CRRT for the Experience User 1. Claudio Ronco, M.D. David Selewski, M.D. Rolando Claure-Del Granado, M.D. AKI & CRRT Conference March, 2018
|
|
- Dylan Cummings
- 5 years ago
- Views:
Transcription
1 CRRT for the Experience User 1 Claudio Ronco, M.D. David Selewski, M.D. Rolando Claure-Del Granado, M.D. AKI & CRRT Conference March, 2018
2 Disclosures I have no actual or potential conflict of interest in relation to this presentation.
3 Outline Prescribe before starting RRT Precision RRT and solute control Factors that affect achieving a prescribed dose: Quality measures Dose is not only urea clearance Conclusions
4 Case A 69 year old man develops AKI after undergoing a total hip replacement surgery. Nephrology is consulted 3 days later for evaluation of RRT. Weight 52 Kg BP 90/54 on dopamine drip SaO2 96% on 2L NC, no pulmonary congestion K 6.1, HCO3 17, BUN 85, scr 5.4, Hto 30% UO 0.1 ml/kg/h (last 8 hours) He had a positive cumulative fluid balance of 4.7 liters. RRT orders: CVVH post filter, Qb 100 ml/min, Qr 1000 ml/hr, no anticoagulation
5 Outline Prescribe before starting RRT Precision RRT and solute control Factors that affect achieving a prescribed dose: Quality measures Not only urea Conclusions
6 KDIGO Clinical Practical Guideline for Acute Kidney Injury Kidney Int suppl 2:89-115; 2012
7 Survey Survey of 26 of questions 26 questions 7 questions 7 questions for IHD for IHD and and SLED SLED that that included: included: - target - target dosage dosage of therapy of therapy - whether - whether and and how how frequently frequently delivered delivered dose was dose asses was asses 9 questions 9 questions for CRRT for CRRT - characterized - characterized dose dose ml/h ml/h vs. ml/kg/h vs. ml/kg/h - no -target no target dosage dosage or assessment or assessment of of delivered delivered dose dose was was evaluate. evaluate. Only Only 21% 21% of practitioners of practitioners assessed assessed delivered delivered dialysis dialysis dose dose (IHD). (IHD). < 20% < 20% of practitioners of practitioners reported reported using using weight-based weight-based dosing dosing of CRRT. of CRRT. Absence Absence of a of consistent a consistent standard standard for for prescription prescription and and monitoring monitoring of RRT of RRT during during AKI. AKI.
8 KDIGO Clinical Practical Guideline for Acute Kidney Injury Kidney Int suppl 2:89-115; 2012
9 Dialysis Dose-Outcome trials and dose measurements Bouchard J et al. Am J Kidney Dis; 2010.
10 Delivered RRT dose and survival Kellum JA and Ronco C Nature Reviews Nephrology; 2010
11 Post-dilutional CVVH K = [effluent flow rate] Q e *(C e /C b ) Post-dilutional CVVH: Q b 100 ml/min.; Hto 30% Q ef l/h BUN 110 mg/dl FUN 110 mg/dl K urea = 1000 ml/h * 110/110 = 1000 ml/h = 17 ml/min. (19 ml/kg/hr)
12 Post-dilutional CVVH Prescribed dose K urea = 1000 ml/h * 110/110 = 1000 ml/h = 17 ml/min. (19 ml/kg/hr) Efficiency = K (clearance) Measuring delivered dose Intensity = efficiency x time Blood volume cleared after a certain period of time (ml/kg) Intensity = 19 ml x 24 h = 456 ml/kg
13 Outline Prescribe before starting RRT Precision RRT and solute control Factors that affect achieving a prescribed dose: Quality measures Not only urea Conclusions
14
15 Prescribed dose RRT modality Blood flow Dialysis flow Replacement fluid flow Filter Time Ultra filtration Anticoagulation Vascular access Delivered dose Target solute control Target clearance control Target volume control Evaluate outcomes Achievement of desired clearance, acid-base balance, volume control, etc. Patient clinical status Quality measures Measured solute clearance Delivered/prescribed dose ratio Effective treatment time Circuit and filter pressures trends Bioimpedance
16 Outline Prescribe before starting RRT Precision RRT and solute control Factors that affect achieving a prescribed dose: Quality measures Not only urea Conclusions
17
18 Post-dilutional CVVH 20 hours (filter clotted) K = [effluent flow rate] Q e *(C e /C b ) Post-dilutional CVVH: Q b 100 ml/min.; Hto 30% Q ef l/h BUN 90 mg/dl FUN 60 mg/dl K urea = 1000 ml/h * 60/90 (0.66) = 660 ml/h = 11 ml/min. (13 ml/kg/hr) FUN/BUN < 0.8 P/D dose ratio < 0.8 (0.68) 20 hours Intensity = 13 ml x 20 h = 380 ml/kg 456 ml/kg
19
20 Post-dilutional CVVH K = [effluent flow rate] Q e *(C e /C b ) Post-dilutional CVVH: Q b 100 ml/min.; Hto 30% Q eff l/h BUN 90 mg/dl FUN 60 mg/dl K urea = 1000 ml/h * 60/90 = 660 ml/h = 11 ml/min. (13 ml/kg/hr) Filtration fraction: Q eff /Q p Q p = Q b ml/hr *(1-Hto) Filter clotting FF=25% FF = 1000 / (6000 * (1-0.30)) = 0.24 (24%) Prevent clotting: Increase Q b Use pre-dilution Anticoagulation type
21 Factors Influencing RRT Clearance Patient factors Treatment factors
22 Treatment Related Factors Catheter Filter Time out of therapy
23 Treatment Related Factors Catheter Filter Time out of therapy
