rrt in icu dr. nisith kumar mohanty. when to start rrt in icu? controversial controversial...

RRT IN ICURRT IN ICU

DR. NISITH KUMAR MOHANTYDR. NISITH KUMAR MOHANTY

WHEN TO START RRT WHEN TO START RRT IN ICU? IN ICU? CONTROVERSIALCONTROVERSIAL EARLY/LATEEARLY/LATE RRT COMPLICATION-RRT COMPLICATION- Bleeding,thrombosis,Bleeding,thrombosis,hypotensionhypotension,, Arrhythmias, Arrhythmias, infectioninfection

YEARS OF WRONG YEARS OF WRONG TEACHINGTEACHING INDICATION OF RRT TEXT BOOK INDICATION OF RRT TEXT BOOK

TEACHING-TEACHING- S/S OF UREMIC SYNDROMES/S OF UREMIC SYNDROME REFRACTORY HYPERVOLEMIAREFRACTORY HYPERVOLEMIA HYPERKALAEMIAHYPERKALAEMIA ACIDOSISACIDOSIS BUN>100BUN>100

WHY WE SHOULD WHY WE SHOULD START EARLY?START EARLY? 50/M50/M DM,2DM,2NDND POD CABG,3 POD CABG,3

INOTROPES,OLIGURIA INOTROPES,OLIGURIA -24/H,FEBRILE,TLC COUNT -24/H,FEBRILE,TLC COUNT 14000/cmm/Hb 7gm/dl14000/cmm/Hb 7gm/dl

BU-50mg/Scr/2mgBU-50mg/Scr/2mg K-4.5meq/l Na-130meq/lK-4.5meq/l Na-130meq/l CXR-SIGN OF UPPER LOBE VESSEL CXR-SIGN OF UPPER LOBE VESSEL

PROMINENCEPROMINENCE

EARLY RRT-EARLY RRT-

TO PREVENT FLUID OVER RATHER TO PREVENT FLUID OVER RATHER THAN TREAT FLUID OVERLOADTHAN TREAT FLUID OVERLOAD

TO PREVENT OR MINIMIZE TO PREVENT OR MINIMIZE BIOCHEMICAL ABNORMALITYBIOCHEMICAL ABNORMALITY

NO RCT /BUT NOTHING AGAINSTNO RCT /BUT NOTHING AGAINST EPIDEMIOLOGIC STUDIESEPIDEMIOLOGIC STUDIES PHYSIOLOGIC REASONINGPHYSIOLOGIC REASONING

INDIACTION RRT IN ICUINDIACTION RRT IN ICU

OLIGURIA<200ML/24HOLIGURIA<200ML/24H ANURIA<50ML/12HANURIA<50ML/12H ACIDOSIS Ph<7.1ACIDOSIS Ph<7.1 Azotemia>BU>200mgAzotemia>BU>200mg Hyperkalemia>6.5Hyperkalemia>6.5 UREMIC ORGAN INVOLEMENT-UREMIC ORGAN INVOLEMENT-

pericarditis,encephalopathy,neuropericarditis,encephalopathy,neuropathy, myopathypathy, myopathy

INDI-INDI-

SEVERE SEVERE DYSNATREMIA->160/<115DYSNATREMIA->160/<115

CLINICALLY SIGNIFICANT ORGAN CLINICALLY SIGNIFICANT ORGAN OEDEMA-LUNGOEDEMA-LUNG

LARGE FLUID REQUIREMENT LARGE FLUID REQUIREMENT DRUG OVER DOSEDRUG OVER DOSE

WHEN TO STOP?WHEN TO STOP?

NO STUDY-SO VARIABLENO STUDY-SO VARIABLE ALL CRITERIA FOR INITIATING RRT ALL CRITERIA FOR INITIATING RRT

ABSENTABSENT URINE OUT PUT 1ml/min/24hURINE OUT PUT 1ml/min/24h No fluid imbalanceNo fluid imbalance Developed complication of RRTDeveloped complication of RRT

WHICH FORM RRT?WHICH FORM RRT?

IHDIHD CRRT CRRT SLEDDSLEDD

CONCEPTCONCEPT

DIFUSSIONDIFUSSION CONVECTIONCONVECTION

IHDIHD

AvailabityAvailabity Low cost of machine and consumableLow cost of machine and consumable Easy to operateEasy to operate Two recent RCT comparing with CRRTTwo recent RCT comparing with CRRT Uehlinger et al—n-125ptUehlinger et al—n-125pt Hemodiaf group—n-175Hemodiaf group—n-175 Observational study-n-398- CRRT-Observational study-n-398- CRRT-

206,IHD-192206,IHD-192

RCTRCT

CONLUSION-CONLUSION- LACK OF DIFFERENCE IN LACK OF DIFFERENCE IN

OUTCOMEOUTCOME MORE PT FROM CRRT - >IHD MORE PT FROM CRRT - >IHD

BECAUSE OF COMPLICATIONBECAUSE OF COMPLICATION LESS PRACTICAL PROBLEM EVEN LESS PRACTICAL PROBLEM EVEN

IN UNSTABLE PTIN UNSTABLE PT

FREQUENCY FREQUENCY

CHRONIC DIALYSIS STRATEGIES CHRONIC DIALYSIS STRATEGIES NOT SUITABLE FOR ARFNOT SUITABLE FOR ARF

DAILY>3 WEEKDAILY>3 WEEK

Adapted from Shiffl et al. N Engl J Med. 2002;346:305-10.

100100

9090

8080

7070

6060

5050

4040

3030

2020

1010

003/wk HD3/wk HD

wKT/V = 3.6wKT/V = 3.67/wk HD7/wk HD

wKT/V = 7.4wKT/V = 7.4

54 % 72 %

Survival vs. Dialysis Dose In IntermittentSurvival vs. Dialysis Dose In IntermittentHaemodialysisHaemodialysis

CRRTCRRT

MOST PHYSIOLOGICALMOST PHYSIOLOGICAL NEEDS COSTLY REPLACEMENT NEEDS COSTLY REPLACEMENT

FLUID/ DISPOSABLE/EQUIPMENTFLUID/ DISPOSABLE/EQUIPMENT TYPESTYPES

FIRST CRRTFIRST CRRT

SLEDDSLEDD

SLOW DAILY EXTENDED SLOW DAILY EXTENDED DIALYSIS/SUSTAINED LOW DIALYSIS/SUSTAINED LOW EFFICIENCY DIALYSISEFFICIENCY DIALYSIS

LOW DIALYSATE FLOW/LOW LOW DIALYSATE FLOW/LOW BLOOD FLOWBLOOD FLOW

ADVANTAGEADVANTAGE

EFFICIENT CLEARANCE OF SMALL EFFICIENT CLEARANCE OF SMALL SOLUTESOLUTE

GOOD HAEMODYNAMIC GOOD HAEMODYNAMIC TOLERABILITYTOLERABILITY

FLEXIBLE TREATMENTFLEXIBLE TREATMENT REDUCED COSTREDUCED COST

TIME

EFFECT

CVVH

IDH

TAKE HOME MESSAGETAKE HOME MESSAGE

TREAT PT TIMELY AND TREAT PT TIMELY AND AGGRESIVELYAGGRESIVELY

TAILER THE RRT FOR THE TAILER THE RRT FOR THE PARTICULAR PTPARTICULAR PT

DAILY DIALSIS IS BETTER THAN ¾ DAILY DIALSIS IS BETTER THAN ¾ /WEEK DAILYSIS/WEEK DAILYSIS

THANKS FOR KIND THANKS FOR KIND ATTENTIONATTENTION