Protokol dari sebuah tindakan yang dilakukan

Protokol

1. CRRT
Continue Renal Replacement Therapy
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配置簡圖
CVVH
Continuous
Veno-Venous
Hemofiltration
P
R
I
S
M
A
CVVH 模式下, 置換液流速
最高可達 4500ml/hr

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