Objectives Define Heart Failure Define Sepsis Discuss medical management of heart failure and sepsis Describe indications for CRRT for these disorders.

Objectives Define Heart Failure

Define Sepsis

Discuss medical management of heart failure and sepsis

Describe indications for CRRT for these disorders

Case Study

Clinical syndrome that can result Clinical syndrome that can result from any structural or functional from any structural or functional cardiac disorder that impairs the cardiac disorder that impairs the ability of the ventricle to fill with ability of the ventricle to fill with or eject bloodor eject blood

Incidence of Heart Failure

More deaths from heart failure than from all forms of cancer

Nearly 1 millions people are admitted to the hospital with CHF and 30%-60% are readmitted

Contributed to 53,000 deaths in the U.S. each year

About 550,000 new cases per year

Affects men and women equally

Related to the aging population, lower death rate from MI, and improved treatment for heart disease

http://health.usnews.com/health-conditions/heart-health/congestive-heart

Main causes

Ischemic heart disease, Cardiomyopathy, Hypertension, Diabetes

Other causes: Valvular heart disease, Congenital heart

disease, Alcohol and drugs, Hyperdynamic circulation

(anemia, thyrotoxicosis, hemochromatosis, Paget's

disease), Right heart failure (RV infarct, pulmonary

hypertension, pulmonary embolism, cor pulmonale

(COPD)), Arrhythmia and Pericardial disease.

Impaired cardiac contractility as in myocardial infarction and cardiomyopathy

Ventricular outflow obstruction (pressure overload) as in hypertension and aortic stenosis

Impaired ventricular fillings as in mitral stenosis and constrictive pericarditis

Volume overload as in mitral regurgitation

Infections

Arrhythmias

Physical, Dietary, Fluid, Environmental, and Emotional Excesses.

Myocardial infarction

Pulmonary embolism

Anemia

Thyrotoxicosis and pregnancy

Aggravation of hypertension

Rheumatic, Viral, and Other Forms of Myocarditis

Infective endocarditis

Diabetes

1. Hypertrophy & Dilatation

E.D.V

2. Sympathetic activity:

H.R.• V.C

Angiotensin

Aldosterone

TYPES OF HEART FAILURE

Left- sided or left ventricular (LV) heart failure

is commonly caused by ischemic heart disease but can also occur with valvular heart disease and hypertension. 2 types of (LV) heart failure

diastolic failure is a syndrome consisting of symptoms and signs of heart failure with preserved left ventricular ejection fraction above 45–50% and abnormal left ventricular relaxation assessed by echocardiography

systolic failure is when the left ventricle loses it’s ability to contract normally, can pump enough blood into the systemic circulation

Right-sided or right ventricular (RV)heart failure

may be secondary to chronic( LV ) heart failure but can occur with primary and secondary pulmonary hypertension, right ventricular infarction.

TYPES of HEART FAILURE Congestive Heart Failure-

Blood flow out of the heart slows, blood returning to the heart through the veins backs up and congestion in the body’s tissues

Will see edema, SOB, can affect kidney function

Symptoms & Signs OF Heart Failure

Left heart failure

Symptoms are predominantly fatigue,

exertional dyspnea, orthopnea and PND

Physical signs: Cardiomegaly, gallop

functional mitral regurgitation and crackles a the lung bases.

Right Heart Failure

Symptoms (fatigue, breathlessness, anorexia and nausea) relate to distension and fluid accumulation in areas drained by the systemic veins.

Physical signs are usually more prominent than the symptoms, with:

jugular venous distension

tender smooth hepatic enlargement

dependent pitting edema

development of free abdominal fluid (ascites)

Pleural effusion (commonly right-sided).

Dilatation of the right ventricle produces cardiomegaly and may give rise to functional tricuspid regurgitation. Tachycardia and a right ventricular third heart sound are usual.

Classification of Heart Failure

Functional Capacity Class I – patients with cardiac disease and no

limitation of physical activity

Class II- patients with cardiac disease slight limitation of physical activity results in fatigue, palpitation, dyspnea or angina

Class III-patients with cardiac disease marked limitation of physical activity comfortable at rest

Class IV-patients with cardiac disease inability to carry on any physical activity, symptoms of heart failure at rest

http://www.heartorg/HEARTORG/Conditions/Heart

1. Hypertrophy & Dilatation

E.D.V

2. Sympathetic activity: H.R.• V.C

Angiotensin

Aldosterone

If Resistant to Diuretics

MAY NEED

Ultrafiltration

UNLOAD STUDY The UNLOAD study was a randomized, multicenter

study of 200 patients involving 28 hospitals and medical centers across the United States. UNLOAD compared the short and long-term safety and efficacy of an advanced form of ultrafiltration therapy(Aquapheresis) to the use of conventional diuretic drug therapy in fluid overloaded heart failure patients.

