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