CRRT

Continue Renal Replacement Therapy

1. CVVH
2. CVVHD
3. CVVHDF
 Indications
• In critically ill patients with renal failure an
d hemodynaemic instability
• For patients in whom continuous removal of
volume or toxic substance is desirable ( as i
n septic shock , AMI , severe GI bleeding ,
ARDS or condition with or at risk for cerebr
al edema ….)
 Procedure 共同處
1. Driving force : external pump
2. Circuit : Venovenous
3. Dialysis solutions : 一般使用 1.5% PD so
lution
4. Replacement fluid : several types of replac
ement fluid can be used , depending on pa
tient requirements , 一般使用 pre-dilutio
n 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 DISADVANTAGES
 Easy to perform • Occasional
Thrombocytopenia
 Useful method
 Hemorrhagic Risk
 Inexpensive with Bleeding patient
 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 betwe

en 0.1 and 0.4 µ/ml
 Different Dosages for LMW heparin
LOW MOLECULAR WEIGHT
(LMW) HEPARIN
• ADVANTAGES • DISADVANTAGES
 Expensive
 Decreased Risk
 Special and difficult
of Bleeding monitoring
 With low doses
frequent filter clotting
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 : • DISADVANTAGES :
 No Bleeding  Complex for the set up
 No  Ca++ monitoring needed
Thrombocytopenia  Occasional Alkalosis
 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
Dialysis modalities in the ICU
 CVVH 配置簡圖

CVVH
Continuous P
R

Veno-Venous I
S
M

Hemofiltration A

CVVH 模式下 , 置換液流

速
最高可達 4500ml/hr
 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 k
eep 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 en
d
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
Continuous
Veno-Venous
Hemodialysis
P
R
I
S
M
A

S
 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 k
eep 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 P
R
I
S
M
A

S
 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 k
eep 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 en
d
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.