The UNLOAD study was published in the February 13, 2007 issue of Journal of American College of Cardiology. (Costanzo MR et al. JACC 2007; 49(6):675-683).

UNLOAD StudyResults

28% with greater fluid loss with UF

43% reduction in patients being re-hospitalization for HF

63% fewer hospital days for HF

What is SIRS?

The systemic inflammatory response syndrome is systemic level of acute inflammation, that may or may not be due to infection, and is generally manifested as a combination of vital sign abnormalities including fever or hypothermia, tachycardia, and tachypnea.

Definitions Severe SIRS – SIRS in which at least 1 major organ

system has failed.

Sepsis – SIRS which is secondary to infection.

Severe Sepsis – Severe SIRS which is secondary to infection.

Septic Shock – Severe sepsis resulting in hypotensive cardiovascular failure.

Systemic Inflammatory Reponse(SIRS)

Can be triggered by infectious and non-infectious events

Infectious causes bacteria or fungi

Non infectious causes are prancreatitis,burns, trauma

SIRS is the term used for noninfectious causes

Criteria for SIRSRequires 2 of the following 4 features to be present:

Temp >38.3° or <36.0° C

Tachypnea (RR>20 or MV>10L)

Tachycardia (HR>90, in the absence of intrinsic heart disease)

WBC > 10,000/mm3 or <4,000/mm3 or

>10% band forms on differential

Criteria for Severe SIRSMust meet criteria for SIRS, plus 1 of the following: Altered mental status SBP<90mmHg or fall of >40mmHg from baseline Impaired gas exchange Metabolic acidosis (pH<7.30 & lactate > 1.5 x

upper limit of normal) Oliguria (<0.5mL/kg/hr) or renal failure Hyperbilirubinemia Coagulopathy (platelets < 80,000-100,000/mm3,

INR >2.0, PTT >1.5 x control, or elevated fibrin degredation products)

Pathophysiology of Sepsis

Overwhelming inflammatory response

Increased production of proimflamatory cytokines and decreased production of cytokines( which inhibit inflammation)

Clotting cascade activated

Peripheral Vasodilatation systemic vascular resistance

Pathophysiology of Sepsis

continued C/O decreases

Intravascular fluid loss

Decreased pre load-hypotension

ATN-renal hypoperfusion and ischemic injury

MODS

MOF

Relationship Between SIRS and Sepsis

Adapted from: Marini JJ, et al. Critical Care Medicine, 2nd ed. 1997.

Risk Factors for SIRS/Sepsis

Age

Indwelling lines/catheters

Immunocompromised states

Malnutrition

Alcoholism

Malignancy

Diabetes

Cirrhosis

Male sex

Genetic predisposition?

PrognosisOverall mortality from SIRS/sepsis in the U.S. is approximately 20%. Mortality is roughly linearly related to the number of organ failures, with each additional organ failure raising the mortality rate by 15%.

Hypothermia is one of the worst prognostic signs. Patients presenting with SIRS and hypothermia have an overall mortality of ~80%.

Treatment Fluid Resuscitation

Vasopressors

Antibiotics

Eradication of infection

Ventilatory support, activated protein C, steroids, glycemic control, nutrition

CRRT

CONTINUOUS

RENAL REPLACMENT

THERAPY

CRRT Definition

CRRT = Continuous Renal Replacement Therapy

Defined as “Any extracorporeal blood purification

therapy intended to substitute for impaired renal function over an extended period of time and applied for or aimed at being applied for 24 hours /day.” *

* Bellomo R., Ronco C., Mehta R,Nomenclature for Continuous Renal Replacement Therapies,AJKD, Vol 28, No. 5, Suppl 3, November 1996

Introduction to CRRT

Why continuous therapies?