24 Pre-dilution CVVHDF Filter 0.9 m 2 AN69 Anticoagulation LMW Heparin Filter change each 72 hrs. or if clotted Randomized -15 patients (46 treatments) PNT catheter -15 patients (46 treatments) ST catheter Prescribed and delivered clearance was assessed No difference in Qb No difference in recirculation rate ST catheters less catheter related thrombosis and infection Klouche K et al. Am J Kidney Dis, 2007
25
26
27 Treatment Related Factors Catheter Filter Time out of therapy
28 Treatment Related Factors Catheter Filter Down time due to filter clotting is the major reason for reduced RRT dose Concentration polarization reduces ultrafiltration rate and the filtrate concentrations of several medium / large sized proteins Convection Diffusion interactions Time out of therapy
29 Data from 52 critically ill patients, AKI requiring dialysis (Pre-dilution CVVHDF) Regional citrate anticoagulation. Filter efficacy was assessed by calculating FUN/BUN ratios q12 hr. Prescribed urea clearance (K, ml/min) - Effluent volume rate = Qd (ml/min) + Qr (ml/min) + Qnet (ml/min) K Estimated = Effluent volume adjusted for effective time of treatment. K delivered = FUN (mg/dl)/bun (mg/dl)] x effluent volume rate (ml/min) Claure-Del Granado et al. CJASN, 2011
30 Reasons for Discontinuing CRRT and Filter efficacy Claure-Del Granado et al. CJASN, 2011
31 Delivered CRRT Dose Based on Effluent Collection Claure-Del Granado et al, Clin J Am Soc Nephrol 2011 Conclusion: Measured effluent volume normalized for effective treatment time significantly overestimates delivered dose of small solutes in CRRT. To achieve a prescribed dialysis dose, effluent-based dose should be increased by 20-25%* to account for decreases in treatment time and reduced filter efficacy during CRRT.
32 Jaffrin MY. Art Organs, Claure-Del Granado R and Mehta RL. Sem Dialysis; 2011
33 Claure-Del Granado et al. Hemodial Int 18: 641-9; 2014.
34 Type of anticoagulant Median (IQR) Filter Life in Hours Citrate vs. Heparin, p < Citrate vs. no anticoagulant, p < Heparin vs. no anticoagulant, p = Citrate 48 ( ) Heparin 15.9 ( ) 6.1 ( ) 8.1 ( ) 7.4 ( ) No anticoagulant 17.5 (9.5 to 32) p value < Claure-Del Granado et al Hemodialysis Int, 2014
35 Anticoagulation UFH No heparin after mayor surgery, epidural procedures (24 48 h.) Prime circuit with 5000 UI (1st bolus) Second bolus like shown on table UFH infusion 10,000 UI en 1000 ml = 10 UI/ml Label as just for CRRT use Add the volume of heparin to the final amount of UF Pre-filter administration Lab control at 6 h, then each 12 h. UFH NIR TTPa Platelets 70 UI*kg 10 UI Kg/h 35 UI*Kg 5 UI Kg/h <1.5 <40 s >150 >1.5 - < 2.5 > 40 s <150 - >60 No bolus >2.5 >60 s <60
36 Pre-dilution CVVH Q b 100 ml/min.; Hto 30% Q r pre 2000 ml/hr Started on anticoagulation Dilution factor: Q b /(Q b +Q r ) Pre-dilution CVVH K = Q eff * (C e /C b )* [Q b /(Q b + Q r )] K = 2000 ml/h * 0.95 * (6000/( )) = 1425 ml/h Prescribed = 1500 ml/h = 29 ml/kg/hr Delivered = 23 ml/min 27 ml/kg/hr Pre-dilution CVVH FF: 1000 / [(6000(1-0.3)) ] 0.19 (19%) FUN/BUN > 0.8 P/D dose ratio > 0.8 (0.93) 20 hours
37 Outline Prescribe before starting RRT Precision RRT and solute control Factors that affect achieving a prescribed dose: Quality measures Dose is not only urea clearance Conclusions
38 Urea as the only marker of RRT dose? The marker solute (urea) cannot and does not represent all the solutes that accumulate in AKI. Its kinetics and volume of distribution are also different from those of the solutes of interest. Its removal during RRT is not representative of the removal of other solutes. The use of a single marker molecule to define treatment adequacy should be abandoned. Adequacy should be a broader term that includes several aspects of treatment.
39 Davenport and Farrington Lancet; 2010
40 618 patients enrolled in a prospective multicenter observational study (PICARD). Fluid overload was defined as more than a 10% increase in body weight relative to baseline. ( daily (fluid intake (L) total output (L))/body weight (in kilograms)) x100. Dialyzed patients, survivors had significantly lower fluid accumulation when dialysis was initiated compared to non-survivors after adjustments for dialysis modality and severity score. Non-dialyzed patients, survivors had significantly less fluid accumulation at the peak of their serum creatinine. Bouchard et al. Kidney Int; 2009
41
42 Proposed parameters for Dose Assessment Claure-Del Granado R and Mehta RL. Sem Dialysis; 2011
43
44 Dosing in RRT for AKI: Practical considerations An effluent flow of at least ml/kg per hour and a Kt/V of 3.9 per week could be sufficient, so long as there is careful attention to ensuring that the target dose of therapy is actually delivered. In order to ensure delivery of the target dose, a prescription of ml/kg per hour and a Kt/V of per week may be needed. Solute Clearances are not the sole measure of dialysis adequacy. Fluid removal and fluid balance are equally if not more important parameters to be monitored.
