CRRT: It

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CRRT Its Not Just for Renal Failure Anymore

• Presented by
• Sue Fallone,MS,RN,CNN
• Clinical Nurse Specialist
• Adult and Pediatric Dialysis
• Albany Medical Center

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Objectives

• Define Heart Failure
• Define Sepsis
• Discuss medical management of heart failure and
  sepsis
• Describe indications for CRRT for these disorders
• Case Study

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HEART FAILURE
Clinical syndrome that can result from any
structural or functional cardiac disorder that
impairs the ability of the ventricle to fill with
or eject blood
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Incidence of Heart Failure

• More deaths from heart failure than from all
  forms of cancer
• Nearly 1 millions people are admitted to the
  hospital with CHF and 30-60 are readmitted
• Contributed to 53,000 deaths in the U.S. each
  year
• About 550,000 new cases per year
• Affects men and women equally
• Related to the aging population, lower death rate
  from MI, and improved treatment for heart disease
• http//health.usnews.com/health-conditions/heart-
  health/congestive-heart
  

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Causes of Heart Failure

• Main causes
• Ischemic heart disease, Cardiomyopathy,
  Hypertension, Diabetes
• Other causes Valvular heart disease, Congenital
  heart
• disease, Alcohol and drugs, Hyperdynamic
  circulation
• (anemia, thyrotoxicosis, hemochromatosis, Paget's
• disease), Right heart failure (RV infarct,
  pulmonary
• hypertension, pulmonary embolism, cor pulmonale
• (COPD)), Arrhythmia and Pericardial disease.

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Mechanisms Leading to Heart Failure

• Impaired cardiac contractility as in myocardial
  infarction and cardiomyopathy
• Ventricular outflow obstruction (pressure
  overload) as in hypertension and aortic stenosis
• Impaired ventricular fillings as in mitral
  stenosis and constrictive pericarditis
• Volume overload as in mitral regurgitation

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Precipitating Factors

• Infections
• Arrhythmias
• Physical, Dietary, Fluid, Environmental, and
  Emotional Excesses.
• Myocardial infarction
• Pulmonary embolism
• Anemia
• Thyrotoxicosis and pregnancy
• Aggravation of hypertension
• Rheumatic, Viral, and Other Forms of Myocarditis
• Infective endocarditis
• Diabetes

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Cardiac remodeling
? C.O.P

1. Hypertrophy Dilatation

2. ?Sympathetic activity

• ? H.R.
• V.C

?

• ? E.D.V

? After-load
? Pre-load.
Angiotensin
Na water retention
?
Aldosterone
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TYPES OF HEART FAILURE

• Left- sided or left ventricular (LV) heart
  failure
• is commonly caused by ischemic heart disease but
  can also occur with valvular heart disease and
  hypertension. 2 types of (LV) heart failure
• diastolic failure is a syndrome consisting of
  symptoms and signs of heart failure with
  preserved left ventricular ejection fraction
  above 4550 and abnormal left ventricular
  relaxation assessed by echocardiography
• systolic failure is when the left ventricle loses
  its ability to contract normally, can pump
  enough blood into the systemic circulation
• Right-sided or right ventricular (RV)heart
  failure
• may be secondary to chronic( LV ) heart failure
  but can occur with primary and secondary
  pulmonary hypertension, right ventricular
  infarction.

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TYPES of HEART FAILURE

• Congestive Heart Failure-
• Blood flow out of the heart slows, blood
  returning to the heart through the veins backs up
  and congestion in the bodys tissues
• Will see edema, SOB, can affect kidney function

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Symptoms Signs OF Heart Failure

• Left heart failure
• Symptoms are predominantly fatigue,
• exertional dyspnea, orthopnea and PND
• Physical signs Cardiomegaly, gallop
• functional mitral regurgitation and crackles a
  the lung bases.

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• Right Heart Failure
• Symptoms (fatigue, breathlessness, anorexia and
  nausea) relate to distension and fluid
  accumulation in areas drained by the systemic
  veins.
• Physical signs are usually more prominent than
  the symptoms, with
• jugular venous distension
• tender smooth hepatic enlargement
• dependent pitting edema
• development of free abdominal fluid (ascites)
• Pleural effusion (commonly right-sided).
• Dilatation of the right ventricle produces
  cardiomegaly and may give rise to functional
  tricuspid regurgitation. Tachycardia and a right
  ventricular third heart sound are usual.

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Major symptoms signs of heart failure
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Classification of Heart FailureFunctional
Capacity

• Class I patients with cardiac disease and no
  limitation of physical activity
• Class II- patients with cardiac disease slight
  limitation of physical activity results in
  fatigue, palpitation, dyspnea or angina
• Class III-patients with cardiac disease marked
  limitation of physical activity comfortable at
  rest
• Class IV-patients with cardiac disease inability
  to carry on any physical activity, symptoms of
  heart failure at rest
• http//www.heartorg/HEARTORG/
  Conditions/Heart

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Treatment of heart failure
? C.O.P
Positive Inotropics
2. ?Sympathetic activity

1. Hypertrophy Dilatation

• ? H.R.
• V.C

?
? Pre-load.

