CRRT
CONTINUOUS RENAL REPLACEMENT
THERAPY
Continuous renal replacement therapy (CRRT) is
commonly used to provide renal support for critically
ill patients with acute kidney injury, particularly
patients who are hemodynamically unstable.
• Approximately 5% to 10% of patients with AKI
require renal replacement therapy (RRT)
during their ICU stay,1
TYPES
• VENOVENOUS
• ARTERIOVENOUS
• Initially developed as an arteriovenous
therapy
• most CRRT is now performed using pump-
driven venovenous extracorporeal circuits
• Pump-driven venovenous circuit provides
higher and more consistent blood flows
• Eliminates the hazards associated with
prolonged arterial cannulation with a large-
bore catheter
VEOVENOUS
TYPES
• Continuous Venovenous Hemofiltration with
predominantly convective solute clearance(CVVH)
• Continuous venovenous hemodialysis with
predominantly diffusive solute clearance, (CVVHD)
• Continuous Venovenous Hemodiafiltration,
which combines both dialysis and hemofiltration.
(CVVHDF)
ARTERIOVENOUS
• Continuous arteiovenous Hemofiltration (CAVH)
• Continuous arteriovenous hemodialysis (CAVHD)
• SCUF (Slow Continuous Ultrafiltration):
SCUF is the removal of water from the patient's blood
as it travels through the filter. Water removal is
referred to as ultrafiltration. SCUF is a therapy
designed to only remove surplus water.
The amount of water removed is not sufficient to
remove wastes.
Indications RRT
Patients with AKI-haemodynamically unstable
• older age,
• male sex,
• higher severity of illness,
• sepsis,
• decompensated heart failure,
• cardiac surgery,
• liver failure,
• use of mechanical ventilation.
Comparison-IHD&CRRT
• IHD provides rapid solute clearance and
ultrafiltration during relatively brief (3- to 5-h)
treatments;
• the continuous therapies provide more
gradual fluid removal and solute clearance
over prolonged treatment times (optimally,
24 h per day)
• The major difference between intermittent and
continuous therapies is the speed at which water and
wastes are removed.
• Intermittent hemodialysis removes large amounts of
water and wastes in a short period of time (usually over
2-4 hours), whereas, continuous renal replacement
therapies remove water and wastes at a slow rate more
consistent of that of native renal function.
• While intermittent dialysis allows chronic renal failure
patients to limit the amount of time that they are
connected to a machine, the rapid clearance of solutes
and fluid can be poorly tolerated when a patient is
hemodynamically unstable.
continuous hemofiltration.
• Blood flow through the hemofilter is shown
from left to right.
• An ultrafiltrate is generated across the
hemofilter membrane,
• Solute loss through convection
• Haemodilution using replacement fluid
• Fluid replaced with prefilter and/or postfilter
replacement solution.
• In CVVH, a high rate of ultrafiltration across
the semi-permeable hemofilter membrane is
created by a hydrostatic gradient, and solute
transport occurs by convection .
• Solutes are entrained in the bulk flow of water
across the membrane, a process often
referred to as “solvent drag.”
Continuous Hemodialysis
• Blood flow through the hemodialyzer is
shown. from left to right.
-Dialysate is perfused through the
hemodialyzer on the opposite side of the
membrane countercurrent to the direction of
blood flow.
-The effluent consists of spent dialysate plus
the volume of ultrafiltrate desired to achieve
negative fluid balance
DIALYSATE-that used for peritoneal dialysis
continuous Hemodiafiltration,
• . Blood through the hemodiafilter is shown from left to right.
• As in continuous hemodialysis, dialysate is perfused through
the hemodialyzer on the opposite side of the membrane
,countercurrent to the direction of blood flow.
• The effluent consists of spent dialysate plus ultrafiltrate.
• As in continuous hemofiltration, excess ultrafiltrate above
the volume desired for negative fluid balance is replaced
with replacement solution.
• In the figure, replacement solution is shown being infused
postfilter; replacement solution can also be infused prefilter.
Convection and diffusion
Convection and diffusion.
A, Convection: solute transfer across the
membrane occurs via entrainment of solutes
in the bulk flow of water during ultrafiltration
• Higher molecular weight solutes (larger
symbols) and lower molecular weight solutes
(smaller symbols) are transported across the
membrane with equal efficiency until the
molecular radius of the solute exceeds the
membrane pore size
.
• High ultrafiltration rates are needed to achieve
sufficient solute clearance, and the ultrafiltrate
volume beyond what is required to achieve desired
net fluid removal is replaced with balanced IV
crystalloid solutions.
These replacement solutions may be infused into the
extracorporeal circuit either prior to or following the
hemofilter.
• Because the high ultrafiltration rate hemoconcentrates the
blood as it passes through the hemofilter fibers, the risk of
sludging and fiber occlusion is increased.