45 Spock s Advice on Dialysis in AKI Allow clinical trials and clinical practice guidelines to inform, not define practice. Think logically Don t allow emotions alter decision-making Listen to humanoids (patients) Glenn Chertow AKI&CRRT 2017
Can We Achieve Precision Solute Control with CRRT?
Can We Achieve Precision Solute Control with CRRT? Claudio Ronco, M.D. David Selewski, M.D. Rolando Claure-Del Granado, M.D. AKI & CRRT Conference February, 2019 Disclosures I have no actual or potential
More informationCan We Achieve Precision Solute Control with CRRT?
Can We Achieve Precision Solute Control with CRRT? Claudio Ronco, M.D. David Selewski, M.D. Rolando Claure-Del Granado, M.D. AKI & CRRT Conference February, 2019 Disclosures I have no actual or potential
More informationDialysis Dose Prescription and Delivery. William Clark, M.D. Claudio Ronco, M.D. Rolando Claure-Del Granado, M.D. CRRT Conference February 15, 2012
Dialysis Dose Prescription and Delivery William Clark, M.D. Claudio Ronco, M.D. Rolando Claure-Del Granado, M.D. CRRT Conference February 15, 2012 Dose in RRT: Key concepts Dose definition Quantifying
More informationCRRT: The Technical Questions Modality & Dose. Ashita J. Tolwani, MD, MSc University of Alabama at Birmingham 2018
CRRT: The Technical Questions Modality & Dose Ashita J. Tolwani, MD, MSc University of Alabama at Birmingham 2018 Case A 24YOM with HTN and OSA presents with acute pancreatitis. Despite aggressive fluid
More informationRationale for renal replacement therapy in ICU: indications, approaches and outcomes. Richard Beale
Rationale for renal replacement therapy in ICU: indications, approaches and outcomes Richard Beale RIFLE classification (ADQI group) 2004 Outcome AKIN classification Definition: Abrupt (within 48 hrs)
More informationTiming, Dosing and Selecting of modality of RRT for AKI - the ERBP position statement
Timing, Dosing and Selecting of modality of RRT for AKI - the ERBP position statement Prof. Dr. Achim Jörres Dept. of Nephrology and Medical Intensive Care Charité University Hospital Campus Virchow Klinikum
More informationASN Board Review: Acute Renal Replacement Therapies
ASN Board Review: Acute Renal Replacement Therapies Ashita Tolwani, M.D., M.Sc. University of Alabama at Birmingham 2014 Key issues for boards: RRT for AKI When should therapy be initiated? What are the
More informationCRRT Fundamentals Pre-Test. AKI & CRRT 2017 Practice Based Learning in CRRT
CRRT Fundamentals Pre-Test AKI & CRRT 2017 Practice Based Learning in CRRT Question 1 A 72-year-old man with HTN presents to the ED with slurred speech, headache and weakness after falling at home. He
More informationhigher dose with progress in technical equipment. Continuous Dialysis: Dose and Antikoagulation. prescribed and delivered
1 2 Continuous Dialysis: Dose and Antikoagulation higher dose with progress in technical equipment Comparison of pump-driven and spontaneous continuous haemofiltration in postoperative acute renal failure.
More informationMODALITIES of Renal Replacement Therapy in AKI
MODALITIES of Renal Replacement Therapy in AKI Jorge Cerdá, MD, MS, FACP, FASN Clinical Professor of Medicine Albany Medical College Albany, NY, USA cerdaj@mail.amc.edu In AKI, RRT is a multidimensional
More informationCRRT Fundamentals Pre- and Post- Test Answers. AKI & CRRT 2017 Practice Based Learning in CRRT
CRRT Fundamentals Pre- and Post- Test Answers AKI & CRRT 2017 Practice Based Learning in CRRT Question 1 A 72-year-old man with HTN presents to the ED with slurred speech, headache and weakness after falling
More informationCRRT. ICU Fellowship Training Radboudumc
CRRT ICU Fellowship Training Radboudumc Timing RRT Consider the following: Underlying cause and reversibility. Rapid improvement unlikely with high dose vasopressors and continuous exposure to other risk
More informationCRRT Fundamentals Pre- and Post- Test. AKI & CRRT Conference 2018
CRRT Fundamentals Pre- and Post- Test AKI & CRRT Conference 2018 Question 1 Which ONE of the following statements regarding solute clearance in CRRT is MOST correct? A. Convective and diffusive solute
More informationToward the optimal dose metric in continuous renal replacement therapy
Int J Artif Organs 2012; 35 ( 6 ): 413-424 DOI: 10.5301/ijao.5000041 ORIGINAL ARTICLE Toward the optimal dose metric in continuous renal replacement therapy Rolando Claure-Del Granado 1, Etienne Macedo
More informationRecent advances in CRRT
Recent advances in CRRT JAE IL SHIN, M.D., Ph.D. Department of Pediatrics, Severance Children s Hospital, Yonsei University College of Medicine, Seoul, Korea Pediatric AKI epidemiology and demographics
More informationOlistic Approach to Treatment Adequacy in AKI
Toronto - Canada, 2014 Olistic Approach to Treatment Adequacy in AKI Claudio Ronco, MD Department of Nephrology, St. Bortolo Hospital, International Renal Research Institute Vicenza - Italy 1) RRT
More informationCRRT Interactive Hyperkalemia Cases AKI & CRRT conference 2018
CRRT Interactive Hyperkalemia Cases AKI & CRRT conference 2018 Case 1 Potassium Clearance A 70 kg male is placed on CVVH with a total ultrafiltration rate (effluent rate) of 20 ml/kg/hr. The Blood Flow
More informationCRRT Interactive Hyperkalemia Cases AKI & CRRT conference 2018
CRRT Interactive Hyperkalemia Cases AKI & CRRT conference 2018 Case 1 Potassium Clearance A 70 kg male is placed on CVVH with a total ultrafiltration rate (effluent rate) of 20 ml/kg/hr. The Blood Flow
