CRRT Continue Renal Replacement Therapy 1 CVVH 2

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共同處 1. Driving force : external pump 2. Circuit : Venovenous 3. Dialysis solutions : 一般使用 1. 5% PD solution 4. Replacement fluid : several types of replacement fluid can be used , depending on patient requirements , 一般使用 predilution 方式.

Anti-coagulation 的方式 • STANDARD HEPARIN • TYPICAL REGIMEN IN CRRT : ñPriming of the circuit ( 5000 IU / L ) ñInitial Heparin Bolus : 5 - 8 IU / kg ñInfuse 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 ïEasy to perform ïUseful method ïInexpensive DISADVANTAGES • Occasional Thrombocytopenia ï Hemorrhagic Risk with Bleeding patient

LOW MOLECULAR WEIGHT (LMW) HEPARIN • TYPICAL REGIMEN IN CRRT : ï Priming of the circuit : 20 mg in 1 L ï Maintenance dose : 10 to 40 mg q 6 hrs Monitor anti- factor Xa (a. Xa) units. Adjust between 0. 1 and 0. 4 µ/ml Different Dosages for LMW heparin

LOW MOLECULAR WEIGHT (LMW) HEPARIN • ADVANTAGES ïDecreased Risk of Bleeding • DISADVANTAGES ï Expensive ï Special and difficult monitoring ï With low doses frequent filter clotting

Regional Citrate Anticoagulation • TYPICAL REGIMEN : ï Citrate anticoagulation is always regional ï Citrate infusion (4%) at 170 ml/hr initially ï 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 ) ï Ca. CL 2 (0. 75%) by central I. V at 40 -60 ml/hr, ï Maintain ionized Ca++ at 0. 96 - 1. 20 mmol/L

Citrate • ADVANTAGES : ïNo Bleeding ïNo Thrombocytopenia ïImproved Filter Life and Efficacy • DISADVANTAGES : ï Complex for the set up ï Ca++ monitoring needed ï 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配置簡圖 CVVH Continuous Veno-Venous Hemofiltration CVVH 模式下, 置換液流速 最高可達 4500 ml/hr P R I S M A

CVVH order l Prepare Heparin 2 cc + N/S 3 cc, then inject 1. 6 cc into each femoral cath. l For AK priming: (GAMBRO, Polyarylethersulfone, 6 S) *1 st N/S 1000 cc. *2 nd Heparin 2, 500 U. *3 rd N/S 500 cc. l *Prepare Heparin 25, 000 U + N/S 500 cc IVD 10 cc/hr with pump to keep a. PPT 1. 5 -2 and adjust as followed: a. PPT bolus hold dose(cc/hr) <1. 0 2000 U - +4 1. 0 -1. 5 - +2 1. 5 -2. 0 - - 2. 0 -2. 5 - 30 min -2 >2. 5 - 60 min -4

CVVH order • If non-heparin , N/S 200 cc q ½ hr to rinse the AK • Predilution run 500 cc/hr alternately as followed via artery end 1 st bottle N/S 500 cc + Sinca 1 amp 2 nd bottle N/S 500 cc + 10% Mg. SO 4 4 cc 3 rd bottle N/S 500 cc 4 th bottle D 5 W 500 cc + Na. HCO 3 5 amp • Warm dialysate to 37 C • Record I/O and BP q 1 hr • UF target I-O ( ) cc/hr • Check BUN, Crea, Na, K, Cl, a. PPT q 6 hr for 1 day & then q 8 hr. • Check Ca, P, Mg qd.

CVVHD配置簡圖 CVVHD Continuous Veno-Venous Hemodialysis P R I S M A S

CVVHD order l Prepare Heparin 2 cc + N/S 3 cc, then inject 1. 6 cc into each femoral cath. l For AK priming: (GAMBRO, Polyarylethersulfone, 6 S) *1 st N/S 1000 cc. *2 nd Heparin 2, 500 U. *3 rd N/S 500 cc. l *Prepare Heparin 25, 000 U + N/S 500 cc IVD 10 cc/hr with pump to keep a. PPT 1. 5 -2 and adjust as followed: a. PPT bolus hold dose(cc/hr) <1. 0 2000 U - +4 1. 0 -1. 5 - +2 1. 5 -2. 0 - - 2. 0 -2. 5 - 30 min -2 >2. 5 - 60 min -4

CVVHD order • • • If non-heparin , N/S 200 cc q ½ hr to rinse the AK 1. 5% PD solution 500 cc/hr run as dailysate Warm dialysate to 37 C Record I/O and BP q 1 hr UF target I-O ( ) cc/hr Check BUN, Crea, Na, K, Cl, a. PPT q 6 hr for 1 day & then q 8 hr. • Check Ca, P, Mg qd.

CVVHDF配置簡圖 CVVHDF Continuous Veno-Venous Hemodiafiltration P R I S M A S

CVVHDF order l Prepare Heparin 2 cc + N/S 3 cc, then inject 1. 6 cc into each femoral cath. l For AK priming: (GAMBRO, Polyarylethersulfone, 6 S) *1 st N/S 1000 cc. *2 nd Heparin 2, 500 U. *3 rd N/S 500 cc. l *Prepare Heparin 25, 000 U + N/S 500 cc IVD 10 cc/hr with pump to keep a. PPT 1. 5 -2 and adjust as followed: a. PPT bolus hold dose(cc/hr) <1. 0 2000 U - +4 1. 0 -1. 5 - +2 1. 5 -2. 0 - - 2. 0 -2. 5 - 30 min -2 >2. 5 - 60 min -4

CVVHDF order • If non-heparin , N/S 200 cc q ½ hr to rinse the AK • Predilution run 500 cc/hr alternately as followed via artery end 1 st bottle N/S 500 cc + Sinca 1 amp 2 nd bottle N/S 500 cc + 10% Mg. SO 4 4 cc 3 rd bottle N/S 500 cc 4 th bottle D 5 W 500 cc + Na. HCO 3 5 amp • 1. 5% PD solution 500 cc/hr run as dailysate • Warm predilution and dialysate to 37 C • Record I/O and BP q 1 hr • UF target I-O ( ) cc/hr • Check BUN, Crea, Na, K, Cl, a. PPT q 6 hr for 1 day & then q 8 hr. • Check Ca, P, Mg qd.