CRRT Fundamentals Pre- and Post- Test. AKI & CRRT Conference 2018

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1 CRRT Fundamentals Pre- and Post- Test AKI & CRRT Conference 2018

2 Question 1 Which ONE of the following statements regarding solute clearance in CRRT is MOST correct? A. Convective and diffusive solute clearance is inversely proportional to the effluent flow rate. B. The sieving coefficient for small molecular weight molecules such as creatinine is zero. C. Diffusive solute clearance is optimized with dialysate/blood flow ratio > 0.3 D. The urea clearance for CVVHD and pre-dilution CVVH is the same if the total effluent rates are the same. E. The sieving coefficient for urea decreases over time.

3 Question 2 A 57 year old alcoholic is admitted to the ICU with sepsis and multi-lobar pneumonia requiring mechanical ventilation. Blood and sputum cultures are positive for E. coli. Nephrology is consulted on hospital day 3 for AKI. He is mechanically ventilated and requires 80% FIO 2. He is febrile, heart rate 122 beats/minute, blood pressure 98/60 mmhg on norepinephrine infusion, and CVP 13 cm H 2 O. He has a Stroke Volume Index (SVI) increase of less than 10%. Examination of the chest reveals coarse breath sounds and inspiratory crackles throughout both lungs. He has generalized anasarca. He has made 300 ml of urine over the last 24 hours; he had made 750 ml over the preceding 24 hrs. His weight is 85 kg (admission weight 76 kg). Labs: Blood urea nitrogen 105 mg/dl Creatinine 5.2 mg/dl (admit creatinine 2.1 mg/dl) Electrolytes Sodium 135 meq/l Potassium 6.2 meq/l Chloride 97 meq/l Bicarbonate 14 meq/l Phosphorous 6.9 mg/dl Creatinine phosphokinase 65,200 U/L Serum ph 7.28 Urinalysis 4+ blood; 0-1 erythrocytes/hpf; 0-2 white blood cells/hpf; numerous granular casts and renal tubular epithelial cells

4 Question 2 Which of the following is the MOST appropriate next step in this patient s management? A. Start continuous intravenous fluids with bicarbonate for rhabdomyolysis. B. Initiate continuous venovenous hemofiltration (CVVH) with total ultrafiltration (effluent) rate of 1400 ml/hr for myoglobin removal. C. Initiate continuous venovenous hemodialysis (CVVHD) with total effluent rate of 2200 ml/hr for urea clearance and electrolyte management. D. Initiate continuous venovenous hemodiafiltration (CVVHDF) with total effluent rate 3400 ml/hrfor myoglobin removal. E. Initiate high volume hemofiltration (HVHF) with total ultrafiltration (effluent) rate of 4300 ml/hr for cytokine and myoglobin removal.

5 Question 3 A 43 year old female (current weight 90 kg) is admitted to the MICU with severe shock requiring vasopressors, acute respiratory failure, and AKI. She is mechanically ventilated and on multiple vasopressors. She has bilateral infiltrateson CXR and was started on vancomycin and Piperacillin/tazobactam in the ED. Shortly after admission to the ICU she is initiated on CRRT for severe acidemia with the following settings: CVVHDF, Prismaflex, blood flow rate 150 ml/min, ACD-A citrate 250 ml/hr on pre-blood pump, dialysate flow rate 1000 ml/hr, post-filter replacement fluid rate 1000 ml/hr, fluid removal 150 ml/hr. Which of the following is the MOST correct statement regarding dosing of antibiotics with CRRT? A. Adjust antibiotic dosing for estimated creatinine clearance < 10 ml/min in setting of AKI B. Adjust antibiotic dosing for estimated creatinine clearance of ml/min C. Adjust antibiotic dosing to estimated creatinine clearance of > ml/min D. Change to prolonged intermittent renal replacement therapy (PIRRT) as antibiotic dosing is more readily known in PIRRT

6 Question 4 A 79 year-old critically ill male with AKI is placed on CVVH on NxStage Device with post filter replacement fluid. He has a hematocrit of 30% and weighs 70 kg. Blood flow rate Post-filter replacement fluid rate Fluid removal rate Anticoagulation 100 ml/min 1200 ml/hr 300 ml/hr 4% trisodium citrate (TSC) delivered through a y-connector at the arterial access external to the CRRT device at 180 ml/hr His post-filter ica levels are < 0.25 mmol/l. Access pressures are as follows: arterial press = -75 mmhg, venous press = 100 mmhg. His access is a 13 French 15 cm double lumen catheter inserted in Right IJ. He clots his hemofilter twice in 24 hours. Which of the following management options is BEST to decrease the chance of further filter clotting? A. Switch to heparin anticoagulation B. Increase the replacement fluid rate C. Increase the blood flow rate D. Increase the citrate rate E. Replace the dialysis access

