【持续性肾脏替代治疗crrt英文】renal-replacement-therapy课件

RenalReplacementTherapyJohn Mc DonaldJohn Mc DonaldConsultant AnaesthetistConsultant AnaesthetistSGHSGHRenal Replacement Therapy Joh1Criteriafordiagnosisofacuterenalfailure Fallinurinevolumetolessthan500mlperdayFallinurinevolumetolessthan500mlperday RisingplasmaureaandcreatinineconcentrationsRisingplasmaureaandcreatinineconcentrations RisingplasmapotassiumandphosphateplusRisingplasmapotassiumandphosphateplusfallingcalciumandvenousbicarbonatefallingcalciumandvenousbicarbonateCriteria for diagnosis of acut2Investigations that may help to differentiate renal Investigations that may help to differentiate renal hypoperfusion from acute renal failure in oliguric hypoperfusion from acute renal failure in oliguric patientspatients Measurement Renal hypoperfusionAcute renal failureUrinarysodium(mmol/l)40Urine:plasmaurearatio20210cmofwaterandaurineoutputof40aimingforaCVP10cmofwaterandaurineoutputof40mL/minute.mL/minute.Meanarterialpressure80mmHg,achievedandMeanarterialpressure80mmHg,achievedandmaintainedbyadequatevolumereplacementwithormaintainedbyadequatevolumereplacementwithorwithoutinotropicsupport.withoutinotropicsupport.StrategiestoreducetheincidenceofnosocomialStrategiestoreducetheincidenceofnosocomialinfections,suchas,theconservativeuseandrapidremovalinfections,suchas,theconservativeuseandrapidremovalofintravascularandintravesicalcatheters.ofintravascularandintravesicalcatheters.Cautioususeofantibiotics.Cautioususeofantibiotics.Sepsisneedstobeaggressivelyinvestigatedandtreated.Sepsisneedstobeaggressivelyinvestigatedandtreated.RestricteduseandwherepossiblethetotalavoidanceofRestricteduseandwherepossiblethetotalavoidanceofpotentiallynephrotoxicagentspotentiallynephrotoxicagentsMeasures for minimizing surgic5Drugs that may cause acute interstitial nephritis in intensive careAntibioticslactamslactams RifampicinRifampicin SulphonamidesSulphonamides VancomycinVancomycinDiureticsThiazidesFrusemideNon-steroidalanti-inflammatorydrugs DiclofenacDiclofenac RofecoxibRofecoxibOthersRanitidineCimetidinePhenytoinDrugs that may cause acute int6Drugs that induce renal damageDecreaseinrenalperfusionDiuretics,angiotensinconvertingenzymeinhibitors,blockers,vasodilatorsImpairedintra-renalhaemodynamicsNon-steroidalanti-inflammatories,radiocontrastagentsTubulartoxicityAminoglycosides,amphotericin,cisplatinAllergicinterstitialnephritislactams,non-steroidalanti-inflammatoriesDrugs that induce renal damage7Guidelines for immediate management of patients with oliguria or anuriaAssessandcorrectanyrespiratoryorcirculatoryimpairmentManageanylifethreateningconsequencesofrenaldysfunction(hyperkalaemia,saltandwateroverload,severeuraemia,extremeacidosis)ExcludeobstructionoftheurinarytractEstablishunderlyingcause(s)andinstitutepromptremedialactionGetadrughistoryandalterprescriptionsappropriatelyGethelpfromseniorappropriatelytrainedspecialistsGuidelines for immediate manag8The cause of acidosis will determine the treatment Tissue hypoxia/lactic acidosisTissue hypoxia/lactic acidosis optimise circulation and oxygenation optimise circulation and oxygenation Salt and water depletionSalt and water depletion normal saline normal saline Established renal failure(acute or chronic)Established renal failure(acute or chronic)sodium bicarbonate,?RRT sodium bicarbonate,?RRT Poisoning(methanol,ethylene glycol,salicylate)Poisoning(methanol,ethylene glycol,salicylate)sodium bicarbonate,?dialysis sodium bicarbonate,?dialysis Diabetes mellitusDiabetes mellitus insulin,saline insulin,saline The cause of acidosis will det9IndicationsforstartingRRTOliguria Urine output 30 ml/hrOliguria Urine output 30 mmol/l and/or Creatinine 300 Urea 30 mmol/l and/or Creatinine 300 Hyperkalaemia Hyperkalaemia KK+6.5 mmols with renal impairment or failure to 6.5 mmols with renal impairment or failure to respond to resonium/glucose insulinrespond to resonium/glucose insulinVolume overload Volume overload Metabolic AcidosisMetabolic AcidosisIndications for starting