• Prefilter infusion of replacement fluid dilutes the blood
entering the hemofilter, mitigating this hemoconcentration.
•
• However, prefilter administration of replacement fluid dilutes
the solute content of the blood, reducing effective solute
clearance at a fixed ultrafiltration rate.
• Postfilter infusion has no such effects
. B, Diffusion: solute transfer across the
membrane occurs by movement down a
concentration gradient from blood
to dialyste.
• Lower molecular weight (< 500-1,500 Daltons)
solutes (smaller symbols) cross the membrane
more readily than higher molecular weight
solutes (larger symbol)
Convection and diffusion
• In CVVHD, dialysate is perfused across the external surface
of the dialysis membrane, and solutes exit from blood to
dialysate by diffusion down their concentration gradient
Ultrafiltration rates are relatively low compared with those
in CVVH, permitting net negative fluid balance without the
need for IV replacement fluids.
• Although commonly considered as a purely diffusive
therapy, unmeasured bidirectional filtration into the
dialysate compartment and back-filtration from dialysate
to blood result in significant convective solute transport.
• CVVHDF is a hybrid, combining the dialysate flow of CVVHD
with the high ultrafiltration rates and use of replacement
fluids of CVVH.,and diffusion.
Indications for Initiation of
Continuous Renal Replacement Therapy
.
• Volume overload
• Metabolic acidosis
• Electrolyte abnormalities
• Hyperkalemia
• Hyponatremia
• Hyperphosphatemia
• Uremia Encephalopathy
• Pericarditis
• Persistent/progressive acute kidney injury
• Drug and Toxin Removal
• A variety of toxins and drugs, such as toxic alcohols,
lithium, salicylate, valproic acid, and metformin, are
dialyzable, and the timely use of RRT in cases of
poisoning and drug intoxications with these agents
may be able to avert serious complications.
• The ability of RRT to remove a particular drug or
toxin from the circulation is a function of its size,
volume of distribution, and protein binding capacity.
Vascular Access
• Initiation of CRRT requires vascular access,
which is generally established through
placement of a large-bore double lumen
catheter in an internal jugular, femoral, or
subclavian vein.
• In adults, catheter design and position must
be sufficient to sustain blood flow rates of 200
to 300 mL/min
• femoral catheters are generally associated
with higher rates of bacteremia
• Subclavian cannulation is generally avoided
because of the higher risk of insertion
complications and because of the risk of
subsequent venous stenosis
• the right internal jugular vein is the preferred
location for catheter placement, followed by
the femoral and the left internal jugular vein
Strategies to minimize the risk of clotting of the extracorporeal circuit
Clotting of the extracorporeal circuit is the most common complication
during CRRT
Strategies to minimize the risk of clotting of the extracorporeal circuit
include the following:
• use of higher blood flow rates;
• minimization of filtration fraction (the ratio of ultrafiltration
to plasma flow) by using CVVHD rather than CVVH,
• by infusing replacement fluids prefilter during CVVH and
CVVHDF;
anticoagulation for CRRT
• When anticoagulation is used,
Either unfractionated heparin (UFH) or
low-molecular-weight heparin may be used.
Nutritional Management
• Patients with AKI who are undergoing CRRT are usually in
substantial negative nitrogen balance due to high protein
catabolic rates
• . In addition, CRRT results in amino acid loss as well as
losses of water-soluble vitamins and other
micronutrients.
• Caloric intake of approximately 35 kcal/kg per day should
be provided, with a target protein intake of 1.5 g/kg per
day and with supplementation of water-soluble vitamins.
• Although enteral feeding is preferred, parenteral support
may be necessary.
Complications Associated With CRRT
Catheter-related complications
• Hemorrhage
• Infection
• Venous thrombosis
• Venous stenosis
• Traumatic arteriovenous fistula
• Pneumothorax
• Hemothorax
• Air embolism
• Visceral injury
Extracorporeal circuit-related complications
Allergic reaction to hemodialyzer/hemofilter or tubing
Circuit thrombosis
Hemolysis
Air embolism
Hypothermia
Hypotension
Electrolyte disturbances
Hypophosphatemia
Hypokalemia
Hypocalcemia
Hypomagnesemia
Incorrect medication dosing
Discontinuation of CRRT
• There are no specific criteria for discontinuation
of CRRT because of recovery of kidney function
or transition to other modalities of RRT.
• An initial manifestation of recovery of kidney
function is increased urine output,
• a urine output > 400 mL/d without
concomitant diuretic therapy is a predictor of
successful CRRT discontinuation.
Ng care
• Assessment-vital signs,RFT,LOC, vascular access site,
• interventions
• Flow rate monitoring,
• adequate heparinisation,
• mintaining haemodynamic status,
• intake output chart,
• RFT evaluation,
• Monitor for complications
• Prevention of infection
• Follow Strict asceptic technique
• Check vascular access patency
• Nutrition
• DVT prophylaxis
• prevention of pressure ulcer