7 Question 5 A 65 year-old critically ill male with AKI is placed on continuous venovenous hemodiafiltration (CVVHDF) with post filter replacement fluid. He has a hematocrit of 30% and weighs 85 kg. He clots his filter several times in 24 hours. His Prismaflex CVVHDF parameters are as follows: Blood flow rate: 200 ml/min Post-filter replacement fluid rate: 1000 ml/hr Dialysate: 1000 ml/hr Fluid removal rate: 300 ml/hr Anticoagulation: ACD A 2.2% Citrate (on PBP pump) Calcium gluconate infusion: 60 ml/hr (delivered through separate CVL) Post-filter ica 0.51 mmol/l, Systemic ica 1.1 mmol/l Arterial press = -50 mmhg, venous press = 60 mmhg Which ONE of the following management options would BEST decrease the chance of filter clotting? A. Increase the replacement fluid rate B. Increase the blood flow rate C. Switch to continuous venovenous hemofiltration (CVVH) D. Increase the citrate rate E. Replace the dialysis access

8 Question 6 A 35-year-old man is admitted to the neurosurgical critical care unit after a motor vehicle accident in which he sustained head trauma. A computed tomography (CT) scan reveals intracerebral bleeding and brain edema. His course is complicated by oligo-anuric AKI. Hypernatremia is induced with hypertonic sodium chloride (3% saline). Other medicaons include nicardipine, omeprazole, propofol, and levatiracetam. On examination: blood pressure 150/90 mmhg, heart rate 90 beats/min, bladder pressure 12 mmhg, weight 100 kg. He is intubated and unresponsive. Urine output 10 ml/h for the last 12 hours. Urinalysis reveals protein 100 mg/dl and 4+ hemoglobin by dipstick. Urine microscopy reveals moderate coarse granular casts and no red blood cells. Day 1 Day 2 Sodium meq/l Potassium meq/l Bicarbonate meq/l BUN mg/dl Creatinine mg/dl Creatinekinase U/L 12,000 20,000

9 Question 6 The decision is made to initiate renal replacement therapy (RRT) for severe AKI. In addition to close monitoring of the serum sodium, which of the following initial prescriptions for renal replacement therapy is MOST appropriate? A. Daily hemodialysis utilizing blood flow of 300 ml/min and dialysate flow of 600 ml/min, dialysate sodium of 150 meq/l, dialysate potassium of 2 meq/l for 3 hours per session B. Alternative day hemodialysis utilizing blood flow of 300 ml/min, dialysate flow of 600 ml/min, dialysate sodium of 150 meq/l, dialysate potassium of 2 meq/l for 4 hours per session C. Continuous venovenous hemofiltration with blood flow of 300 ml/min, total ultrafiltration rate (effluent rate) 35 ml/kg/hr, pre-filter replacement fluid with sodium of 140 meq/l and potassium of 2 meq/l and postfilter replacement fluid of 0.9% saline at 200 ml/hr D. Continuous veno-venous hemodiafiltration (CVVHDF) utilizing blood flow rate of 150 ml/min, effluent rate of 20 ml/kg/hr, dialysate sodium of 140 meq/l, dialysate potassium of 2 meq/l, and postfilter replacement fluid of 3% saline at 50 ml/h

10 Question 7 A 59-year-old man with alcoholic cirrhosis and type 2 diabetes mellitus is admitted to the intensive care unit for severe sepsis from pneumonia. He is given intravenous fluid resuscitation and norepinephrine to improve his mean arterial pressure to 70 mmhg and develops oliguricaki. His current medications include norepinephrine, cefepime, vancomycin, lactulose, and insulin. On exam, he is intubated and sedated. Anasarca is present, and there are coarse breath sounds over both lung fields. Laboratory studies show: Sodium 134 meq/l Potassium 5.7 meq/l Chloride 102 meq/l Total CO2 20 meq/l BUN 84 mg/dl Creatinine 3.2 mg/dl Albumin 3.6 mg/dl, Total calcium 9.1 mg/dl ( mg/dl) Ionized calcium 5.0 mg/dl (reference range, mg/dl) (1.25 mm; reference range, mm)

11 Question 7 CRRT is begun using citrate anticoagulation. Over the next 48 hours, he remains stable, and CRRT is used to achieve a net ultrafiltration of 100 ml/h. On the third day of therapy, the following laboratory studies are obtained: Sodium 137 meq/l Potassium 3.8 meq/l Chloride 98 meq/l Total CO2 18 meq/l BUN 30 mg/dl Creatinine 2.1 mg/dl Total calcium 10.4 mg/dl (2.6 mm) Ionized calcium 3.9 mg/dl (0.975 mm) Which one of the following is MOST consistent with citrate toxicity in this patient? A. The calcium corrected for the serum albumin B. The difference in ionized calcium before and after CRRT C. The ratio of the total calcium to ionized calcium D. The difference between the total and ionized calcium

12 Question 8 A 24 year old male develops severe ARDS related to near-drowning and is placed on conventional veno-venous extracorporeal membrane oxygenation (ECMO) with initial settings that include blood flow of 4 L/min and fresh ( sweep ) gas flow of 3 L/min. He develops anuria and is started on CRRT placed in combination with the ECMO circuit. The CRRT access limb (providing blood flow to the CRRT machine)is inserted into the ECMO circuit distal to the membrane oxygenator. The CRRT return limb (providing blood flow from the CRRT machine back to the patient) is optimally placed: A. Into the ECMO circuit distal to the oxygenator B. Into the ECMO circuit proximal to the oxygenator C. Into a separate central venous line D. Into a separate peripheral intravenous line

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