• ? E.D.V

? After-load
vasodilators
Angiotensin
ACE inhibitors
Diuretics
Na water retention
?
Aldosterone
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If Resistant to Diuretics

• MAY NEED
• Ultrafiltration

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UNLOAD STUDY

• The UNLOAD study was a randomized, multicenter
  study of 200 patients involving 28 hospitals and
  medical centers across the United States. UNLOAD
  compared the short and long-term safety and
  efficacy of an advanced form of ultrafiltration
  therapy(Aquapheresis) to the use of conventional
  diuretic drug therapy in fluid overloaded heart
  failure patients.
• The UNLOAD study was published in the February
  13, 2007 issue of Journal of American College of
  Cardiology. (Costanzo MR et al. JACC 2007
  49(6)675-683).

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UNLOAD StudyResults

• 28 with greater fluid loss with UF
• 43 reduction in patients being
  re-hospitalization for HF
• 63 fewer hospital days for HF

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What is SIRS?

• The systemic inflammatory response syndrome is
  systemic level of acute inflammation, that may or
  may not be due to infection, and is generally
  manifested as a combination of vital sign
  abnormalities including fever or hypothermia,
  tachycardia, and tachypnea.

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Definitions

• Severe SIRS SIRS in which at least 1 major
  organ system has failed.
• Sepsis SIRS which is secondary to infection.
• Severe Sepsis Severe SIRS which is secondary to
  infection.
• Septic Shock Severe sepsis resulting in
  hypotensive cardiovascular failure.

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Systemic Inflammatory Reponse(SIRS)

• Can be triggered by infectious and
  non-infectious events
• Infectious causes bacteria or fungi
• Non infectious causes are prancreatitis,burns,
  trauma
• SIRS is the term used for noninfectious causes

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Criteria for SIRS

• Requires 2 of the following 4 features to be
  present
• Temp gt38.3 or lt36.0 C
• Tachypnea (RRgt20 or MVgt10L)
• Tachycardia (HRgt90, in the absence of intrinsic
  heart disease)
• WBC gt 10,000/mm3 or lt4,000/mm3 or
• gt10 band forms on differential

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Criteria for Severe SIRS

• Must meet criteria for SIRS, plus 1 of the
  following
• Altered mental status
• SBPlt90mmHg or fall of gt40mmHg from baseline
• Impaired gas exchange
• Metabolic acidosis (pHlt7.30 lactate gt 1.5 x
  upper limit of normal)
• Oliguria (lt0.5mL/kg/hr) or renal failure
• Hyperbilirubinemia
• Coagulopathy (platelets lt 80,000-100,000/mm3,
  INR gt2.0, PTT gt1.5 x control, or elevated fibrin
  degredation products)

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Pathophysiology of Sepsis

• Overwhelming inflammatory response
• Increased production of proimflamatory cytokines
  and decreased production of cytokines( which
  inhibit inflammation)
• Clotting cascade activated
• Peripheral Vasodilatation ? systemic vascular
  resistance

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Pathophysiology of Sepsiscontinued

• C/O decreases
• Intravascular fluid loss
• Decreased pre load-hypotension
• ATN-renal hypoperfusion and ischemic injury
• MODS
• MOF

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Relationship Between SIRS and Sepsis
Adapted from Marini JJ, et al. Critical Care
Medicine, 2nd ed. 1997.
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Risk Factors for SIRS/Sepsis

• Age
• Indwelling lines/catheters
• Immunocompromised states
• Malnutrition
• Alcoholism
• Malignancy
• Diabetes
• Cirrhosis
• Male sex
• Genetic predisposition?

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Prognosis

• Overall mortality from SIRS/sepsis in the U.S. is
  approximately 20. Mortality is roughly linearly
  related to the number of organ failures, with
  each additional organ failure raising the
  mortality rate by 15.
• Hypothermia is one of the worst prognostic signs.
  Patients presenting with SIRS and hypothermia
  have an overall mortality of 80.

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Treatment

• Fluid Resuscitation
• Vasopressors
• Antibiotics
• Eradication of infection
• Ventilatory support, activated protein C,
  steroids, glycemic control, nutrition
• CRRT

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CONTINUOUS RENAL REPLACMENT THERAPY
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CRRT Definition

• CRRT Continuous Renal Replacement Therapy
• Defined as
• Any extracorporeal blood purification therapy
  intended to substitute for impaired renal
  function over an extended period of time and
  applied for or aimed at being applied for 24
  hours /day.
• Bellomo R., Ronco C., Mehta R,Nomenclature for
  Continuous Renal Replacement Therapies,AJKD, Vol
  28, No. 5, Suppl 3, November 1996

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Introduction to CRRT

• Why continuous therapies?
• Continuous therapies closely mimic the native
  kidney in treating ARF and fluid overload
• Slow gentle
• Remove fluid and waste products over time
• Tolerated well by the hemodynamically unstable
  patient

