acute renal failre in icu
TRANSCRIPT
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cute Renal Failure in Intensive
Care Units
*High Mortality
* Mortality relates to severity of underlying condition
*Acute renal failure occurs as part of a complex of
multiple organ failure caused by infection sepsis
hypotension hypovolemia and drug therapy
*Fluid overload causes pulmonary edema
*Increase in interstitial !ater !ith "lea#y capillary"leading to impaired tissue perfusion
*Acid$base and electrolyte abnormalities
*%isseminated intravascular coagulation
*&oxic metabolites and drug accumulation*Fre'uently hemodynamic unstable
*Re'uired positive pressure ventilation
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ropose r ter a or t e n t at on oRenal Replacement &herapy in Adult
Critically Ill (atients
1.Oliguria (urine output
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Renal Replacement &herapy for
cute Renal Failure in Intensive
Care Units
*Intermittent therapies Intermittent
hemodialysis +IH%, extended daily
dialysis +-%%, slo! lo!$efficiency
dialysis +./-%,
*(eritoneal dialysis +(%,
*Continuous renal replacement therapy
+CRR&, .CUF C 0H C 0H% C 0H%F
C00H C00H% C00H%F
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dvantages of CRR& Compared !ith
IH%
12CRR& maintains consistent homeostasis through slo!
gradual shifts in volume status and serum osmolality
32 CRR& avoids hypotensive or dyse'uilibrium episode
42CRR& permits continuous control of fluid balance and
reduces the need to restrict fluid administration
52CRR& re'uires a lo!er volume of blood to be
circulating outside the body
62CRR& has less effect on complement or leu#ocytes
72CRR& does not re'uire expensive e'uipment or extensive
training of personnel
82CRR& has greater clearance of mid$molecular !eight
solute
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(rinciples of CRR&
%iffusion Movement ofsolute across asemipermeable membrne
from high concentration
to lo! concentration
Convection 9ater
affected by hydrostatic
pressure is transferred
across a membrane from
high pressure to lo!pressure2 Remove fluid
as !ell as solute
Adsorption affinity
gradient
%iffusion
Convection
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,on'etion '-. iu-ion
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:perational Characteristics of CRR&Continuous Hemofiltration
* &ransport of solute is by convection based on a pressure gradient
Capacity of a solute to press through membrane expressed by sieving
coefficient +.,2
. ; Cufation
can influence sieving coefficient2
*Main determinant of . is extent of protein binding and for most
solutes e'uals the unbound fraction +a,2
* Convective clearance of solute ; Ultrafiltration rate
ClHF; ?f x . +a,
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:perational Characteristics of
CRR&
Continuous Hemodialysis
*.olute removal based on diffusion driven by concentration
gradient*/arge molecules more restricted and diffusive clearance
decreases !ith increasing molecular !eight
*In CRR& blood flo! rates exceed dialysate flo! rates thereby
resulting in complete e'uilibration bet!een blood and
dialysate*Capacity of solute to diffuse through membrane and saturation
dialysate is expressed as .d2
.d ; Cd
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&ypes of CRR& for &reating RF
(hysicochemical bases Urea
clearance +cc
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Anticoagulation %uring CRR&*-fficacy of filter in fluid and solute removal
*:verall filter longevity
*:ptimum patient treatment
*Insufficiency filtration performance deteriorates
filter clot blood loss
*-xcessive bleeding complication* Modalities for anticoagulation
.aline solution Regional
citrate
Heparin
(rostacyclin
/M9 heparin afomostate
mesilate
Regional heparin o anticoagulant
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.olution
*/actate RingerDs solution
*126E peritoneal dialysate solution
*icarbonate !ith dextrose
*icarbonate !ithout dextrose
ag A ag
1 liter =2GE aCl 1 liter =256E aCl
B= ml 8E aHC:4 1= ml 6E CaCl3
5 ml 16E Cl 5ml 1=E Mg.:5
ag A ag run 1 1
a 153 m-'
