CONTINUOUS RENAL REPLACEMENT THERAPYCRRT

All patients are treated with

Indications of CRRT

Bellomo & Ronco. Critical Care. 2000; 4:339 – 345

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

Non obstructive oliguria (u/o <200 ml/12 hr) or Anuria.

Severe Acidemia (pH <7.1) d/t metabolic acidosis

sepsis

Hyperkalemia (K >6.5 mmol/L)

Progressive severe dysnatremia (Na >180 or 115 mmol/L)

Suspected uremic organ involvement (pericarditis)

Drug overdose for dialyzable toxins

Hyperthermia (core temp. >39.5oC)

Clinical Conditions to Consider

ARF and need for fluid management related to

SIRS

Unstable on IHD

Organ transplants

CHF /volume overload

Post CV surgery

Post trauma patients

Severe Burns

What is Sepsis ? ACCP/SCCM Consensus Definitions

(ACCP/SCCM Consensus Conference Committee. American College of Chest Physicians/Society of Critical Care Medicine. )

Severe Sepsis

Sepsis

Organ dysfunction

Septic shock

Sepsis

Hypotension despite fluid resuscitation

Multiple Organ Dysfunction Syndrome (MODS)

Altered organ function in an acutely ill patient

Homeostasis cannot be maintained without intervention

Infection

Inflammatory response to microorganisms, or

Invasion of normally sterile tissues

Systemic Inflammatory Response Syndrome (SIRS)

Systemic response to a variety of processes

Sepsis

Infection plus

۲ SIRS criteria

Removal of immunomodulatory substances in sepsis

Conclusion

Sepsis & SIRS

The most important complicationof intermittent hemodialysis

۱ – Hypotension % ۲۵ – ۵۰

۲ – Muscle cramp % ۵ – ۲۰

۳ – Arrythmia

Complications

Suitable Dialysis

۱ – Better clinical tolerance

۲ – Better solute clearance

۳ – Improvement acid , base &

electrolytes

۴ – Biocompatibility

۵ – Minimum complications

۶ – Suitable monitoring during the

treatment

Molecular Weights

Terminology

Hemodialysis

transport process by which a solute passively diffuses down its concentration gradient from one fluid compartment (either blood or dialysate) into the other

Hemofiltration

use of a hydrostatic pressure gradient to induce the filtration (or convection) of plasma water across the membrane of the hemofilter.

Hemodiafiltration

dialysis + filtration.

Solute loss primarily occurs by diffusion dialysis but 25 percent or more may occur by hemofiltration

Overview of CRRT

Slow Continuous Therapy

Low Blood Flow Rate

Low Dialysate Flow Rate

Low Replacement Flow Rate

Low Ultrafiltration Rate

THERAPIES

Treatment Modalities

SCUF
Slow Continuous Ultrafiltration

Primary therapeutic goal
Safe management of fluid removal
UF rate ranges up to 2 L/Hr
No dialysate
No replacement fluids
Large fluid removal by ultrafiltration
Blood Flow rates = 10 – 450 ml/min

Goals of Fluid Management

Normovolemia
Remove fluid to create a space for fluid therapy (24/7)
Optimize hemodynamic parameters

Avoid hypotension – drop down of systemic BP will cause marked fall in renal blood flow and will lead to further damage, insult or injury to kidneys

Fluid Management

Management

Monitor Intake & Output parameters on the status screen every hour of the machine
Monitor the condition of the patient;
– Excessive fluid loss, will lead to Hypotension and / or Hypovolemia