CRRT

Continue 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
1. Driving force : external pump 2. Circuit : Venovenous 3. Dialysis solutions :1.5% PD solution 4. Replacement fluid : several types of replacement fluid can be used , depending on patient requirements , predilution .

Anti-coagulation
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 / hr ACT on post filter : Adjust heparin rate to keep ACT between 1.5 & 2.0 times

STANDARD HEPARIN
ADVANTAGES Easy to perform Useful method Inexpensive
DISADVANTAGES Occasional Thrombocytopenia Hemorrhagic Risk with Bleeding patient

LOW MOLECULAR WEIGHT (LMW) HEPARIN

TYPICAL REGIMEN IN CRRT : Priming of the circuit : 20 mg in 1 L Maintenance dose : 10 to 40 mg q6 hrs
Monitor anti- factor Xa (aXa) units . Adjust between 0.1 and 0.4 /ml Different Dosages for LMW heparin

LOW MOLECULAR WEIGHT (LMW) HEPARIN

ADVANTAGES Decreased Risk of Bleeding
DISADVANTAGES Expensive Special and difficult monitoring With low doses frequent filter clotting

Regional Citrate Anticoagulation

TYPICAL REGIMEN : Citrate anticoagulation is always regional Citrate infusion (4%) at 170 ml/hr initially Special 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 Bleeding No Thrombocytopenia Improved Filter Life and Efficacy
DISADVANTAGES : Complex for the set up Ca++ monitoring needed Occasional 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

CVVH
Continuous Veno-Venous Hemofiltration
P R I S M A

CVVH , 4500ml/hr

CVVH order
l
Prepare Heparin 2cc + N/S 3cc, then inject 1.6cc into each femoral cath. l For AK priming: (GAMBRO, Polyarylethersulfone, 6S) *1st N/S 1000cc. *2nd Heparin 2,500U. *3rd N/S 500cc. l *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 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 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
CVVHD
Continuous Veno-Venous Hemodialysis
P R I S M A

CVVHD order
l
Prepare Heparin 2cc + N/S 3cc, then inject 1.6cc into each femoral cath. l For AK priming: (GAMBRO, Polyarylethersulfone, 6S) *1st N/S 1000cc. *2nd Heparin 2,500U. *3rd N/S 500cc. l *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 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
CVVHDF
Continuous Veno-Venous Hemodiafiltration

P R I S M A

CVVHDF order
l
Prepare Heparin 2cc + N/S 3cc, then inject 1.6cc into each femoral cath. l For AK priming: (GAMBRO, Polyarylethersulfone, 6S) *1st N/S 1000cc. *2nd Heparin 2,500U. *3rd N/S 500cc. l *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 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 q8hr. Check Ca,P,Mg qd.