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Important (arameter for CRR&Clinical data
* .#in turgor humidity of slin folds body !eight
* %etermination of total fluid loss
-stimate of fluid loss in !ound secretion and stool fluid
loss by perspiration insensiblities in relation to body
temperature respiration
* lood pressure pulse rate body temperature respiratory rate
* C0( (ulmonary capillary pressure
* Chest @$ray -J monitoring
Clinical chemistry
a Ca Mg ( Cl blood gas urea creatinine glucose
total protein albumin J:& J(& Al#$( cholesteroltriglyceride hemoglobin hematocrit leu#ocytes platelets
(& A(&&
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Joals of Continuous &herapy
-lectrolyte balance
a Cl Ca Mg C:3
Fluid balance
Medication &( Colloids
A>otemia control
U .cr (CR (hosphorus
Cyto#ine maniputation
Factor maniputation
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Applications for CRR&
Renal Applicationvs on$renal
Application
Renal Application + Renal replacement and Renal support,
*Acute renal failure + specifically complicated ARF
!ith multiple organ failure and cardiovascular
failure,*:ligouric ARF needs large amount of fluid or nutrition
*Acute renal failure !ith cerebral edema
*Acute renal failure !ith hypercatabolism
*An alternative to H% in the mass casualty situation
*-lectrolytes and acid base disturbance
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Renal Application vs on$renal
Applicationon$renal Application
*Hepatic failure complicated !ith hepatic coma
*Congestive heart failure refractory to diuretics
*:verhydration during K after cardiac surgery + C( ,
* .epsis
*/ife$threatening hyperthermia
*/actic acidosis
*Cyto#ine removal cute respiratory distress syndrome
* &umor lysis syndrome
*Crush inLury
*Inborn errors of metabolism maple syrup disease
urea cycle disorder
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.ystemic Complications of Fluid Resuscitation
* JI tract
Fluid flux in stomach and intestine
Jut edema and loss of protein
%ecreased motility diarrhea
&issue hypoxia
* Heart
Myocardial edema
%ecreased cardiac function
* (ulmonary edema
* .#in
-dema
(oor !ound healing
%ecreased tissue :3
* Central nervous system
Cerebral edema
* Increased mortality
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CRR& Fluid Removal vs Fluid
Regulation
Fluid removal Fluid
Regulation
Ultrafiltration rate &o meet anticipated needs
Jreater than +UFR,
anticipated needs
Fluid management dLust UFR dLust
amount of
replacement fluid
Fluid balance ero or negative balance (ositive
negative
or >ero balance
0olume removed ased on physician estimate %riven by
patient
characteristics
pplication -asy similar to Re'uires
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-ffects of in vitro hemofiltration +HF,
on levels of inflammatory mediatorsAuthors Membrane Adsorption Convection
of
arrera et al 1GG3 (A &F I/$1 minimal for &F K
I/$1
/onneman et al 1GG4 (A and (. &F I/$1
aga#i et al 1GG3 (A and (. &F minimal &F
Ronco et al 1GG6 (. I/$1 I/$B (AF no &F
ro!n et al 1GG5 (A &F I/$1
Joldfarb et al 1GG5 (A I/$1
van ommel et al 1GG6 (A &F I/$1
I/$7
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ec s o n vo emo ra on+HF, on /evels of Inflammatory
Mediators
Author Membrane Adsorption of Convection oellum et al2 1GGB A7G &Fa I/7 I
1=
Hoffmanne et al 1GG6 (A C4a C6a I/$
Andreasson et al 1GG4 (A C4a C6a
Riegel et al 1GG6 (. and (A C4aC6a I/$7
Nournois et al 1GG7 (A C4a &F I/$
17B1=
Jasche et al 1GG7 (A factor %
van ommel et al 1GG6 (. and (A &Fminimal for &F
ellomo et al 1GG4 (A &F I/$1
&onnessen et al 1GG4 (. I/$1 not I/$
Millar et al 1GG4 (A I/$7
ellomo et al 1GG6 (A I/$7 I/$BHeidemann et al 1GG5 (. &x3
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(ost Cardiac .urgery RF
O Intra$operative support and post$operative problems
O a2 :xygenator membranes and cyto#ine generation
O b2 lood tubing and extraction of plastici>ers
+%-H(,
O
c2 (rolonged by$pass time and hemodynamicconse'uences
O Application of aggressive ultrafiltration in the cardiac
support of children and outcome improvement
O %ialysis variants added to extracorporeal cardiacsupport system
O a2 0A% and support
