CRRT Continuous Renal Replacement Therapies

Oct 25, 2013 Dr. M.Susca 1/46 C R R T Continuous Renal Replacement Therapies Technical and Practical Aspects Oct 25, 2013 Dr. M.Susca 2/47 continuous ambulatory peritoneal dialysis (CAPD) continuous cyclical peritoneal dialysis (CCPD) slow continuous ultrafiltration (SCUF) continuous arterio-venous hemofiltration (CAVH) continuous arterio-venous hemodialysis (CAVHD) continuous arterio-venous hemodiafiltration (CAVHDF) continuous veno-venous hemofiltration (CVVH) continuous veno-venous hemodialysis (CVVHD) continuous veno-venous high-flux dialysis (CVVHFD) continuous veno-venous hemodiafiltration (CVVHDF) intermittent peritoneal dialysis (IPD) hemoperfusion (HP) hemoconcentration ther. plasmapheresis (PEX, PAP) hemodialysis (HD) hemofiltration (HF) hemodiafiltration (HDF) continuous intermittent Blood Purification Procedures in ICU Oct 25, 2013 Dr. M.Susca 3/47 CRRT Indications in ICU • Acute renal failure, which often is a part of multi-organ failure with complications such as shock, cardial and non-cardial pulmonary edema, hemodynamic instability, bleeding, hypercatabolism • diuretic-resistant fluid overload • parenteral nutrition in cases of oligoanuria • Hyperpotassiemia • hypernatriaemia • elimination of toxins and mediators (endotoxin, prostaglandin, leukotrins etc.) Oct 25, 2013 Dr. M.Susca 4/47 1977 Kramer et al. Report for the first time on continuous arterio-venous hemofiltration (CAVH) 1981 Bischoff develops a pump-driven procedure as continuous veno-venous hemofiltration (CVVH) 1985 Geronemus further develops continuous arterio-venous hemodialysis (CAVHD) 1987 Uldall introduces continuous veno-venous hemodialysis (CVVHD) Historical Overview Oct 25, 2013 Dr. M.Susca 5/47 Disadvantages • filtration dependes on blood flow (low efficiency) • arterial access (bleeding, clot formation) Advantage • technically not complicated A V heparin UF h i g h - f l u x CAVH Continuous arterio-venous hemofiltration Oct 25, 2013 Dr. M.Susca 6/47 Disadvantages • filtration dependes on blood flow (low efficiency) • arterial access (bleeding, clot formation) A V heparin UF R Advantage • technically not complicated h i g h - f l u x CAVH Continuous arterio-venous hemofiltration Oct 25, 2013 Dr. M.Susca 7/47 heparin Disadvantages • filtration dependes on blood flow (low efficiency) • backfiltration • bad elimination of large molecules • complex machinery • fluid balance complicated • arterial access (bleeding, clot formation) Advantage • better elimination of small molecules A V D UF D l o w - f l u x CAVHD Continuous arterio-venous hemodialysis Oct 25, 2013 Dr. M.Susca 8/47 A V R heparin D UF D Disadvantages • filtration dependes on blood flow (low efficiency) • backfiltration • complex machinery • fluid balance complicated • arterial access (bleeding, clot formation) Advantage • better elimination of small and large molecules h i g h - f l u x CAVHDF Continuous arterio-venous hemodiafiltration Oct 25, 2013 Dr. M.Susca 9/47 PA heparin Disadvantages • complex machinery • expensive • fluid balance complicated Advantage • no arterial access • blood flow sufficient • good filtration V V PV UF BLD SAD h i g h - f l u x SCUF Slow continuous ultrafiltration Oct 25, 2013 Dr. M.Susca 10/47 heparin V V PV PA Disadvantages • complex machinery • expensive • fluid balance complicated Advantage • no arterial access • blood flow sufficient • good elimination of large molecules • good filtration UF BLD SAD R heater h i g h - f l u x CVVH Continuous veno-venous hemofiltration [...]... Treatment Intermittent Continuous Advantages Disadvantages low heparinisation continuous heparinisation easy patient mobilisation difficult patient mobilisation high clearance of small molecules low clearance of small molecules Advantages Disadvantages disequilibrium syndrom continuous and slow elimination hemodynamic instability hemodynamic stability accumulation of fluid and toxinxs continuous removel... -46% -7% Effect of Dialysis on Renal Function in AKF Patients (Manns, 1995) In CVVH similar observations! (Davenport, Bellomo) Oct 25, 2013 Dr M.Susca 23/47 Conclusion Renal function significantly drops down during and after HD Post-ischemic kidney is more sensitive for Hypotension paradoxe vasoconstriction blood circulation ↓ Kidney demage Kidney recovement delayed Continuous treatment protects the... UF R Sub Volume ↑ • Filter Clotting ↓ • E • xpensive Oct 25, 2013 Dr M.Susca 30/47 Heparinisation in CRRT Initial IU/kg Continuous IU/kg/h PTT sec ACT sec 50 10-20 60 . Dr. M.Susca 1/46 C R R T Continuous Renal Replacement Therapies Technical and Practical Aspects Oct 25, 2013 Dr. M.Susca 2/47 continuous ambulatory peritoneal. dialysis (CAPD) continuous cyclical peritoneal dialysis (CCPD) slow continuous ultrafiltration (SCUF) continuous arterio-venous hemofiltration (CAVH) continuous