CRRT Protocol

CRRTContinue 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 pump2. Circuit : Venovenous3. Dialysis solutions : 一般使用 1.5% PD

solution4. Replacement fluid : several types of

replacement fluid can be used , depending on patient requirements , 一般使用 pre-dilution 方式 .

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 / hrACT on post filter : Adjust heparin rate to

keep ACT between 1.5 & 2.0 times

STANDARD HEPARIN

• ADVANTAGESEasy to performUseful methodInexpensive

DISADVANTAGES• Occasional

ThrombocytopeniaHemorrhagic Risk

with Bleeding patient

LOW MOLECULAR WEIGHT (LMW) HEPARIN

• TYPICAL REGIMEN IN CRRT :Priming of the circuit : 20 mg in 1 LMaintenance 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

LOW MOLECULAR WEIGHT (LMW) HEPARIN

• ADVANTAGESDecreased Risk

of Bleeding

• DISADVANTAGESExpensiveSpecial and difficult

monitoringWith low doses

frequent filter clotting

Regional Citrate Anticoagulation

• TYPICAL REGIMEN :Citrate anticoagulation is always regional Citrate infusion (4%) at 170 ml/hr initiallySpecial 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

Citrate

• ADVANTAGES :No BleedingNo

ThrombocytopeniaImproved Filter

Life and Efficacy

• DISADVANTAGES :Complex for the set upCa++ monitoring neededOccasional 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

CVVHContinuous Veno-Venous Hemofiltration

PRISMA

CVVH CVVH 模式下模式下 , , 置換液流置換液流速速最高可達最高可達 4500ml/hr4500ml/hr

CVVH order    Prepare Heparin 2cc + N/S 3cc, then inject 1.6cc into each femoral

cath.  For AK priming: (GAMBRO, Polyarylethersulfone, 6S) *1st N/S 1000cc. *2nd Heparin 2,500U. *3rd 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

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 1st bottle N/S 500cc + Sinca 1amp

2nd bottle N/S 500cc + 10% MgSO4 4cc 3rd bottle N/S 500cc 4th 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.

CVVHD 配置簡圖CVVHD

Continuous Veno-Venous Hemodialysis

PRISMA

S

CVVHD order

    Prepare Heparin 2cc + N/S 3cc, then inject 1.6cc into each femoral cath.

  For AK priming: (GAMBRO, Polyarylethersulfone, 6S) *1st N/S 1000cc. *2nd Heparin 2,500U. *3rd 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

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.

CVVHDF 配置簡圖

CVVHDFContinuous

Veno-Venous Hemodiafiltration P

RISMA

S

CVVHDF order

    Prepare Heparin 2cc + N/S 3cc, then inject 1.6cc into each femoral cath.

  For AK priming: (GAMBRO, Polyarylethersulfone, 6S) *1st N/S 1000cc. *2nd Heparin 2,500U. *3rd 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

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 1st bottle N/S 500cc + Sinca 1amp

2nd bottle N/S 500cc + 10% MgSO4 4cc 3rd bottle N/S 500cc 4th 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.