O b2 -CM: and support
O c2 IA( and support
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dvantage of CRR& for utritonal
.upport
*Fluid restrictions are removed
*-lectrolyte overload is avoided
*Hyperosmolar nutrition solutions are safe
*CRR& result in a cumulative t
!ith the avoidance of repeatedly high pea# serum nitrogen
values
+ Clar# 9R et al2 N2 m2 .oc2 ephrol2 1GG5,
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Reasons for CRR&
6ehta et al. 7 Am 8 ephrol 1
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(otential Complications !ith CRR&
&echnical Clinical
0ascular access leeding malfunction Hematomas
Circuit clotting &hrombosis
Circuit explosion Infection and
sepsisCatheter and circuit #in#ing Allergic
reactions
Insufficient blood flo! Hypothermia
/ine$catheter disconnection utrient losses
Fluid balance errors Insufficient
blood
purification
/oss of efficiency
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omp ca ons o recor e n a o a
of 313 patients
Complication o
E
leeding 1BB25
Haematoma B
428
Access Malfunction 1
=25
/ine disconnection 18
B2=
Fre'uent filter clotting 6
324
&reatment$induced hypotension 8
424
Cannulation site infection 3
=2G
Hypothermia 5=2G
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Recommendation for Initial
%ialysis Modality for ARF
Indication Clinical condition (referred
&herapy
Uncomplicated RF ntibiotic nephrotoxicity IH% (%
Fluid removal Cardiogenic shoc# CRR&
C( bypass
Uremia Complicated RF in ICU CRR&
IH%
Increased
intracranial pressure .ubarachnoid hemorrhage CRR&
) hepatorenal syndrome
).hoc# .epsis R%. CRR&
utrition urns CRR&
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ey (layers in CRR& (rogram
Administration
ICU physician
ephrologistICU nurses
Hemodialysis nurses
(harmacistsutritionists
&echnicians
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,99: an Outome- in ,ritial
;llne--
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99: '-. no 99: in the ;,
For RRT: Hyperkalemia kills
Pulmonary edemakills
Experience before
RRT available
Visible effects of
uremia
Against RRT Costs money
No RCT it makesany difference
Side effects
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'- -tanar ;H
PD: Hemodynamic
stability Continuous therapy
Standard IHD: etter clearances
No !lycemic s"in!s No abdominal leaks
No splintin! of
diaphra!m
#ecreased risk of
infection
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=ioompatile '-.
ioinompatile ialy-i-
Biocompatible: iolo!ic rationale
T"o RCTs sho"in!clinical advanta!e
Non issue if
convective CRRT
used
Bioincompatible: Cheaper
Some ne!ative RCTs
$po"er limitations%
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&tanar ;H '-. ,99:
Standard IHD: cheaper in some parts
of the "orld $&S'%
CRRT: better volume control
hemodynamic stability
better a(otemic control
better nutrition
no cerebral edema
better renal recovery same cost in )elbourne
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,hange- in [urea"7 ,99: '-. ;H
05
10
15
20
25
30
35
40
45
50
0 1 2 3 4 5 6
CRRT
IHD
van ommel et al* 'm + Nephrol ,--.
urea
$mmol/0%
p12*2.
#ays
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,hange- in [reatinine"7
,99: '- ;H
0100
200
300
400
500
600
700
800
0 1 2 3 4 5 6
CRRT
IHD
3creat4
$mcmol/0%
p12*2.
#ays
van ommel 'm + Nephrol ,--.
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Ahie'ing lui goal-7
,99: '-. ;H
0
5
10
15
20
25
30
ol!me
con"#ol
CRRT
IHD5 of patients
p12*2.
)ehta e al* +'SN ,--6 $abstract%
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Ai>a-e homeo-ta-i-7 ,99: '-.
;H
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
$H
CRRT
IHD
Chan!e in pHafter 78 h of treatment p12*2.
ellomo et al* lood Purif ,--8
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#ays of Treatment
)etabolic acidosis durin! RRT
3HC9:;4mmol/0
2
.
,2
,.
72
7.
:2
:.
82
HC9;2
HC9;,
HC9;7
HC9;:
HC9;8
HC9;.
HC9;6
HC9;;,
>;7
>;:
>;8
>;.
>;6
>;;=
>;-
>;,2
>;,,
>;,7
>;,:
Normali(ation of serum potassium durin! RRT
3>?4mmol/0
#ays of Treatment
p
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,,.
,72
,7.
,:2
,:.
,82
,8.
,.2
,..
,62
Na;2
Na;,
Na;7
Na;:
Na;8
Na;.
Na;6
Na;