CRRT. ICU Fellowship Training Radboudumc

Transcription

1 CRRT ICU Fellowship Training Radboudumc

2 Timing RRT Consider the following: Underlying cause and reversibility. Rapid improvement unlikely with high dose vasopressors and continuous exposure to other risk factors for AKI Urine production in relation to intake and fluid balance Consequences of fluid overload (oxygenation) Degree of metabolic derangement and subsequent consequences Adverse effects of RRT

3 Timing of RRT and outcome N = MV - Inotropic agents 28-D mortality (%) Start 7 uur 48.2 ml/kg/hr P = 0.80 P = 0.25 Start 7 uur 20.1 ml/kg/hr Start 42 uur 19.0 ml/kg/hr Early HV Early LV Late LV Median duration AKI survivors (D) Early HV Early LV Late LV N = 35 N = 35 N = 36 > 50% of patients after cardiac surgery Bouman CS. Crit Care Med 2002;30:

4 Timing of RRT N = 648, postoperative AKI - observational Corrected for multiple risk factors Shiao CC. PLOSOne 2012;7:e42952

5 Early versus late RRT (Early < 24 hours after AKI III) N = Early P = Late 77,9 60 % 40 51, Mortality Lower duration of MV and RRT Leite TT. Crit Care 2013;17:R62

6 Bagshaw SM. Crit Care 2009;13:317

7 Dutch guideline Start RRT immediately in case of life threatening AKI associated symptoms in fluid balance, acidbase balance or electrolytes Consider RRT if despite optimization of the circulation AKI persists and the patients suffers from persistent metabolic derangements or diuretic resistent fluid overload

8 Dutch guideline Do not start RRT with mild metabolic derangements that are likely temporary or when treatment appears to be futile

9 Hemofiltration

10 Hemodialysis

11

12 Dutch guideline Intermittent hemodialysis is a good alternative for the stable patient Friedrich JO. Crit Care 2012;16:R146

13 RCT SLED vs CVVH N = hrs SLED lower costs Better metabolic control, MV - 3D, ICU LOS - 4D Schwenger V. Crit Care 2012;16:R140

14 CONVINT trial N = Single centre prospective RCT Daily IHD vs CVVH IHD CVVH % 50 60,5 56, Mortality 14 D after stop RRT No differences in LOS -days on RRT - MV duration Schefold JC. Crit Care 2014;18:R11

15 RRT dose Does should be sufficient to remove uremic toxins and correct metabolic acidosis Higher dose may be needed during hypermetabolism but side effects increase Filter down-time often 20-25% Pre dilution decreases dose (correct: BF + UF / BF)

16 Critically ill Age 18 Acute Kidney Injury CVVHDF Blood flow > 150 ml/min 40 ml/kg/hr 25 ml/kg/hr N = 721 N = 743 No baseline differences 50 Low dose High dose Mortality (%) ,7 44,7 36,9 38,5 90 D mortality 28 D mortality 0 46,2% 47,6% 1 35,4% 35,2% 2 14,7% 13,9% 3 3,4% 3,2% 4 0,4% 0,1% Number non-renal organ failure (%) No difference in need RRT in survivors at D 28 and day 90 RENAL Replacement Therapy Study Investigators. N Engl J Med 2009;361:

17 RRT - dose Study Year N Low dose High dose Survival LD Survival HD Ronco ml/kg/hr 35 ml/kg/hr 41% 57% Bouman ml/kg/hr 48 ml/kg/hr 72% 74% Saudan ml/kg/hr 42 ml/kg/hr 39% 59% Tolwani ml/kg/hr 35 ml/kg/hr 56% 49% VA/NIH trial (IHD/ SLED) 35 (IHD/ SLED) 48% 46% Renal study ml/kg/hr 40 ml/kg/hr 55% 55% Survival Dose dependent region Inflection point Dose independent region Hypotension Electrolyte disorders Micro-nutrient depletion Hypothermia Changes in acid-base status Error in drugs RRT dose Schiffl H. Int Urol Nephrol 2010;42:

18 Dutch guideline CRRT: effluent dosis (filtrate + dialysate) ml/ kg/hr with compensation for: filter down-time pre dilution No indication for high-volume CVVH

19 Citrate versus LMWH for CVVH N = 200 LMWH Citrate 70 P < P = 0.02 P = 0.03 P = , ,5 0 Discontinuation Renal recovery Hospital mortality 3 M mortality No improvement in need for transfusion or circuit survival time Oudemans-van Straaten HM. Crit Care Med 2009;37:

20 The three citrate trials

21 CRRT-citrate and elevated T/ I Ca 2+ ratio Prospective observational - N = need for CRRT (citrate) Independent predictor of 28 D mortality Associated with hepatic failure or MODS Indirect marker of systemic citrate accumulation Necessity to increase citrate clearance Link A. Crit Care 2012;16:R97

22 Link A. Crit Care 2012;16:R97

23 Link A. Crit Care 2012;16:R97

24 Link A. Crit Care 2012;16:R97

25 Argatroban therapy 100 μg/kg bolus i.v. 1 μg/kg/min continuously aptt (2-3 fold elevated) Dosage adaption In critically ill patients maintenance 0.2 μg/kg/min Link A. Crit Care Med 2009;37:

26 N = 30 Link A. Crit Care Med 2009;37:

27 Vaara ST. Acta Anaesthesiol Scand 2012;56: Is there a volume effect with CRRT All ICU s in Finland 18/year 28/year 54/year