Transcript Continuous Renal Replacement Therapy (CRRT) Maureen Walter,Raquel Lomeli Anika Stevenson,Nellie Preble

Continuous Renal
Replacement Therapy (CRRT)
Maureen Walter,Raquel Lomeli
Anika Stevenson,Nellie Preble
5/22/2016
Intensive Care; Acute Renal
Failure
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What is CRRT
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Continuous Dialysis of Critically Ill Patients in the ICU
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The concept behind CRRT is to dialyse patients in a
more physiologic way, slowly over 24 hours, just like
the kidney. Intensive care patients are particularly
suited to the techniques as they are by definition, bed
bound and when acutely sick, intolerant of fluid
swings associated with IHD
What is the difference between CRRT and IHD
 Slow continuous natural like the kidneys vs
rapid/qod
Why is it necessary in the ICU
 Patients are hemodynamically unstable
Intensive Care; Acute Renal
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IHD vs CRRT
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While IHD is an important treatment therapy for
patients with ESRD it may be contraindicated for
patients in the ICU suffering from ARF due to their
other disease processes.
IHD is done only 3-4 times a week in order to extract 2
days worth of accumulated fluid. The process takes
about 3-4 hours.
CRRT is a continuous process that slowly and gently
provides for the removal of fluids electrolytes and
uremic toxins.
Intensive Care; Acute Renal
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Indications for RRT in Critically
Ill Patients
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Oliguria (urine output <200ml/12hr)
Anuria (urine output <50ml/12hr)
Hyperkalemia (K+>6.5mmol/l and rising)
Severe acidemia (pH<7.1)
Azotemia (urea>30mmol/l or creat >300umol/l)
Pulmonary edema
Uremic encephalopathy
Uremic pericarditis
Uremic myopathy or neuropathy
Severe Dysnatremia (Na+>160 or <115mmol/l)
Hyperthermia
Drug overdose with filterable toxins
(Lithium,Vancomycin,Procainamide etc.)
Anasarca
Imminent/ongoing massive blood product administration
Intensive Care; Acute Renal
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Major complications of IHD
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Intermittent hemodialysis (IHD) for critically ill patients may be
limited or ineffective due to the critical nature of their ilness.
Volume overload and hemodynamic instability may not be
treated adequately with conventional forms of dialysis.
Complications of IHD:
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Systemic hypotension(leads to Multi organ dysfunction
Arrhythmias
Hypoxemia
Hemmorrhage
Infection
Line related complications (e.g. pneumothorax)
Seizure/dialysis disequalibrium
Pyrogen reaction or hemolysis
? Delay in recovery of renal function(r/t ischemia)
Fluid overload between treatments(Acute respiratory distress
syndrome)
Intensive Care; Acute Renal
Failure
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Why CRRT--Treatment Goals
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Reduces hemodynamic instability preventing secondary
ischemia
 Precise Volume control/immediately adaptable
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Ensures creatinine clearance
Uremic toxin removal
 Effective control of
uremia,hypophosphatemia,hyperkalemia
Acid base balance
 Rapid control of metabolic acidosis
Electrolyte Management/dialisate to mirror ideal blood
composition
Allows for provision of nutritional support
Management of sepsis/plasma cytokine filter
Safer for patients with head injuries
Probable advantage in terms of renal recovery
Improved nutritional support(full protein diet)
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Accute Renal Failure
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Acute renal failure is a common complication of
critically ill patients in today’s intensive care units.
Three types
 Pre-decline in renal blood flow resulting in
decreased renal perfusion
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Intra—injury to kidneys by nephrotoxins resulting in
tubular cell injury
Post– obstruction to outflow
In the ICU most ARF is associated with prerenal and
intrarenal failure.
Intensive Care; Acute Renal
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Mortality related to ARF
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40%-70%
Factors
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Increased age of patient population and multi system
organ failure
How soon CRRT was started after admission*
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In one study Patients who survived were started on
CRRT 8 days earlier than those who died
Comorbidities—DM,HTN,CVD,ESRD,Malignancy etc
Gender--Male>Female
Intensive Care; Acute Renal
Failure
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Summary of CRRT
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Although ARF mortality remains high, CRRT is
becoming the therapy of choice for the treatment of
ARF in the critically ill patient.
Timely initiation of CRRT may improve patient survival
Surviving patients (without preexisting ESRD) are
likely to experience recovery of renal function.
CRRT has many benefits including
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Hemodynamic stability
Excellent fluid and solute removal
Enhanced cytokine removal and prevention of sepsis
Intensive Care; Acute Renal
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Question
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Prerenal failure occurs in response
to:
A. Uncontrolled hypertension
 B. Decline in renal blood flow
 C. Exposure to nephrotoxins
 D. Obstruction to urine outflow
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Intensive Care; Acute Renal
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Question
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Intermittent hemodyalisis of
critically ill patients results in
hemodynamic instability due to:
A. Rapid urea removal
 B. Excessive urea losses
 C. Rapid fluid removal
 D. excessive urine output
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Intensive Care; Acute Renal
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Question
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The key indication for CRRT is:
A. Respiratory failure on mechanical
ventilation
 B.Multisystem organ failure on
vasopressors
 C. Anuria with refractory hypertension
 D. Fluid overload with hemodynamic
instability
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