Continuous therapies closely mimic the native kidney in treating ARF and fluid overload Slow & gentle Remove fluid and waste products over time Tolerated well by the hemodynamically unstable patient

2

Intra-Intra-cellular cellular SpaceSpace

Extra-Extra-cellular cellular SpaceSpace

Intra-Intra-Vascular Vascular SpaceSpace

Circulating Circulating Blood VolumeBlood Volume

Toxins

Fluid

Toxins

Fluid

Toxins

Fluid

Dialyzer

23 L 17 L 23 L 17 L 40 Liters40 Liters

5 Liters5 Liters

Three Compartment Model

Indications for Therapy

Acute kidney injury- preferred in the critically ill patient

Fluid overload- can removed large amounts of fluid slowly

Hemodynamically unstable- continuous therapy allow for slow hourly fluid removal which allows the intravascular spaces to refill

Indications continued

Highly catabolic patients who need increased clearance rates

Patients needing large molecular weight substances removed

Sepsis

Molecular Weight SMALL MOLECULES- 0-500 daltons (urea, creatinine)

MIDDLE MOLECULES- 500-5000 daltons ( vitamin B12)

LARGE MOLECULES- 5000-50,000 daltons ( heparin, Beta 2 drugs)

CRRT Modalities

SCUF OR ULTRAFILTRATION - Slow Continuous UltraFiltration

CVVHD - Continuous Veno-Venous HemoDialysis

CVVH - Continuous Veno-Venous Hemofiltration

CVVHDF – Continuous Veno-Venous Hemodiafiltration

SCUF/Ultrafiltration

Primary therapeutic goal: Safe management of fluid removal

Patient UF rate ranges up to 2 L/Hr

No dialysate;No replacement fluids No molecule removal

Large fluid removal via ultrafiltration

Blood Flow rates = 100-200 ml/min

SCUF/ULTRAFILTRATION

Slow Continuous UltraFiltration

AccessAccess

ReturnReturn

EffluentEffluent

45

Ultrafiltration

Particles move through a semi-permeable membrane by use of HYDROSTATIC pressure.

The separation of particles from a suspension by passage through a filter. The separation is accomplished by convective transport.

Convection – Step 1 Filter Action

U

Na

Na

Na

K

U

U

U

U

U

U

U

U

U

U

U

H2O

K

K

K

K

K

K

K

K

K

H2O

H2O

H2O

H2O

H2O

H2O

H2O

H2OH2O

H2O

H2O

Na

Na

Na

Na

Na

Na

Na Na

Na

Na

K

Na

Na

Na

Na

Na

Na

Na

H2O

H2O

H2O

Red Cell

Red Cell

Red Cell

Red Cell

Red Cell

Convection: The movement of solutes with a water-flow,“solvent drag”, e.g... the movement of membrane-permeablesolutes with water across the semipermeable membrane

Solute Removal by Convection

CVVH

Continuous Veno-Venous Hemofiltration

ReplacementReplacement(pre or post dilution(pre or post dilution))

AccessAccess

ReturnReturn

EffluentEffluent

Molecular Transport Mechanisms

Convection - The movement of solutes with a water-flow, “solvent drag”, the movement of membrane-permeable solutes with water across the semipermeable membrane

Convection – Step 1 Filter Action

U

Na

Na

Na

K

U

U

U

U

U

U

U

U

U

U

U

H2O

K

K

K

K

K

K

K

K

K

H2O

H2O

H2O

H2O

H2O

H2O

H2O

H2OH2O

H2O

H2O

Na

Na

Na

Na

Na

Na

Na Na

Na

Na

K

Na

Na

Na

Na

Na

Na

Na

H2O

H2O

H2O

Red Cell

Red Cell

Red Cell

Red Cell

Red Cell

Convection: The movement of solutes with a water-flow,“solvent drag”, e.g... the movement of membrane-permeablesolutes with water across the semipermeable membrane

Solute Removal by Convection

CVVHD - Continuous VV Hemodialysis

Primary therapeutic goal: Solute removal by diffusion Safe fluid volume management by ultrafiltration

Requires Dialysate solution

Patient UF rate ranges 2-7 L/24 hours (~300 ml/hr)

Dialysate Flow rate = 15-45 ml/min (~2 L/hr)

Blood Flow rate = 100-200 ml/min

No replacement solution

Solute removal determined by Dialysate Flow rate.

