CRRT Indications

CRRT Indications

1. CRRT
Continue Renal Replacement
Therapy
By Syed Hussain – Clinical
Application Specialist
1.CVVH
2.CVVHD
3.CVVHDF

2. 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 ….)

3. 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 pre-dilution 方式.

4. Anti-coagulation 的方式
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

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

6. 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 µ/ml
Different Dosages for LMW heparin

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

8. 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

9. Citrate
ADVANTAGES :
No Bleeding
No Thrombocytopenia
Improved Filter Life and
Efficacy
•DISADVANTAGES :
Complex for the set up
Ca++ monitoring needed
Occasional Alkalosis

11. 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

12. Dialysis modalities in
the ICU

13. CVVH
CVVH
Continuous
Veno-Venous
Hemofiltration
P
R
I
S
M
A
CVVH 4500ml/hrCVVH 4500ml/hr

14. CVVH order
    Prepare Heparin 2cc + N/S 3cc, then inject 1.6cc into each
femoral cath.
  For AK priming: (GAMBRO, Polyarylethersulfone, 6S)
*1
st
N/S 1000cc.
*2
nd
Heparin 2,500U.
*3
rd
N/S 500cc.
     *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

15. CVVH order
If non-heparin , N/S 200cc q ½ hr to rinse the AK
Predilution run 500cc/hr alternately as followed via
artery end
1
st
bottle N/S 500cc + Sinca 1amp
2
nd
bottle N/S 500cc + 10% MgSO4 4cc
3
rd
bottle N/S 500cc
4
th
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.

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

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

18. CVVHD order
If non-heparin , N/S 200cc q ½ 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.

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

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

21. CVVHDF order
If non-heparin , N/S 200cc q ½ hr to rinse the AK
Predilution run 500cc/hr alternately as followed via
artery end
1
st
bottle N/S 500cc + Sinca 1amp
2
nd
bottle N/S 500cc + 10% MgSO4 4cc
3
rd
bottle N/S 500cc
4
th
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.