Admission Day 2 Na Potassium Cl Bicarb BUN Cr Hb Hct platelets

Transcription

1 Nithin Karakala

2 Mr. Clark Kent was admitted to the hospital with multiple injuries after an epic battle with the Kryptonians. He was hypotensive at the time of admission. Over the next 24 hours he develops worsening septic shock with hypotension requiring pressors and has minimal urine output (80ml/day). During an employment physical for the Daily Planet last month his Cr was 0.8 mg/dl. He was diagnosed with rhabdomyolysis, AKI, shock liver and DIC Admission Day 2 Na Potassium Cl Bicarb BUN Cr Hb Hct platelets

3 } The decision was taken to start CRRT. After obtaining consent from Lois Lane, a right IJ quinton catheter was placed and CRRT was started. Admission Wt: 90 kg, Hct 30% Machine: Prismaflex Anticoagulation: none Mode: CVVHDF Dose: 25 ml/kg/hr Blood flow rate: 200 ml/min Post filter replacement fluid: 2.5 Lit Prismasol(BGK2) all post filter Hourly UF to maintain at even balance 500 ml/hr During rounds the next day the nurse tells you that the filter clotted 3 times in the last 24 hours. What is the problem? How do you fix the problem?

4 } Is it a true filter clotting? } Is there a problem with the access? Check filter pressure, access pressure and return pressure.

5 } Access pressure: -70 mmhg (-50 to -150 mmhg) } Return pressure: 90 mmhg (50 to 150 mmhg) } Filter pressure: 350 mmhg (100 to 250 mmhg) How do you prevent filter clotting? Increase anticoagulation Decrease filtration fraction (<25%)

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7 } FF= Q rf +UF/Q b (1-Hct)+Q pre rf } FF= Q eff -Q d /Q b (1-Hct)+Q pre rf Q rf : Replacement fluid rate Q b : Blood flow rate Q pre rf : Pre filter replacement fluid Q d : Dialysate fluid rate.

8 } Filtration fraction > 25% is associated with increased risk of filter clotting. } How do you reduce filtration fraction Increase blood flow rate Decrease replacement fluid rate Decrease UF rate

9 } Following changes are made to the prescription Machine: Prismaflex Anticoagulation: none Mode: CVVHDF Dose: 25 ml/kg/hr Blood flow rate: 400 ml/min Post filter replacement fluid: 1.5 Lit Prismasol(BGK2) Dialysate fluid: 1 lit prismasate (BGK2) Hourly UF to maintain at even balance 500 ml/hr The patient still has increasing CPK, increasing myoglobin concentration and worsening sepsis Next day the nurse tells you that the filter clotted twice in the last 12 hrs. What do you do next?

10 } Access pressure: -70 mmhg (-50 to -150 mmhg) } Return pressure: 90 mmhg (50 to 150 mmhg) } Filter pressure: 350 mmhg (100 to 250 mmhg) PD: 110 mmhg TMP: 210 mmhg

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12 } High filter pressure } Increase pressure drop (>150mmHg): Clotting } Increase in TMP (>150mmHg): Clogging

13 Pressure Drop Transmembrane Pressure

14 } If there is high degree of inflammation clogging may not be completely prevented. } Risk of clogging can be reduced by Decreasing replacement fluid rate Changing to CVVHD Citrate anticoagulation

15 } Following changes are made to the prescription Machine: Prismaflex Anticoagulation: none Mode: CVVHDF Dose: 25 ml/kg/hr Blood flow rate: 400 ml/min Post filter replacement fluid: 1 Lit Prismasol(BGK2) Dialysate fluid: 1.5 lit prismasate (BGK2) Hourly UF rate 300 ml/hr Mr Kent is slowly recovering over the next 2 days, but has not yet regained his healing powers. His pressor needs are down from 4 to 2 pressors but he is still anuric. He was taken for a CT scan at 12 am. Next day the nurse tell you that the machine stopped twice since midnight. Treatment was restarted with a new setup

16 Yesterday } } } Filter pressure: 328 mmhg ( mmhg) Pressure drop: 40mmHg TMP: 135 mmhg Today

17 } Access pressure: -108 mmhg } Return pressure: 300 mmhg Return pressure: this is the positive pressure needed to return the blood back to the patient. High return pressure Kinked return blue line Kinked catheter Clot in the catheter Catheter against the vessel wall Low return pressure Return line disconnected

18 Check of any kinks or clamps in the blue line High return pressure Normal return pressure No alarm, continue treatment Adjust the position of the patient and catheter High return pressure Normal return pressure No alarm, continue treatment Check an X ray to reconfirm catheter position and adjust.

19 Check an X ray to reconfirm catheter position and adjust. High return pressure Normal return pressure No alarm, continue treatment Can try TPA for 2 hours, replace catheter

20 } Following changes are made to the prescription Machine: Prismaflex Anticoagulation: none Mode: CVVHDF Dose: 25 ml/kg/hr Blood flow rate: 400 ml/min Post filter replacement fluid: 1 Lit Prismasol(BGK2) Dialysate fluid: 1.5 lit prismasate (BGK2) Hourly UF rate 300 ml/hr Mr Kent is slowly recovering over the next 2 days, but has not yet regained his healing powers. His pressors needs are down from 4 to 2 pressors but he is still anuric. He was taken for a CT scan at 12 am. Next day the nurse tell you that the machine stopped twice since midnight. Treatment was restarted with a new setup

21 } Filter pressure: 130 mmhg ( mmhg) } Pressure drop: 92mmHg } TMP: 86 mmhg } Access pressure: -320 mmhg } Return pressure: 70 mmhg

22 } Access pressure: -320 mmhg } Return pressure: 70 mmhg Access pressure: this is the negative pressure created by the blood pump to draw blood into the machine. Low Access Pressure (High negative) Kinked access red line Kinked catheter Clot in the catheter Catheter against the vessel wall Catheter against the vessel wall Another catheter aspirating blood from the same site

23 Check of any kinks or clamps in the red line negative access pressures Normal Access pressure No alarm, continue treatment Adjust the position of the patient and catheter negative access pressures Normal access pressure No alarm, continue treatment Check an X ray to reconfirm catheter position and adjust. Check for signs decreased circulatory volume

24 Switch catheter ports Negative access pressure Normal access pressure No alarm, continue treatment Can try TPA for 2 hours, replace catheter

25 Filter/ Machine Access

26 } You decide to change the line and placed a new right IJ catheter. } At this time the US government decided that Mr Kent will get VA privileges as he fought for the country and was transferred to the VA next door. } The nurse at the VA starts CRRT. } The nurse informs you of a funny alarm that she has never seen. Access pressure: + 20 mm Hg.

27 Positive Access Pressure (High negative) Arterial cannulation

28 } CRRT circuit starts and ends at the access. } Thank you