Diffusion – Filter Action

U

Na

NaNa

KU

U

U

U

U

U

U

U

U

U

UH2O

KK

KK

K

K

K

Mg

K

H2O

H2O

H2O

H2O

H2O

H2O

H2O

H2O

H2O

H2O

H2O

Na

Na

Na

Na

Na

NaNa Na

Na

Na

K

Na

Na

Na

Na

Na

Na

Na

Mg Mg

Mg

Mg

Vascular Access Depending on the device used lumen size matters

If using AquaDex FlexFlow Fluid Removal System midline catheters can be used

If using CRRT devices hemodialysis type catheters need to be placed.

Catheter Size Adults

12.5 to 14 french Length will vary

16,19,24,cm Femoral placement

least preferred

Children (weight based) 5 french single

catheter 7 fr dual lumen8 fr dual lumen10 fr dual lumen11 fr dual lumen

Length9 cm, 10 cm, 12 cm, 15 cm

Case Study #1

Mr. G is a 60 year old man with CAD s/p MI and PTCA to LAD in 1997, dyslipidemia, and tobacco use who called 911 for severe chest pain on 11/01/10. This pain was similar in nature to his previous MI.

ECG in the ambulance

History In the ambulance en route to the emergency room,

the patient developed two episodes of ventricular fibrillation which both successfully responded to DC cardioversion. After arrival to the cath lab, the patient developed cardiogenic shock and recurrent ventricular fibrillation requiring multiple shocks (he was shocked 11 times in the cath lab prior to intervention) and intubation with mechanical ventilation.

Cath Lab Course Coronary angiography showed:

Totally occluded mid LAD with thrombus Mild diffuse atherosclerosis of left circumflex and right

coronary arteries

Soon after the first injection there was proximal propagation of the LAD thrombus which occluded the left main coronary artery

A wire was passed to the distal LAD and an AngioJet thrombectomy device was used which re-established flow

Cath Lab Course After the Impella device was placed, the patient had

no further episodes of ventricular fibrillation

Immediately Post Cath Patient admitted to the CCU on IV Epinephrine,

Dobutamine, and Dopamine continuous infusions

Echocardiogram the next day showed severe anterior wall hypokinesis with EF 25%

The patient was placed on CVVH then on SCUF to remove excess fluid

Hospital Course

Hospital day 3: Impella device was removed

Hospital Day 6: Repeat echocardiogram, EF 50-55%

Hospital Day 8: Extubated, neurologically intact

Hospital Day 16: Discharged to home

Case Study#2

Alan is a 20 year old admitted to a cardiology unit with CHF and Situs Inversus. He had SOB , anascara, arrythmias. His blood pressure was 110/60 mm Hg. He has a serum creatinine of 1.5 mg/dl. He is in need of a pacemaker but first needs 10 liters of fluid removed before placement of a pacemaker.

He is started on furosemide 80 mg every 8 hours and metolazone 10mg/d for 2 days. On day three he is given mannitol 25 g every eight hours.

He is putting out 3L of urine a day but has only decreased his net fluid loss by 3 L due to lack of adherance to his fluid restriciton

Case StudyContinued

Because of his need for a pacemaker, the decision was made to place the patient on SCUF.

After three days of therapy the patient was at his dry weight and stable and was able to receive his pacemaker

Consideration has to be given related to rate of fluid removal and his overall renal function

Patient was discharged to home with a follow up to a nephrologist

Case Study#3

Mrs. D was admitted to MICU for sepsis. She had been hypotensive that required vasopressors. During the course of her stay in MICU, she developed AKI. To manage her fluid and electrolytes, she was started on CRRT. She seemed to tolerate CRRT well.

On her 5th day of therapy, her Serum Creatinine was down to 1.2 from 6.9 and her electrolytes were stable, her BP was borderline with MAP > 60 mmHg and < 70 mmHg.

CRRT was discontinued and only to be restarted after 2 days when the patient became hypotensive again that regular HD was not possible given her hemodynamic parameters.

Patient was started on phenylephrine at 200 mcg/min and nor-epinephrine at 10 mcg/min. On the 3rd day of the 2nd therapy, the patient had the following data:

Patient Data

Questions What happened in this scenario?

What should have been considered in setting the net fluid removal rate?

How would we assess for the intravascular vs extra-vascular fluid status?

When will be the right time to advocate for discontinuance of CRRT?

Conclusion CRRT therapies can be applied to many clinical

situations

The patient goals/outcomes can be enhanced with early initiation of this therapy