RRTOl10Indications IIClinicallysignificantorgandysfunctionClinicallysignificantorgandysfunction(especiallypulmonaryoedema)(especiallypulmonaryoedema)UreamicencephalopathyUreamicencephalopathyUreamicpericarditisUreamicpericarditisUreamicneuropathy/myopathyUreamicneuropathy/myopathySeveredysnatremia(Na160Severedysnatremia(Na160mEq/L)mEq/L)HyperthermiaHyperthermiaDrugoverdosewithdialyzabletoxinDrugoverdosewithdialyzabletoxinIndications IIClinically sign11Indications IIIHypothermia for extracorporial warmingMeningococcal Septicaemia(Based on a number of case reports)Severe HypertensionIndications IIIHypothermia for12Modes of RRTHaemodialysisHaemofiltrationPeritoneal dialysisModes of RRTHaemodialysis13HaemodialysisFast efficient ideal for maintenance therapy in established CRFProne to cause Haemodynamic InstabilityMay cause Cerebral Oedema due to Fluid ShiftsNeed for AnticoagulationHaemodialysisFast efficient id14HaemodialysisThemovementofsolutesfromacompartmentinwhichtheyareinhighconcentrationtooneinwhichtheyareinlowerconcentrationalonganelectrochemicalgradient.Anelectrolytesolutionrunscountercurrenttobloodflowingontheothersideofasemipermeable(smallpore)filter.Smallmoleculessuchasureamovealongtheconcentrationgradientintothedialysatefluid.Largermoleculesarepoorlyremovedbythisprocess.Soluteremovalisdirectlyproportionaltothedialysateflowrate HaemodialysisThe movement of s15Peritoneal DialysisHastheadvantageofbeingsimpleandHastheadvantageofbeingsimpleandcosteffective.costeffective.NoExtracorporealcircuitisneededwhichNoExtracorporealcircuitisneededwhichavoidstheneedforanticoagulation.avoidstheneedforanticoagulation.ThemajordisadvantagesofPDare:ThemajordisadvantagesofPDare:poorsoluteclearance,poorsoluteclearance,pooruraemiccontrol,pooruraemiccontrol,riskofperitonealinfectionandmechanicalriskofperitonealinfectionandmechanicalobstructionofpulmonaryandcardiovascularobstructionofpulmonaryandcardiovascularperformance.performance.ItisalsounsuitableforpatientswhohaveItisalsounsuitableforpatientswhohaveundergoneabdominalsurgeryundergoneabdominalsurgeryPeritoneal DialysisHas the adv16HaemofiltrationInthepastArterio-venoushaemofiltrationwasusedwherethepatientsownheartpumpedbloodthroughthefilterfromanarterialcannulaandreturnedtothepatientviaavenouscanulae.ThesystemworkedbutcouldbeunreliableRecentlymachineswhichused2venous(orasingledoublelumen)canulaeandamechanicalpumphavereplacedthisandVeno-venoushaemofiltrationnowthetreatmentofchoiceinIntensivecareunits.ModernmachinesarelargelyautomaticandcanaccuratelymonitorremovalofeffluentandadministrationofreplacementfluidandheparinHaemofiltrationIn the past Art17ULTRAFILTRATION:The movement of fluid through a membrane caused by a pressure gradient.UltrafiltrationULTRAFILTRATION:The movement18HaemofiltrationSoluteiscarried(insolution)afluidacrossasemipermeablemembraneinresponsetoatransmembranepressuregradientTherateofultrafiltrationdependsupontheporosityofthemembraneandthehydrostaticpressureoftheblood,whichdependsuponbloodflow.Thisisveryeffectiveinremovaloffluidandmiddle-sizedmolecules,whicharethoughttocauseuremia.Moreover,mostofthecytokinesinvolvedinsepsisare“middlemolecules”.Haemofiltration19Continuous Veno-venous Haemofiltration Blood is pumped through a Blood is pumped through a semi-permiable membrane in semi-permiable membrane in the filter under pressure.the filter under pressure.Small and mid sized Small and mid sized molecules such as water and molecules such as water and urea are squeezed out and urea are squeezed out and form the effluent.form the effluent.The haematocrit of fluid The haematocrit of fluid coming out of the filter is coming out of the filter is higher due to fluid loss.higher due to fluid loss.Replacement fluid is then Replacement fluid is then added and the blood is added and the blood is returned to the patient.returned to the patient.Continuous Veno-venous Haemofi20HaemodialysisProcessusesdialysisthereisaconcentrationgradientbetweenplasmaandthedialysisfluidandUreaandCreatininemoveacrossthemembraneTheprocessismoreefficientthanfiltrationifUreaandCreatininelevelsarehighHaemodialysisProcess