More informationPhysiology of Blood Purification: Dialysis & Apheresis. Outline. Solute Removal Mechanisms in RRT
Physiology of Blood Purification: Dialysis & Apheresis Jordan M. Symons, MD University of Washington School of Medicine Seattle Children s Hospital Outline Physical principles of mass transfer Hemodialysis
More informationImplementing therapy-delivery, dose adjustments and fluid balance. Eileen Lischer MA, BSN, RN, CNN University of California San Diego March 6, 2018
Implementing therapy-delivery, dose adjustments and fluid balance. Eileen Lischer MA, BSN, RN, CNN University of California San Diego March 6, 2018 Objectives By the end of this session the learner will
More informationWho? Dialysis for Acute Renal Failure: Who, What, How, and When? Kathleen D. Liu, MD, PhD, MAS June 2011
Dialysis for Acute Renal Failure: Who, What, How, and When? Kathleen D. Liu, MD, PhD, MAS June 2011 Dorre Nicholau MD PhD Clinical Professor Department of Anesthesia and Perioperative Care University of
More informationDOSE DIALITICA E OUTCOME: UN PROBLEMA ANCORA APERTO
DOSE DIALITICA E OUTCOME: UN PROBLEMA ANCORA APERTO Angelo F. Perego Nefrologia e Dialisi Ospedale Vittorio Emanuele III Monselice (PD) ULSS 17 Veneto GDS SIN TRATTAMENTI DEPURATIVI IN AREA CRITICA STAMPA
More informationEffluent Volume in Continuous Renal Replacement Therapy Overestimates the Delivered Dose of Dialysis
Article Effluent Volume in Continuous Renal Replacement Therapy Overestimates the Delivered Dose of Dialysis Rolando Claure-Del Granado,* Etienne Macedo,* Glenn M. Chertow, Sharon Soroko,* Jonathan Himmelfarb,
More informationCitrate Anticoagulation
Strategies for Optimizing the CRRT Circuit Citrate Anticoagulation Prof. Achim Jörres, M.D. Dept. of Nephrology and Medical Intensive Care Charité University Hospital Campus Virchow Klinikum Berlin, Germany
More informationProf Patrick Honoré,MD, PhD,FCCM Intensivist-Nephrologist
Pro-Con Debate on High Volume Hemofiltration :Burial or Ressurection? The Pro Position 1.-Why Moving From Dose To Membranes? 4.-AN69 Oxiris LPS Adsorptive Membranes in Sepsis 2.- High Cut-Off Membranes
More informationAnticoagulation, delivered dose and outcomes in CRRT: The program to improve care in acute renal disease (PICARD)
Hemodialysis International 2014; : Anticoagulation, delivered dose and outcomes in CRRT: The program to improve care in acute renal disease (PICARD) Rolando CLAURE-DEL GRANADO, 1 Etienne MACEDO, 1 Sharon
More informationProlonged Dialysis: 24-hr SLED Is It CRRT? Balazs Szamosfalvi, MD
Prolonged Dialysis: 24-hr SLED Is It CRRT? Balazs Szamosfalvi, MD Medical Director, In-patient Dialysis and CRRT Henry Ford Hospital, Detroit, Michigan, USA Presenter Disclosure Information I will discuss
More informationRenal replacement therapy in Pediatric Acute Kidney Injury
Renal replacement therapy in Pediatric Acute Kidney Injury ASCIM 2014 Dr Adrian Plunkett Consultant Paediatric Intensivist Birmingham Children s Hospital, UK Aims of the presentation Important topic: AKI
More informationQuantification and Dosing of Renal Replacement Therapy in Acute Kidney Injury: A Reappraisal
In-Depth Review Blood Purif 2017;44:140 155 Received: January 12, 2017 Accepted: April 4, 2017 Published online: June 7, 2017 Quantification and Dosing of Renal Replacement Therapy in Acute Kidney Injury:
More informationUNDERSTANDING THE CRRT MACHINE
UNDERSTANDING THE CRRT MACHINE Helen Dickie Renal Sister Critical Care Unit Guy s and St.Thomas NHS Foundation Trust 18.10.14 RRT options - IHD vs CRRT (1) Intermittent HaemoDialysis e.g. 4hrs daily or
More informationClinical Application of CRRT for Infants and Children
Clinical Application of CRRT for Infants and Children Geoffrey Fleming Daryl Ingram Jordan Symons 22 nd International Conference on Advances in Critical Care Nephrology San Diego 2017 Introduction Pediatric
More informationUAB CRRT Primer Ashita Tolwani, MD, MSc University of Alabama at Birmingham
UAB CRRT Primer 2018 Ashita Tolwani, MD, MSc University of Alabama at Birmingham 1 CRRT Primer Continuous Renal Replacement Therapy (CRRT) is a "catch all" term used for all the continuous modes of renal
More informationSection 3: Prevention and Treatment of AKI
http://www.kidney-international.org & 2012 KDIGO Summary of ommendation Statements Kidney International Supplements (2012) 2, 8 12; doi:10.1038/kisup.2012.7 Section 2: AKI Definition 2.1.1: AKI is defined
More informationAcute Kidney Injury (AKI) How Wise is Early Dialysis in Critically Ill Patients? Modalities of Dialysis
Acute Kidney Injury (AKI) How Wise is Early Dialysis in Critically Ill Patients? A common condition in ICU patients Associated with high mortality and morbidity Renal Replacement Therapy (RRT) is the cornerstone
More informationSession 1: Circuit, Anticoagulation and Monitoring. Ashita Tolwani, MD, MSc Noel Oabel, BSN, RN, CNN 2019
Session 1: Circuit, Anticoagulation and Monitoring Ashita Tolwani, MD, MSc Noel Oabel, BSN, RN, CNN 2019 Goals n Learn how to set up citrate anticoagulation for CVVH, CVVHD, CVVHDF using Prismaflex n Determine
More informationManaging Acid Base and Electrolyte Disturbances with RRT
Managing Acid Base and Electrolyte Disturbances with RRT John R Prowle MA MSc MD MRCP FFICM Consultant in Intensive Care & Renal Medicine RRT for Regulation of Acid-base and Electrolyte Acid base load
More informationAcute Kidney Injury- What Is It and How Do I Treat It?
