CVVH in the ICU

1. CVVH in the ICU ICU PHILOSOPHY B P LEUNG MD, EDIC Surgical ICU St Martin de Porres Hospital

2. 重 症 醫 學 The “Mystique” The complexity of patient Monitoring & support equipment

3. 重 症 醫 學 Final common pathway “ Multisystem Failure ” 多重器官衰竭

4. Multiple Organ Failure Lung - Heart - Kidney Brain Gut Immune System

5. A single organ doctor today

6. The general practitioner of old

7. Who should be admitted to an ICU ? Potentially reversible organ failure A ‘time-limited’ therapeutic trial Remember not to play God in the ICU

8. Principles of practice of critical care Primum non nocere The considered use of technology Early diagnosis & treatment 7 - 11

10. CRRT in the ICU Continuous Renal Replacement Therapy CAVH CVVH CVVHD CVVHDF Blood Purification

12. Mechanisms of solute removal Diffusion Ultrafiltration Adsorption

14. Renal Replacement Therapy Intermittent vs Continuous Arteriovenous vs Venovenous Haemodialysis vs Haemofiltration Pre-dilution vs Post-dilution

15. Glossary of various types of RRT Peritoneal Dialysis PD Conventional Haemodialysis IHD Haemofiltration Continuous arteriovenous haemofiltration CAVH Continuous venovenous haemofiltration CVVH Haemodialysis Continuous arteriovenous haemodialysis CAVHD Continuous venovenous haemodialysis CVVHD Haemodiafiltration Continuous arteriovenous haemodiafiltration CAVHDF Continuous venovenous haemodiafiltration CVVHDF

17. Which is the best technique of RRT in ICU ? Bias against CRRT Concerns about anticoagulation Supervision 24 hrs/day Better clinical outcome ? ‘People die anyway & it costs more’

18. Which is the best technique of RRT in ICU ? The sickest patients … have the most to gain using CRRT

19. Which is the best technique of RRT in ICU ? To complicate the issue further … Slow Extended Daily Dialysis, SLEDD is being increasing used Effect of under-dosing in CRRT on outcomes of ARF

20. Impact of different haemofiltration doses 425 patients with ARF Randomly assigned ultrafiltration at … 20ml/kg/h 35ml/kg/h 45ml/kg/h Primary endpoint: Survival at 15d after stopping HF 41% 57% 58% Ronco, Lancet 2000

21. Which is the best technique of RRT in ICU ? Is a controlled trial possible ? Multiple complications in critically ill patients Some patients too ill for IHD Cross-over in ICU A consenusus definition for ARF is needed

22. Early Goaled Ultrafiltration Therapy ? Early Goal-Directed Therapy ‘ Not just for sepsis ’

23. Early Goaled Ultrafiltration Therapy ? Volume Optimisation Diuretics  Early Goaled UF Therapy

24. Early Goaled Ultrafiltration Therapy How aggressive ? ‘ Discrepancy between prescribed & delivered clearance ’ How early ? ‘ What is the criteria for initiating RRT ? ’

25.  

27.  * * Magic Bullet ? **

28. Peak Concentration Hypothesis‘Threshold Modulation’

29.  Magic shield !

30. Rationale for High Volume Haemofiltration ‘Renal Dose’ vs ‘Septic Dose’ The ‘SIRS-OSO’ Approach … Overwhelming – Systemic – Overflow So called ‘spill over mediators’ Improved ‘Immunodynamics’

31. High Volume Haemofiltration HVHF Technical limits in HVHF Blood Access 14 Fr Coaxial catheters … Blood Tubing & Membrane Digital Balances & Full Computerisation Nutrient Fluxes, Drug Exchanges & Types of Buffer Thermal Balance & Rewarming Procedure Is this the end of the story ? How far should we go … Ronco : CHVHF - 3 L/h x 24 h ; PHVHF – 6 L/h x 6h Honore’ : 50 … 100 … 125 mL/kg/h

32. Rationale for High Volume Haemofiltration Is this the end of the story ? In vivo experimental studies in septic shock The ‘dose’ story : Human beings are quite large animals Best response in intravascular sepsis models Time to develop established septic shock is not long enough Hemodynamics as the key target

33. Rationale for High Volume Haemofiltration Is this the end of the story ? Removal of mediators of sepsis Experimental studies in vitro Adsorption Clinical studies Plasma levels seldom decrease Improved hemodynamics even in the absence of fall in plasma cytokine levels

34. CRRT Anticoagulation Unfractioned heparin Saline flushes Pre-dilution Regional anticoagulation with protamine Heparinoids Low-molecular-weight heparins Prostacyclin Direct thrombin inhibitors : Hirudin Citrate

35. Citrate Anticoagulation Citrate chelates calcium in extracorporeal circuit No clotting if circuit iCa < 0.25 mmol/L On return to patient blood has normal serum iCa levels Citrate metabolized to HCO3 & H2O Mean filter life : 48 hrs

36. Citrate Anticoagulation Adverse events & Technical errors Metabolic alkalosis Hypernatremia Progressive ionized hypocalcemia Liver patients No commercial substitution solution

37. Gambro AK 10

38. Prisma Blood flow limited to only 180 mL/min Replacement flow rate limited to 2000 mL/h Dialysate rate limited to 2500ml /h A dedicated ready–to-connect circuit Accuracy of fluid balance : 0.45% at max flow rates

39. PrismafleX Blood flow up to 450 mL/min Replacement flow up to 8000 mL/h Dialysate rate up to 8000 ml /h Effluent removal up to 10 L/h Accuracy of fluid balance : 10% of set rate 2 pinch valves for pre- & post- dilution

42. The MARS® principle

43. The MARS® membrane

44. MARS® Combinations (I) Baxter BM25 Fresenius 4008 Gambro AK200 See Homepage TERAKLIN.com or ask TERAKLIN Representative for the latest Information on compatible Dialysis Machines

45. Multiple Organ Support Therapy‘ MOST ’ Extracorporeal organ support therapy Kidney Liver Extracorporeal Organ Support Therapy Lung Heart Immuno- Homeostasis

46. Which is the best technique of RRT in ICU ? Good RRT is like good love-making … as often as possible as long as possible as gently as possible oo000oo