uses dial21Solute ClearanceMembraneMembraneBloodBloodDialysate/UltrafitrateDialysate/UltrafitrateSolute ClearanceMembraneBloodD22Diffusive Solute ClearanceMembraneMembraneBloodBloodDialysate/UltrafitrateDialysate/UltrafitrateDiffusive Solute ClearanceMemb23Diffusive Solute ClearanceMembraneMembraneBloodBloodDialysate/UltrafitrateDialysate/UltrafitrateDiffusive Solute ClearanceMemb24HEMODIALYSISDiffusionHEMOFILTRATION:ConvectionHEMODIALYSISDiffusionHEMOFILT25HaemodiafiltrationAmixtureoffiltrationanddialysisThePrismahastobesetupforthismodewhenprimingthefilterHaemodiafiltrationA mixture of26PrismaHaemodiafiltrationPrisma Haemodiafiltration27Advantages of using CRRT Suitableforuseinhemodynamicallyunstablepatients.Suitableforuseinhemodynamicallyunstablepatients.Precisevolumecontrol,whichisimmediatelyadaptabletoPrecisevolumecontrol,whichisimmediatelyadaptabletochangingcircumstances.changingcircumstances.Veryeffectivecontrolofuremia,hypophosphatemiaandVeryeffectivecontrolofuremia,hypophosphatemiaandhyperkalemia.hyperkalemia.RapidcontrolofmetabolicacidosisRapidcontrolofmetabolicacidosis Improvednutritionalsupport(fullproteindiet).Improvednutritionalsupport(fullproteindiet).Available24hoursadaywithminimaltraining.Available24hoursadaywithminimaltraining.SaferforpatientswithbraininjuriesandcardiovascularSaferforpatientswithbraininjuriesandcardiovasculardisorders(particularlydiureticresistantCCF).disorders(particularlydiureticresistantCCF).Mayhaveaneffectasanadjuvanttherapyinsepsis.Mayhaveaneffectasanadjuvanttherapyinsepsis.ProbableadvantageintermsofrenalrecoveryProbableadvantageintermsofrenalrecovery.Advantages of using CRRTSuita28DisadvantagesofusingCRRTExpenseprobablythesameasIHD.ExpenseprobablythesameasIHD.AnticoagulationtopreventAnticoagulationtopreventextracorporealcircuitfromclotting.extracorporealcircuitfromclotting.Complicationsoflineinsertionandsepsis.Complicationsoflineinsertionandsepsis.Riskoflinedisconnection.Riskoflinedisconnection.Hypothermia.Hypothermia.SeveredepletionofelectrolytesandSeveredepletionofelectrolytesandparticularlyK+andPO4,wherecareisnotparticularlyK+andPO4,wherecareisnottakentakenDisadvantages of using CRRTExp29SettingupandusingCRRTThemachinecircuitissetupasThemachinecircuitissetupasfollows:follows:1.1.Adoublelumencatheter.Adoublelumencatheter.2.2.AlineleadingtothefilterAlineleadingtothefilterwherebloodflowiswherebloodflowiscontrolledbyaseriesofrollercontrolledbyaseriesofrollerpumps:bloodflowisusuallypumps:bloodflowisusuallysetat120ml/min.setat120ml/min.3.3.AnticoagulanttopreventAnticoagulanttopreventbloodclottingonthefilter.bloodclottingonthefilter.4.4.AbagtocollecttheAbagtocollecttheultrafiltrate.ultrafiltrate.5.5.Replacementfluid,toreplaceReplacementfluid,toreplacetheexcessultrafiltrateovertheexcessultrafiltrateoverandabovetherequiredfluidandabovetherequiredfluidremovalremoval.Setting up and using CRRTThe 30VascularAccessLargeboreDoublelumencatheter150-250mmlengthJugular,FemoralorSubclavianveinUse150RIJ,200LIJ,200-250FemoralVascular AccessLarge bore Doub31“Dose”of RRTClinicalbottomline(level1b)Clinicalbottomline(level1b)1.Critically-illpatientswithacuterenalfailurewhoCritically-illpatientswithacuterenalfailurewhoreceivedcontinuousveno-venoushaemofiltrationreceivedcontinuousveno-venoushaemofiltrationatultrafiltrationratesof35or45mg/kg/hratultrafiltrationratesof35or45mg/kg/hrcomparedwith20mg/kg/hrwerelesslikelytocomparedwith20mg/kg/hrwerelesslikelytodie(NNT=6atdays).die(NNT=6atdays).2.TherewasnocleardifferenceinmortalityTherewasnocleardifferenceinmortalitybetweenthe35and45mg/kg/hrgroups.betweenthe35and45mg/kg/hrgroups.3.TherewasnocleardifferenceincomplicationsTherewasnocleardifferenceincomplicationsbetweenthethreegroupsbetweenthethreegroups.RoncoC,BellomoR,HomelP,etal:effectsofdifferentdosesincontinuousveno-venoushaemofiltrationinoutcomesofacuterenalfailure:aprospectiverandomisedtrial.Lancet2000;355:26-30“Dose”of