Crrt continue Renal Replacement Therapy cvvh cvvhd



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CRRT Continue Renal Replacement Therapy

  • CVVH

  • CVVHD

  • CVVHDF


Indications

  • In critically ill patients with renal failure and hemodynaemic instability

  • For patients in whom continuous removal of volume or toxic substance is desirable ( as in septic shock , AMI , severe GI bleeding ,ARDS or condition with or at risk for cerebral edema ….)



Procedure共同處

  • Driving force : external pump

  • Circuit : Venovenous

  • Dialysis solutions :一般使用1.5% PD solution

  • Replacement fluid : several types of replacement fluid can be used , depending on patient requirements ,一般使用 pre-dilution 方式.



Anti-coagulation 的方式

  • STANDARD HEPARIN

  • TYPICAL REGIMEN IN CRRT :

  • Priming of the circuit ( 5000 IU / L )

  • Initial Heparin Bolus : 5 - 8 IU / kg

  • Infuse Heparin at : 5 to 12 IU / kg / hr

  • ACT on post filter : Adjust heparin rate to keep ACT between 1.5 & 2.0 times



STANDARD HEPARIN

  • ADVANTAGES

  • Easy to perform

  • Useful method

  • Inexpensive



LOW MOLECULAR WEIGHT (LMW) HEPARIN

  • TYPICAL REGIMEN IN CRRT :

  • Priming of the circuit : 20 mg in 1 L

  • Maintenance dose : 10 to 40 mg q6 hrs

  • Monitor anti- factor Xa (aXa) units . Adjust between 0.1 and 0.4 µ/ml

  • Different Dosages for LMW heparin



LOW MOLECULAR WEIGHT (LMW) HEPARIN



Regional Citrate Anticoagulation

  • TYPICAL REGIMEN :

  • Citrate anticoagulation is always regional

  • Citrate infusion (4%) at 170 ml/hr initially

  • Special Dialysate at 1 liter/hr ( Na+ 117 ,

  • K+ 4 , Mg++ 1.5 , Cl- 121.5 , dextrose 0.5- 2.5% , no Ca++ , no base )

  • CaCL2 (0.75%) by central I.V at 40-60 ml/hr,

  • Maintain ionized Ca++ at 0.96- 1.20 mmol/L



Citrate

  • ADVANTAGES :

  • No Bleeding

  • No Thrombocytopenia

  • Improved Filter Life and Efficacy





Heparin- free methos

  • Normal saline flush

  • Used in patients with

  • 1. Severe liver disease

  • 2. Acitve or recent bleeding

  • 3. Heparine-induced thrombocytopenia

  • 4. Post-op patients





CVVH配置簡圖



CVVH order

  •     Prepare Heparin 2cc + N/S 3cc, then inject 1.6cc into each femoral cath.

  •   For AK priming: (GAMBRO, Polyarylethersulfone, 6S)

  • *1st N/S 1000cc.

  • *2nd Heparin 2,500U.

  • *3rd N/S 500cc.

  •      *Prepare Heparin 25,000U + N/S 500cc IVD 10cc/hr with pump to keep aPPT 1.5-2 and adjust as followed:

  • aPPT bolus hold dose(cc/hr)

  • <1.0 2000U - +4

  • 1.0-1.5 - - +2

  • 1.5-2.0 - - -

  • 2.0-2.5 - 30min -2

  • >2.5 - 60min -4



CVVH order

  • If non-heparin , N/S 200cc q ½ hr to rinse the AK

  • Predilution run 500cc/hr alternately as followed via artery end

  • 1st bottle N/S 500cc + Sinca 1amp

  • 2nd bottle N/S 500cc + 10% MgSO4 4cc

  • 3rd bottle N/S 500cc

  • 4th bottle D5W 500cc + NaHCO3 5amp

  • Warm dialysate to 37C

  • Record I/O and BP q1hr

  • UF target I-O ( ) cc/hr

  • Check BUN,Crea,Na,K,Cl,aPPT q6hr for 1 day & then q8hr.

  • Check Ca,P,Mg qd.



CVVHD配置簡圖



CVVHD order

  •     Prepare Heparin 2cc + N/S 3cc, then inject 1.6cc into each femoral cath.

  •   For AK priming: (GAMBRO, Polyarylethersulfone, 6S)

  • *1st N/S 1000cc.

  • *2nd Heparin 2,500U.

  • *3rd N/S 500cc.

  •      *Prepare Heparin 25,000U + N/S 500cc IVD 10cc/hr with pump to keep aPPT 1.5-2 and adjust as followed:

  • aPPT bolus hold dose(cc/hr)

  • <1.0 2000U - +4

  • 1.0-1.5 - - +2

  • 1.5-2.0 - - -

  • 2.0-2.5 - 30min -2

  • >2.5 - 60min -4



CVVHD order

  • If non-heparin , N/S 200cc q ½ hr to rinse the AK

  • 1.5% PD solution 500cc/hr run as dailysate

  • Warm dialysate to 37C

  • Record I/O and BP q1hr

  • UF target I-O ( ) cc/hr

  • Check BUN,Crea,Na,K,Cl,aPPT q6hr for 1 day & then q8hr.

  • Check Ca,P,Mg qd.



CVVHDF配置簡圖

  • CVVHDF Continuous

  • Veno-Venous

  • Hemodiafiltration



CVVHDF order

  •     Prepare Heparin 2cc + N/S 3cc, then inject 1.6cc into each femoral cath.

  •   For AK priming: (GAMBRO, Polyarylethersulfone, 6S)

  • *1st N/S 1000cc.

  • *2nd Heparin 2,500U.

  • *3rd N/S 500cc.

  •      *Prepare Heparin 25,000U + N/S 500cc IVD 10cc/hr with pump to keep aPPT 1.5-2 and adjust as followed:

  • aPPT bolus hold dose(cc/hr)

  • <1.0 2000U - +4

  • 1.0-1.5 - - +2

  • 1.5-2.0 - - -

  • 2.0-2.5 - 30min -2

  • >2.5 - 60min -4



CVVHDF order

  • If non-heparin , N/S 200cc q ½ hr to rinse the AK

  • Predilution run 500cc/hr alternately as followed via artery end

  • 1st bottle N/S 500cc + Sinca 1amp

  • 2nd bottle N/S 500cc + 10% MgSO4 4cc

  • 3rd bottle N/S 500cc

  • 4th bottle D5W 500cc + NaHCO3 5amp

  • 1.5% PD solution 500cc/hr run as dailysate

  • Warm predilution and dialysate to 37C

  • Record I/O and BP q1hr

  • UF target I-O ( ) cc/hr

  • Check BUN,Crea,Na,K,Cl,aPPT q6hr for 1 day & then q8hr.

  • Check Ca,P,Mg qd.



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