Ca,P,Mg qd.