RRTClinical bottom l32Anticoagulation for RRTUnfractionated HeparinLow Molecular Weight HeparinProstacyclineCitrateXigrisNoneAnticoagulation for RRTUnfract33SiteofActionofAnticoagulantsSite of Action of Anticoagulan34UnfractionatedHeparinCheap easy to monitorCheap easy to monitorUsually 5000 units flushed through circuit 3-Usually 5000 units flushed through circuit 3-5,000 units given as a bolus then 1,000 units/hr 5,000 units given as a bolus then 1,000 units/hr adjusted to give an INR of around 2adjusted to give an INR of around 2Risk of bleeding and Thrombocytopoenia due Risk of bleeding and Thrombocytopoenia due to HIT and HATto HIT and HATLittle if any relationship between INR and Little if any relationship between INR and Filter LifeFilter LifeUnfractionated HeparinCheap ea35Low Molecular Weight HeparinMore expensive difficult to monitor effectCorrect dosage to optimise filter life and reduce bleeding effects problematicOptimal dose varies depending on which LMW Heparin is usedLow Molecular Weight HeparinMo36Heparin Induced ThrombocytopoeniaHeparin Induced Thrombocytopoenia HIT can be suspected when there is a decrease of at least 30%from the HIT can be suspected when there is a decrease of at least 30%from the initial platelet count,usually commencing 4 to 14 days after institution of initial platelet count,usually commencing 4 to 14 days after institution of heparin.heparin.Thrombocytopenia may occur sooner if there has been previous exposure Thrombocytopenia may occur sooner if there has been previous exposure to the drug,including possible undocumented heparin flushes.to the drug,including possible undocumented heparin flushes.The mean delay of HIT emergence is dramatically longer when LMWH The mean delay of HIT emergence is dramatically longer when LMWH are used compared with unfractionated heparin(mean delay of 28 are used compared with unfractionated heparin(mean delay of 28 vs vs 14 14 days).days).The platelet count declines below 100 The platelet count declines below 100 109/L,often below 60 109/L,often below 60 109/L,but 109/L,but bleeding is uncommon despite the severe thrombocytopenia.bleeding is uncommon despite the severe thrombocytopenia.After heparin withdrawal,the platelet count usually rises to normal levels After heparin withdrawal,the platelet count usually rises to normal levels in 5 to 7 days.Thrombocytopenia recurs promptly on rechallenge within 5 to 7 days.Thrombocytopenia recurs promptly on rechallenge with heparin.heparin.Heparin Induced Thrombocytopoe37Prostacycline Expensive Antiplatelet Expensive Antiplatelet drug used when there is drug used when there is significant risk of significant risk of bleedingbleeding Can cause HypotensionCan cause Hypotension Can be used with Can be used with Heparin but problems Heparin but problems with assessing dosewith assessing dose Filter life may be shorter Filter life may be shorter than that seen with than that seen with HeparinHeparin ProstacyclineExpensive Antipla38Citrate Not widely used but may be more popular in futureCauses anticoagulation by binding CalciumCan be used for regional anticoagulation citrate is infused before the filter and calcium after the filter to leave the patient with normal clottingCitrate Not widely used but ma39【持续性肾脏替代治疗crrt英文】renal-replacement-therapy课件40Xigris Very Expensive anti-Very Expensive anti-inflamatory drug with inflamatory drug with anticoagulant actionsanticoagulant actions If patient is receiving a If patient is receiving a Xigris infusion no other Xigris infusion no other anticoagulants are anticoagulants are usually used because of usually used because of risk of bleedingrisk of bleeding Stop Xigris for 2 hours Stop Xigris for 2 hours before Surgery or Line before Surgery or Line PlacementPlacementXigrisVery Expensive anti-infl41No AnticoagulantUsed when serious clotting disturbances ie platelets 48hoursisverygood24hoursisacceptable12hoursisproblematic49Blood