Acute Kidney Injury- What Is It and How Do I Treat It? Jayant Kumar, MD Renal Medicine Assoc., Albuquerque, NM Incidence of ARF in ICU Causes of ARF Non -ICU ICU 1 KDIGO criteria for AKI Increase in serum
More informationST. DOMINIC-JACKSON MEMORIAL HOSPITAL JACKSON, MISSISSIPPI. CONTINUOUS RENAL REPLACEMENT THERAPY (CRRT) HEPARIN ANTICOAGULATION Page 1 of 5
HEPARIN ANTICOAGULATION Page 1 of 5 Pharmacy Mnemonic: CRRTHEP1 PATIENT DATA: DIAGNOSIS: AKI ESRD Other: WEIGHT: Today: kg Admission Weight:: kg Dry Weight: kg Access TYPE: Temporary Dialysis Catheter
More informationPD In Acute Kidney Injury. February 7 th -9 th, 2013
PD In Acute Kidney Injury February 7 th -9 th, 2013 Objectives PD as a viable initial therapy PD in AKI PD versus dhd PD versus CVVHD Why not PD first PD for AKI Early days (1970 s) PD was the option of
More information[1] Levy [3] (odds ratio) 5.5. mannitol. (renal dose) dopamine 1 µg/kg/min atrial natriuretic peptide (ANP)
[1] Levy [3] 183 174 (odds ratio) 5.5 Woodrow [1] 1956 1989 mannitol (renal dose) dopamine 1 µg/kg/min atrial natriuretic peptide (ANP) McCarthy [2] 1970 1990 insulin-like growth factor-1 (IGF-1) ANP 92
More informationRenal Replacement Therapy in ICU. Dr. Sunil Sharma Senior Resident Dept of Pulmonary Medicine
Renal Replacement Therapy in ICU Dr. Sunil Sharma Senior Resident Dept of Pulmonary Medicine Introduction Need for RRT in patients with ARF is a common & increasing problem in ICUs Leading cause of ARF
More informationPediatric Continuous Renal Replacement Therapy
Pediatric Continuous Renal Replacement Therapy Farahnak Assadi Fatemeh Ghane Sharbaf Pediatric Continuous Renal Replacement Therapy Principles and Practice Farahnak Assadi, M.D. Professor Emeritus Department
More informationECMO & Renal Failure Epidemeology Renal failure & effect on out come
ECMO Induced Renal Issues Transient renal dysfunction Improvement in renal function ECMO & Renal Failure Epidemeology Renal failure & effect on out come With or Without RRT Renal replacement Therapy Utilizes
More informationContinuous renal replacement therapy. David Connor
Continuous renal replacement therapy David Connor Overview Classification of AKI Indications Principles Types of CRRT Controversies RIFL criteria Stage GFR Criteria Urine Output Criteria Risk Baseline
More informationAdmission Day 2 Na Potassium Cl Bicarb BUN Cr Hb Hct platelets
Nithin Karakala 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
More informationComparing RRT Modalities: Does It Matter What You Use If The Job Is Done?
Comparing RRT Modalities: Does It Matter What You Use If The Job Is Done? Sean M Bagshaw, MD, MSc Division of Critical Care Medicine University of Alberta Disclosure Consulting: Alere, Baxter, Gambro,
More informationCRRT: QUALITY MANAGEMENT SYSTEMS
CRRT: QUALITY MANAGEMENT SYSTEMS Javier A. Neyra, MD, MSCS Director, Acute Care Nephrology & CRRT Program University of Kentucky Medical Center Disclosures and Funding Disclosures Consulting agreement
More informationDialysis in the Acute Setting
Dialysis in the Acute Setting medicine2.missouri.edu/jahm/dialysis-in-the-acute-setting/ October 8, 2015 Kunal Malhotra, MD Division of Nephrology, Department of Medicine, University of Missouri School
More informationCRRT and Drug dosing. Karlee Johnston Lead Pharmacist Division of Critical Care ICU Education June 2017
CRRT and Drug dosing Karlee Johnston Lead Pharmacist Division of Critical Care ICU Education June 2017 This talk In scope CRRT modalities with regard to medicine Principles of drugs with regard to dialysis
More informationCRRT. Sustained low efficiency daily dialysis, SLEDD. Sustained low efficiency daily diafiltration, SLEDD-f. inflammatory cytokine IL-1 IL-6 TNF-
RRT, renal replacement therapy IHDCRRT CRRT 24 CRRT Sustained low efficiency daily dialysis, SLEDD 6 ~ 12 300 Sustained low efficiency daily diafiltration, SLEDD-f inflammatory cytokine IL-1 IL-6 TNF-
More informationSupplemental Quick Reference Guide
Supplemental Quick Reference Guide How to use this Supplemental Quick Reference Guide This guide provides a 5-step method for considering a variety of frequencies and treatment lengths, based on achieving
More informationEssential in Renal Replacement Therapy Pediatrics CRRT
Essential in Renal Replacement Therapy Pediatrics CRRT Konggrapun Srisuwan MD. Dialysis and Transplantation Program, Department of Pediatrics, Phramongkutklao Hospital Correction of fluid overload in patients
More informationDecision making in acute dialysis
Decision making in acute dialysis Geoffrey Bihl MB.BCh M.MED FCP(SA) Nephrologist and Director Winelands Kidney and Dialysis Centre Somerset West South Africa Important questions in AKI What is the cause?
