the role of crrt in the management of fluid overload the management of fluid overload . ......
TRANSCRIPT
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The Role of CRRT
in the Management of Fluid Overload
Dr Antoine G. Schneider MD PhD
28 of January 2016
Colors of Sepsis Symposium
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Disclosures
• Salary support by Canton de Vaud • Grant support from the Leenaards Foundation, Switzerland• Speaking / consulting / Travel support from
• Baxter Healthcare Corp• Fresenius Medical Care• BBraun Avitum
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Fluids in ICU
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Fluids in ICU
• Fluid administration is one of the most common
intervention in ICU
• Fluid administration aims at:
• Maintaining physiological homeostasis
• Enable other drugs administration
• Correcting perceived haemodynamic instability.
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Fluids in ICU
Hall JE In Guyton and Hall Textbook of Medical Physiology, 2011:229 241. Shoemaker WC. Am J Surg 1965, 110:337 341.
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Fluids optimization in ICU
M. C. Bellamy Br. J. Anaesth. 2006;97:755-757
Line of risk
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Fluids in ICU: Controversies
• Type of fluids: o Colloids vs crystalloidso Balanced solutions vs Normal salineo Albumin
• Volume of fluids and optimal target endpoints for fluid therapy during resuscitationo CVPo Lactate clearance
• Fluid challenge: Definition / target endpoints
Finfer S et al. Crit Care 2010; 14: R185
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Fluid Overload
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Fluid Overload: Evidence of Harm
Mc Dermid et al, W J of Crit Care Med 2014
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Harm in Bowel Surgery
Brandstrup et al 2003 Ann surg 238:641-648
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Brandstrup et al ann surg 238:641-648 2003
Harm in bowel surgery
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1000 patients with ALI were randomized to conservative or liberal fluid management strategy.
The conservative strategy had no effect on mortality (primary outcome, 25.5 vs 28.4%) but:
- Improved oxygenation index and the lung injury score- Increased the number of ventilation and ICU free days
Wiedemann et al N Engl J Med 2006;354:2564-75
Harm in Acute Lung Injury
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Yes! But fluids protect the
Kidney!
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Bouchard et al Kidney International (2009) 76, 422–427
On Dialysis initiation Non dialyzed patients
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KIDNEYS ARE HAMPERED BY FLUIDS:
Payen et al Critical Care 2008, 12:R74
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Prowle et al Nat Rev Nephrol 2014
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Prowle et al Nat Rev Nephrol 2014
Potential additional toxicity due to
- Excess chloride toxicity (afferent arterioles constriction)
- Starch Intratubular deposition
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What can we do about it?
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Fluid Management: a Practical Approach
• Limit the intensity and the duration of the initial resuscitation phase to the minimum
• Monitor fluid balance (daily and cumulative) and/or body weight
• Target neutral cumulative fluid balance after the initial phase of resuscitation
• This second stage usually involves FLUID REMOVAL
• Such aim, particularly in the setting of AKI, might involve RRT
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Volume Management with RRT
• RRT techniques are designed to remove fluid from the intravascular compartment.
• Hemodynamic tolerance is dependent on refilling of the intravascular volume from the interstitial compartment, the PLASMA REFILL RATE (PRR)
• Matching fluid removal to the PRR might be easier with continuous modalities (CRRT)
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Volume Management with CRRT
Goals:
- Remove excess fluids without compromising cardiac output and
effective circulating volume (easier with continuous monitoring)
- Compensate for increased fluids given to provide adequate
nutrition and drugs (Fluid balance monitoring)
- Attempts to maintain urinary output
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Potential Errors
• User:
• Inadequate prescription• Inadequate application of prescription• UF rates not optimized to PRR with resulting HD instability
(Absence of prompt recognition of signs of hypovolemia)
• Machine:
• Imprecise Fluid balance management (errors)• Override by operators of safety alarms intended to limit UF
when the gravimetric scale being adjusted
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Potential Errors
• User:
• Inadequate prescription• Inadequate application of prescription• UF rates not optimized to PRR with resulting HD instability
(Absence of prompt recognition of signs of hypovolemia)
• Machine:
• Imprecise Fluid balance management (errors)• Override by operators of safety alarms intended to limit UF
when the gravimetric scale being adjusted
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BJA 2014
THE IMPORTANCE OF NET UF TRAJECTORY
A: Cardio renal syndromeB: Single renal failureC: Severe sepsisD: Septic shock
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Potential Errors
• User:
• Inadequate prescription• Inadequate application of prescription• UF rates not optimized to PRR with resulting HD instability
(Absence of prompt recognition of signs of hypovolemia)
• Machine:
• Imprecise Fluid balance management (errors)• Override by operators of safety alarms intended to limit UF
when the gravimetric scale being adjusted
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Definitions
Ultrafiltrate / Effluent
Reflects therapy DOSE
Replacement volume
= Pre + Post Dilution + Dialysate
Net fluid removal
Importance of Education
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Potential Errors
• User:
• Inadequate prescription• Inadequate application of prescription• UF rates not optimized to PRR with resulting HD instability
(Absence of prompt recognition of signs of hypovolemia)
• Machine:
• Imprecise Fluid balance management (errors)• Override by operators of safety alarms intended to limit UF
when the gravimetric scale being adjusted
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Ganter et al Acta Anesth Scandin 2012
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GOAL-DIRECTED FLUID REMOVAL:Remove unless sign of hemodynamc instability
Ganter et al Acta Anesth Scandin 2012
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Potential Errors
• User:
• Inadequate prescription• Inadequate application of prescription• UF rates not optimized to PRR with resulting HD
instability(Absence of prompt recognition of signs of hypovolemia)
• Machine:
• Imprecise fluid balance management (errors)• Override by operators of safety alarms intended to limit UF
when the gravimetric scale being adjusted
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Potential Errors
• A typical prescription involves 2 to 4 litres exchanges per hour
• A 1% error would lead to 0.5 to 1 liter a loss /gain per day
• Very high precision required!
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Potential Errors
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Potential Errors
• User:
• Inadequate prescription• Inadequate application of prescription• UF rates not optimized to PRR with resulting HD instability
(Absence of prompt recognition of signs of hypovolemia)
• Machine:
• Imprecise Fluid balance management (errors)• Override by operators of safety alarms
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In vitro FB errors on 2nd
generation machines:
Prisma/Prismaflex
Multifiltrate
Diapact
Aquarius
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• Most machines do not stop the treatment after multiple overrides
of the “fluid balance error” alarm.
• Each alarms requires a 20-50 g difference to be triggered
• Hence overriding an alarm 10 x can generate 200 to 500 ml error in
fluid balance
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Conclusions
• Fluid overload an important issue in critical illness associated
with harm in numerous settings
• Fluid administration should be restricted to the minimum
• Fluid restriction has NOT been associated with renal damage
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Conclusions
• Fluid removal is often required after the initial resuscitation
phase and need to follow different trajectories.
• CRRT is often required in such context
• Fluid removal is a key aspect of the CRRT prescription
• Fluid removal has to be fully delivered and monitored
(it is part of the dose)
• Correct fluid balance trajectories have to be set
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Thank you for the Attention!