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CVVH in SICU

CVVH in SICU. 外科加護病房 護理師 蔡壁如. Hemodynamic instability during different forms of dialysis therapy : Do we really know why ?. CRRT Program consideration and evaluation. Which the renal replacement method of first choice in the ICU P ’ t. Simple to manage / low work-load Inexpensive

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CVVH in SICU

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  1. CVVH in SICU 外科加護病房 護理師 蔡壁如

  2. Hemodynamic instability during different forms of dialysis therapy : Do we really know why ?

  3. CRRT Program consideration and evaluation

  4. Which the renal replacement method of first choice in the ICU P’t • Simple to manage / low work-load • Inexpensive • Reliable and predictable ( solute and water removal) • Optimal survival and complication profile • Optimal recovery of renal function

  5. Hybrid therapies in ICU • CRRT (Continuous Renal Replacement Therapy ) • EDD ( Extended daily dialysis ) • SLEDD ( Slow Low-efficient Daily Dialysis ) • SLEDD-f (Sustained Low-Efficiency Daily Dia-filtration ) • IHD ( Intermittent Hemo-dialysis ) • Plasmapheresis

  6. Basic Principle of Renal Replacement Therapy NEJM 336:1303-1309

  7. 血液透析的原理

  8. 脫水的原理

  9. 連續性血液過濾術(CVVH)原理

  10. 人工腎臟吸附毒素

  11. CRRT Dialysis

  12. Introduction of Acute Renal Failure • 17 ~ 25 % of ICU case develop ARF • 5 ~ 10% of cases will require CRRT • Outcome is dependent upon the original cause of ARF • Mortality from underlying disease, and complication like sepsis • Clinical care nephrology, 1998. P405-411

  13. Classification ARF Acute renal failure Pre-renal Intrinsic renal Post-renal Absolute decrease in effective blood volume Haemorrhage Volume depletion Relative decrease in blood Volume (ineffective arterial volume) Congestive heart failure Decompensated liver cirrhosis Arterial occlusion or Stenosis of renal artery Haemodynamic from NSAIDs ACE inhibitors or angiotensin-II receptor in renal- artery stenosis or congestive heart failure Vascular Vasculitis Malignant hypertension Acute glomerulo- nephritis Postinfections Glomerulonephrit tis ,disease caused by antibody to glomerular basement membrane Acute Interstitial nephritis Drug- associated Acute tubular necrosis Obstruction of collecting system or extrarenal drainage Bladder –outlet obstruction Bilateral ureteral obstruction Nephrotoxic Ischaemic Exogenous Antibiotics(gentamicin) Radio contrast agents Cisplatin Endogenous Intratubular pigments(haemoglobinuria, myoglobinuria) Intratubular proteins(myeloma) Intratublar crystals(uric acid,oxalate)

  14. RIFLE Criteria Crit Care Med 2006, Vol. 34 No 7

  15. Acute Kidney Injury stage 3 Renal replacement therapy

  16. CVVH Indication • CAVH in ECMO • Cerebral edema：Mannitol ≧ q12hr in use frequency • Prevention of post-dialytic “ rebound” intoxication：lithium, tumor lysis, rhabdomyolysis, tissue necrosis

  17. 專有名詞 • CAVH, CAVHD, CAVHDF • CVVH, CVVHD, CVVHDF • IHD, EDD, SLEDD, SLEDDF • RRT Renal Replacement Therapy

  18. Effects of different doses in continuous veno-venous hemofiltration on outcomes of acute renal failure : a prospective randomized trial • CVVH Ultrafiltration rate ? • Recommend 2L per hour or more • 20 ml/hr/kg : 41% (survival rate) • 35ml/hr/kg : 57% • 45ml/hr/kg : 58% • High treatment doses might be difficult • Early start of treatment : improved outcome Lancet 2000;355:26-30

  19. 脫水量愈多效果愈好 ? 答案是: 病患的indication 增加護理人力 血流速相對要提高 電解質的的監控: K+ loss The Third International Course on Critical Care Nephrology held in Vicenza, Italy in June 2004

  20. Vascular access • Grade C : avoided subclavian in adults • Grade D : avoided femoral vein in neonates and young (femoral vein thrombosis is a significant problem) • Grade C : Internal jugular vein • Level II and III studies : Ultrasound guidance • Re-circulation is likely to be significant for blood flow in excess of 200 c.c/min, but depending on catheter design and location • The first international consensus conference on CRRT, 2002

  21. Double lumen : Re-circulation rate不是血流速愈高愈好:看導管大小 位置 under 250cc/min blood flow • Subclavian , internal jugular vein < 3% • Catheter length • Femoral vein 24cm : 10%, 15cm : 18% • Blood flow • 400 cc/min : 38% in the femoral vein American Journal of Kidney disease , 1996

  22. Double lumen : Re-circulation rate Blood flow : 298 cc/min • Femoral vs Subclavian:16.1±1.8% vs 4.1 ±0.7% • Femoral cath 13.5 cm vs 19.5 cm : 22.8 ±3.0% vs12.6 ±1.7% • 台大SICU Double lumen準備時要注意 • 14Fr 20cm (Femoral ) • 14Fr 16cm (Neck ) American Journal of Kidney disease, 1996

  23. Anticoagulation • Grade E : priming solution: 2000 U/1000c.c • Grade E : avoided systemic heparin in high risk bleeding p’t • Grade D : without any anticoagulation, circuit life may be less than 24hr • Grade E : anticoagulation monitoring , ACT(activated clotting times) or PTT(partial thromboplastin time) • The first international consensus conference on CRRT, 200

  24. Anticoagulation • Standard protocol • Initial bolus 10-30 unit/kg of heparin • Infusion 10-30 unit/kg to target • ACT :170-220 seconds or • PTT: 2 X N.J.Maxvold, T.E. Bunchman/Crit Care Clin 2003 19(2),563-575

  25. Automatic CRRT 優點: 全自動計算 可加熱 缺點: 太敏感 機器不穩定

  26. Fresenius machine 優點: 容易操作 缺點: 沒有加熱器 溫度散失厲害 外掛的輸液機不穩定

  27. Replacement Fluid A, B Solution

  28. CVVH Solution Formula 1. B solution + 250c.c Rolikan 2. A B溶液單獨進入體內:Ca+HCO3會沉澱 3. 溶液內沒有K離子，注意電解質問題 4. 若要加鉀離子，A液一袋加一支 (20Meq )

  29. Inner lumen 220 µm 220 µm Wallthickness 35 µm 35 µm CVVH 人工腎臟特性 The membrane geometry was adapted to meet the specific needs in CRRT Increased inner lumen:Decreased wall thickness:

  30. Inner lumen 200 µm 200 µm Wallthickness 40 µm Dialysate side 40 µm 40  1 Blood side 血液透析之人工腎臟 FreseniusPolysulfone® : Fibre structure • No pores filling agent • Not wettable: no swelling • Consistency of fibre geometry

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