More informationPractice Based Learning in CRRT: The Science and the Art Pediatric Session. David Askenazi Theresa Mottes Scott Sutherland
Practice Based Learning in CRRT: The Science and the Art Pediatric Session David Askenazi Theresa Mottes Scott Sutherland 1 Objectives Brief Epidemiology Challenges with Pediatric CRRT Indications Prescription
More informationContinuous Renal Replacement Therapy. Gregory M. Susla, Pharm.D., F.C.C.M. Associate Director, Medical Information MedImmune, LLC Gaithersburg, MD
Continuous Renal Replacement Therapy Gregory M. Susla, Pharm.D., F.C.C.M. Associate Director, Medical Information MedImmune, LLC Gaithersburg, MD 1 Definition of Terms SCUF - Slow Continuous Ultrafiltration
More informationContinuous Renal Replacement Therapy
Continuous Renal Replacement Therapy Gregory M. Susla, Pharm.D., F.C.C.M. Associate Director, Medical Information MedImmune, LLC Gaithersburg, MD Definition of Terms SCUF - Slow Continuous Ultrafiltration
More informationPediatric AKI & CRRT: Caring for my Patient & Program? David Selewski, MD Theresa Mottes, RN, NP
Pediatric AKI & CRRT: Caring for my Patient & Program? David Selewski, MD Theresa Mottes, RN, NP Introduction Pediatric AKI is no longer a mystery issue Growing data on epidemiology and outcome Pediatric
More informationRENAL FAILURE IN ICU. Jo-Ann Vosloo Department Critical Care SBAH
RENAL FAILURE IN ICU Jo-Ann Vosloo Department Critical Care SBAH DEFINITION: RIFLE criteria Criteria for initiation of RRT Modes of RRT (options) CRRT = continuous renal replacement therapy SCUF : Ultra-filtration
More informationLarge RCT s s in RRT : What can be learnt for nursing?
Large RCT s s in RRT : What can be learnt for nursing? Ian Baldwin Dept. of Intensive Care, Austin Hospital Adjunct Professor, RMIT University CRRT 2011 Hilton Bayfront, February 22-25 SanDiego Key Hypothesis
More informationKaren Mak R.N. (Team Leader) Renal Dialysis Centre Hong Kong Sanatorium & Hospital
Karen Mak R.N. (Team Leader) Renal Dialysis Centre Hong Kong Sanatorium & Hospital - Renal Transplantation - Peritoneal Dialysis - Extracorporeal Therapy Extracorporeal Therapy It is the procedure in
More informationStefano Romagnoli, M.D., Ph.D.
CORSO CRRT Stefano Romagnoli, M.D., Ph.D. Dip. di Anestesia e Rianimazione AOU Careggi - Firenze Come mantenere la pervietà e il perfetto funzionamento del circuito. Diversi regimi di anticoagulazione.