testingAbaselineclottingscreenandFBCshouldbesent.Youdonotnecessarilyneedtodelaygettingthefilterstartedbywaitingontheresultsinmostcases.Useyourclinicaljudgementandmakeabestguessatwheretostarttheheparin.AllpatientsonunfractionatedIVheparinshouldbeGroupedandSaved.Blood testing A baseline clott50BloodTestingAPTTshouldbechecked6hoursafterstartingthefilter.Thereafteritshouldbechecked6hoursafteranydosechange.Ifasteadystateisachievedintervaloftestingcanbeextendedto12hourly.Inrarecasesofstabilitythiscanbeextendedto24hourlyIftheAPTTisunstableorclinicalcircumstancesdictateincreasefrequencyoftestingasrequired.Thepatientsnurseshoulddocumentlactate,K+andhaemoglobinfrombloodgaseswheneveranABGistaken.Ifyourpatientisstableandhasawellworkingfilter;ifyouunderstandhowRRTworksandcanprescribereplacementfluidsproperlyyoushouldnotneedtocheckformalU&Esmorefrequentlythandaily.Patientorbiochemicalordoctor!factorsmaymeanthisneedsdonemoreoften.Blood TestingAPTT should be ch51Who and by how much to anticoagulateThisisabalancebetweenprolongingcircuitlifeandminimisingtheriskofbleeding.Doingthiswellisasmuchpartoftheartasthescienceofmedicine.Thereisreasonableevidencethatforevery10-secondincreaseinAPTT,theincidenceofcircuitclottingdecreasesby25%,however,atthecostofa50%increasedriskofhaemorrhage.Withfullanticoagulationinhigh-riskgroupstheincidenceofsignificanthaemorrhagecanbeashighas50%.Who and by how much to anticoa52Who and by how much to anticoagulateThe relationship between heparin dose,APTT and filter life suggests that,in the typical critically ill patient,as a starting point,an APTT between 35 and 45 sec APTTr 1.3 1.7 gives the best mix between safety and heparin therapy efficacy.Consideration of alteration of this target based on the life of the first couple of filters vs.patients risk of bleeding can be made thereafter.If the filters are clotting quickly one might cautiously aim for a higher target.If the filters are lasting well despite a low APTTr then one does not need to blindly chase a higher APTTr.Always consider access issues if clotting occurs frequently e.g.2 sequential filters with less than 6 hour run time each.Is the line working well?Is the blood pump speed high enough?Who and by how much to anticoa53Who and by how much to anticoagulateInpatientswithahighriskofbleedingthereisgoodevidencethataround50%-60%canreceiveanticoagulantfreeRRTwithacceptablefilterlife24hrs.IfpatientsareonDrotrecoginalphaXigrisandarereceivingRRTtheyrarelyneedadditionalheparintoachieveacceptablefilterlife.The default position is no heparin whilst on Xigris.PlateletcountsinevitablyfallwhenonRRT.TheyfallfurtheronanticoagulantfreeRRTc.f.thanwiththeuseofheparin.Inapatientwiththrombocytopeniae.g.fromsepsiswhereonechoosestoavoidheparinconsiderationcanbegiventotheuseofepoprostenolinabidtoprolongfilterlifeandattenuatetheanticipatedfallinplateletsc.f.heparinfreeRRT.Who and by how much to anticoa54GROUP 1-Patient at moderate risk of bleedingRegard this as the standard option-thetypicalITURRTpatiente.g.1Average2ormoreorganfailures 4.Surgery48hoursago2Nofloridcoagulopathy5.Noevidenceofactivebleeding3Platelets506.NoureamiccomplicationsHEPARIN BOLUS DOSEINITIAL HEPARIN INFUSION RATETARGET APTT and ratio20-25units/kgmaximum3000units10units/kg/hr35451.31.7GROUP 1-Patient at moderate 55GROUP 2-Patients at low risk of bleeding or where standard approach results in poor filter lifeOnemayrequiretograduallyescalatetothisapproachwherethestandardapproachhasfailedandtheriskisjudgedworthwhile.Therewillbetherarepatientwhojustifiesthisapproachfromthestarte.g.primaryrenalproblem,anotherrequirementforformalanticoagulationHEPARIN BOLUS DOSE INITIAL HEPARIN INFUSION RATE TARGET APTT and ratio 50units/kgmaximum 5000 units15units/kg/hr50-651.92.4AimforthelowerendofthisrangeatfirstifescalatingfromthestandardapproachGROUP 2-Patients at low risk56GROUP3-PatientathighriskofbleedingWithproblemssuchas1.Within48hoursofsurgery4.Platelets25.Recentactivebleeding3.APTT506.Urea45orureamiccomplicationGenerally it is worth trying anticoagulant free RRT in the first instanceGROUP 3-Patien