More informationNutrition in Acute Kidney Injury Enrico Fiaccadori
Nutrition in Acute Kidney Injury Enrico Fiaccadori Nephrology Dept. Parma University Medical School Parma, Italy Diagnosis, epidemiology and prognostic impact of proteinenergy wasting (PEW) in AKI Pathogenetic
More informationANTIBIOTIC DOSE AND DOSE INTERVALS IN RRT and ECMO
ANTIBIOTIC DOSE AND DOSE INTERVALS IN RRT and ECMO Professor Jeffrey Lipman Department of Intensive Care Medicine Royal Brisbane Hospital University of Queensland NO CONFLICT OF INTERESTS Important concept
More informationNurse-Pharmacist Collaboration in the Delivery of Continuous Renal Replacement Therapy
Cedarville University DigitalCommons@Cedarville Pharmacy Faculty Presentations School of Pharmacy 2-23-2012 Nurse-Pharmacist Collaboration in the Delivery of Continuous Renal Replacement Therapy Jeb Ballentine
More informationContinuous Renal Replacement Therapy in PICU: explanation/definitions/rationale/background
Continuous Renal Replacement Therapy in PICU: explanation/definitions/rationale/background Index: 1. Introduction Pg. 1 1.1 Definitions Pg. 2 1.2 Renal replacement therapy principles Pg. 2 2. Continuous
More informationPractical issues - dosing on extracorporeal circuits
Practical issues - dosing on extracorporeal circuits Jason A Roberts B Pharm (Hons), PhD, FSHP Professor of Medicine and Pharmacy The University of Queensland, Australia Royal Brisbane and Women s Hospital,
More informationMetabolismo del citrato nei pazienti critici. Filippo MARIANO Dipartimento di Area Medica, SCDO di Nefrologia e Dialisi Ospedale CTO, Torino
Metabolismo del citrato nei pazienti critici Filippo MARIANO Dipartimento di Area Medica, SCDO di Nefrologia e Dialisi Ospedale CTO, Torino Regional citrate anticoagulation: the history First in hemodialysis
More informationDrug dosing in patients with acute kidney injury
Drug dosing in patients with acute kidney injury They don t know what they are doing Jan Jan T. T. Kielstein Department of of Nephrology and and Hypertension Medical School School Hannover Drug dosing
More informationContrast Induced Nephropathy
Contrast Induced Nephropathy O CIAKI refers to an abrupt deterioration in renal function associated with the administration of iodinated contrast media O CIAKI is characterized by an acute (within 48 hours)
More informationoxiris A single CRRT set with multiple benefits for managing critically ill patients with AKI Adsorption of inflammatory mediators
oxiris A single CRRT set with multiple benefits for managing critically ill patients with AKI Adsorption of inflammatory mediators Heparin-grafted for reduced thrombogenicity Supports renal function POWERED
More informationSolute clearances during continuous venovenous haemofiltration at various ultrafiltration flow rates using Multiflow-100 and HF1000 filters
Nephrol Dial Transplant (2003) 18: 961 966 DOI: 10.1093/ndt/gfg055 Original Article Solute clearances during continuous venovenous haemofiltration at various ultrafiltration flow rates using Multiflow-100
More informationContinuous Renal Replacement Therapy in Dogs and Cats
Continuous Renal Replacement Therapy in Dogs and Cats Mark J. Acierno, MBA, DVM KEYWORDS Continuous renal replacement therapy CRRT Acute kidney injury Dialysis In the early 1900s, a young pharmacologist
More informationOperation-Fluids-Electrolytes-Acid Base COMPLICATIONS OF DIALYSIS 2
Operation-Fluids-Electrolytes-Acid Base COMPLICATIONS OF DIALYSIS 2 Maureen Craig, RN, MSN, CNN University of California Davis Medical Center Sacramento, California macraig@ucdavis.edu Hospital Details
More informationPICANet Renal Dataset supplement Renal Daily Interventions
PICANet Renal Dataset supplement Renal Daily Interventions Version 2.0 (March 2017) 1 Contents PICANet Renal Dataset supplement... 1 Renal Daily Interventions... 1 Version 2.0 (March 2017)... 1 Recording
More information- SLED Sustained Low-Efficiency Dialysis
Continuous Renal Replacement Therapy Gregory M. Susla, Pharm.D., F.C.C.M. Associate Director, Medical Information MedImmune, LLC Gaithersburg, MD 1 Definition of Terms - SCUF - Slow Continuous Ultrafiltration
More informationRenal replacement therapy in acute kidney injury
6 February 2009 CONTENTS Renal replacement therapy in acute kidney injury S Jithoo Commentator: CL Quantock Moderator: LW Drummond INTRODUCTION... 3 WHAT IS RENAL REPLACEMENT THERAPY?... 3 MODES OF RENAL
More informationKit Assembly. Enhanced Simplicity OPERATIONAL BENEFITS. Automatic venous chamber adjustment. User friendly interface
System for CRRT Kit Assembly Enhanced Simplicity User friendly interface Flexible AcuSmart touch screen can be turned 180 degrees with up to 100 degrees of tilt in order to ensure visibility from various
More informationPaul R. Bowlin, M.D. University of Colorado Denver. May 12 th, 2008
Paul R. Bowlin, M.D. University of Colorado Denver May 12 th, 2008 Presentation Overview Background / Definitions History Indications for initiation of therapy Outcomes Studies Conclusions Questions Background
More informationIntensity of continuous renal replacement therapy for acute kidney injury(review)
Cochrane Database of Systematic Reviews Intensity of continuous renal replacement therapy for acute kidney injury(review) Fayad AI, Buamscha DG, Ciapponi A Fayad AI, Buamscha DG, Ciapponi A. Intensity
More informationRegional Citrate Anticoagulation for RRTs in Critically Ill Patients with AKI
In-Depth Review Regional Citrate Anticoagulation for RRTs in Critically Ill Patients with AKI Santo Morabito,* Valentina Pistolesi,* Luigi Tritapepe, and Enrico Fiaccadori Abstract Hemorrhagic complications
More informationRenal Replacement Therapy
Chapter 133 Renal Replacement Therapy Claudio Ronco, Zaccaria Ricci, and Stefano Romagnoli Introduction Despite recent advances in acute kidney injury (AKI) definition, diagnosis, and treatment, many aspects
More informationAlbumin Detoxification for Sepsis
Albumin Detoxification for Sepsis 1.-Sepsis Modulation? 4.- The First «Small Proof» of Concept 2.- The New Hypothesis 5.- Can we Apply to the Recent PRT s... 3.- The Experimentations Explaining this Hypothesis..
More informationRenal Replacement Therapy in Acute Renal Failure
CHAPTER 82 Renal Replacement Therapy in Acute Renal Failure R. Deshpande Introduction Acute renal failure (ARF) is defined as an abrupt decrease in renal function sufficient to result in retention of nitrogenous
More informationTechnical Considerations for Renal Replacement Therapy in Children
Technical Considerations for Renal Replacement Therapy in Children Timothy E. Bunchman, MD,* Patrick D. Brophy, MD, and Stuart L. Goldstein, MD Summary: Provision of renal replacement therapy to the critically
More informationACUTE KIDNEY INJURY. Stuart Linas U. Colorado SOM
ACUTE KIDNEY INJURY Stuart Linas U. Colorado SOM Marked increases in incidence of dialysis-requiring AKI in last decade JASN 24 37 2013 Question 1 Of patients who recover from an episode of AKI, what percentage
More informationCRRT Procedures. and Guidelines. CRRT: Guidelines
CRRT Procedures 2013 and Guidelines Guidelines for the utilization of CRRT (Continuous Renal Replacement Therapies) at Monroe Carell Jr. Children s Hospital at Vanderbilt CRRT: Guidelines CRRT Contacts:
More informationWhen to start a renal replacement therapy in acute kidney injury (AKI) patients: many irons in the fire
Editorial Page 1 of 4 When to start a renal replacement therapy in acute kidney injury (AKI) patients: many irons in the fire Stefano Romagnoli 1,2, Zaccaria Ricci 3 1 Department of Anesthesia and Critical
More informationContinuous renal replacement therapy Gulzar Salman Amlani Aga Khan University, School of Nursing, Karachi.
Special Communication Continuous renal replacement therapy Gulzar Salman Amlani Aga Khan University, School of Nursing, Karachi. Abstract Acute renal failure refers to sudden deterioration in biochemical
More informationPrincipal Equations of Dialysis. John A. Sweeny
Principal Equations of Dialysis John A. Sweeny john@sweenyfamily.net 1 An Equation is Math: A statement that each of two statements are equal to each other. Y 2 = 3x 3 + 2x + 7 Chemistry: A symbolic expression
More informationEnd-Stage Renal Disease. Anna Vinnikova, M.D. Associate Professor of Medicine Division of Nephrology
End-Stage Renal Disease Anna Vinnikova, M.D. Associate Professor of Medicine Division of Nephrology ESRD : Life with renal replacement therapy CASE: 18 month old male with HUS develops ESRD PD complicated
More informationESPEN Congress Vienna Nutritional implications of renal replacement therapy in ICU Nutritional consequences of RRT. E. Fiaccadori (Italy)
ESPEN Congress Vienna 2009 Nutritional implications of renal replacement therapy in ICU Nutritional consequences of RRT E. Fiaccadori (Italy) Nutritional consequences of RRT Enrico Fiaccadori Internal
More information404FM.2 CONTINUOUS RENAL REPLACEMENT THERAPY (CRRT) USING CITRATE Target Audience: Hospital only ICU. (Based on Gambro and Kalmar Hospital protocols)
404FM.2 CONTINUOUS RENAL REPLACEMENT THERAPY (CRRT) USING CITRATE Target Audience: Hospital only ICU (Based on Gambro and Kalmar Hospital protocols) CRRT using regional citrate anticoagulation This is
More information3/21/2017. Solute Clearance and Adequacy Targets in Peritoneal Dialysis. Peritoneal Membrane. Peritoneal Membrane
3/21/2017 Solute Clearance and Adequacy Targets in Peritoneal Dialysis Steven Guest MD Director, Medical Consulting Services Baxter Healthcare Corporation Deerfield, IL, USA Peritoneal Membrane Image courtesy
More informationAccelerated Venovenous Hemofiltration: Early Technical and Clinical Experience
Accelerated Venovenous Hemofiltration: Early Technical and Clinical Experience Casey N. Gashti, MD, Susana Salcedo, MD, Virginia Robinson, RN, and Roger A. Rodby, MD Background: Renal replacement therapies
More informationPICANet Custom Audit Definitions Renal Dataset
PICANet Custom Audit s Renal Dataset Version 1.0 (July 2016) PICANet Renal Custom Audit Data s Manual Version 1.0 July 2016 Renal Dataset Contents PICANet Custom Audit s... 1 Renal Dataset... 1 Version
More informationActive UMMC Protocols
UMMC CRRT 2018 Active UMMC Protocols 1. Standard CRRT Protocol PrismaFlex & NxStage CVVH with Fixed Ratio Regional Citrate Anticoagulation 2. No Anticoagulation Protocol PrismaFlex & NxStage CVVH with
More informationBPG 03: Continuous Renal Replacement Therapy (CRRT)
BPG 03: Continuous Renal Replacement Therapy (CRRT) Statement of Best Practice Patient s requiring Continuous Renal Replacement Therapy (CRRT) will receive appropriate therapy to meet their individual
More informationObjectives. Peritoneal Dialysis vs. Hemodialysis 02/27/2018. Peritoneal Dialysis Prescription and Adequacy Monitoring
Peritoneal Dialysis Prescription and Adequacy Monitoring Christine B. Sethna, MD, EdM Division Director, Pediatric Nephrology Cohen Children s Medical Center Associate Professor Hofstra Northwell School
More informationManual CVVH Automatic machine
Blood pump & infusion pumps Manual CVVH Automatic machine Anticoagulant Predisposing factors : blood flow, hemofilter type, coagulation pathway activation, convective mass transfer Site of thrombus formation
More informationChapter 4. S.A. Nurmohamed B.P. Jallah M.G. Vervloet A. Beishuizen A.B.J. Groeneveld ASAIO J 2011; 57:48-52
Chapter 4 Pre- versus postdilution continuous venovenous hemofiltration: no effect on filter life and azotemic control in critically ill patients on heparin S.A. Nurmohamed B.P. Jallah M.G. Vervloet A.
More information