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Indications for Therapy

• Acute kidney injury- preferred in the critically
  ill patient
• Fluid overload- can removed large amounts of
  fluid slowly
• Hemodynamically unstable- continuous therapy
  allow for slow hourly fluid removal which allows
  the intravascular spaces to refill

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Indications continued

• Highly catabolic patients who need increased
  clearance rates
• Patients needing large molecular weight
  substances removed
• Sepsis

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Molecular Weight

• SMALL MOLECULES- 0-500 daltons (urea,
  creatinine)
• MIDDLE MOLECULES- 500-5000 daltons ( vitamin
  B12)
• LARGE MOLECULES- 5000-50,000 daltons ( heparin,
  Beta 2 drugs)

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CRRT Modalities

• SCUF OR ULTRAFILTRATION - Slow Continuous
  UltraFiltration
• CVVHD - Continuous Veno-Venous HemoDialysis
• CVVH - Continuous Veno-Venous Hemofiltration
• CVVHDF Continuous Veno-Venous
  Hemodiafiltration

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SCUF/Ultrafiltration

• Primary therapeutic goal
• Safe management of fluid removal
• Patient UF rate ranges up to 2 L/Hr
• No dialysateNo replacement fluids
• No molecule removal
• Large fluid removal via ultrafiltration
• Blood Flow rates 100-200 ml/min

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SCUF/ULTRAFILTRATION Slow Continuous
UltraFiltration
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Ultrafiltration

• Particles move through a semi-permeable membrane
  by use of HYDROSTATIC pressure.
• The separation of particles from a suspension by
  passage through a filter. The separation is
  accomplished by convective transport.

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Convection Step 1 Filter Action
Red Cell
Na
K
Na
Na
Na
U
H2O
H2O
U
H2O
Na
Na
U
H2O
Na
Red Cell
K
H2O
H2O
K
H2O
Red Cell
Na
U
U
Na
Na
Na
H2O
U
Red Cell
Na
Na
U
K
K
H2O
H2O
U
K
K
H2O
U
H2O
Na
H2O
Na
Na
U
K
Na
U
K
Red Cell
H2O
K
Na
Na
H2O
Na
U
K
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Solute Removal by Convection
Convection The movement of solutes with a
water-flow,solvent drag, e.g... the movement
of membrane-permeablesolutes with water across
the semipermeable membrane
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CVVH Continuous Veno-Venous Hemofiltration
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Molecular Transport Mechanisms

• Convection - The movement of solutes with a
  water-flow, solvent drag, the movement of
  membrane-permeable solutes with water across the
  semipermeable membrane

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Convection Step 1 Filter Action
Red Cell
Na
K
Na
Na
Na
U
H2O
H2O
U
H2O
Na
Na
U
H2O
Na
Red Cell
K
H2O
H2O
K
H2O
Red Cell
Na
U
U
Na
Na
Na
H2O
U
Red Cell
Na
Na
U
K
K
H2O
H2O
U
K
K
H2O
U
H2O
Na
H2O
Na
Na
U
K
Na
U
K
Red Cell
H2O
K
Na
Na
H2O
Na
U
K
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Solute Removal by Convection
Convection The movement of solutes with a
water-flow,solvent drag, e.g... the movement
of membrane-permeablesolutes with water across
the semipermeable membrane
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CVVHD - Continuous VV Hemodialysis

• Primary therapeutic goal
• Solute removal by diffusion
• Safe fluid volume management by ultrafiltration
• Requires Dialysate solution
• Patient UF rate ranges 2-7 L/24 hours (300
  ml/hr)
• Dialysate Flow rate 15-45 ml/min (2 L/hr)
• Blood Flow rate 100-200 ml/min
• No replacement solution
• Solute removal determined by Dialysate Flow rate.

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Diffusion Filter Action
Na
Na
K
Mg
Mg
Na
Na
U
H2O
Na
Na
U
H2O
Na
H2O
Na
U
Na
K
K
Na
U
H2O
K
Na
Mg
H2O
U
Na
U
H2O
H2O
K
U
H2O
K
U
H2O
Mg
Na
Na
U
K
U
H2O
Na
Na
U
H2O
Na
Na
H2O
K
U
K
Na
Na
Mg
K
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Vascular Access

• Depending on the device used lumen size matters
• If using AquaDex FlexFlow Fluid Removal System
  midline catheters can be used
• If using CRRT devices hemodialysis type catheters
  need to be placed.

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Catheter Size

• Adults
• 12.5 to 14 french
• Length will vary 16,19,24,cm
• Femoral placement least preferred

• Children (weight based)
• 5 french single catheter 7 fr dual lumen
• 8 fr dual lumen
• 10 fr dual lumen
• 11 fr dual lumen
• Length
• 9 cm, 10 cm, 12 cm, 15 cm

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Case Study 1

• Mr. G is a 60 year old man with CAD s/p MI and
  PTCA to LAD in 1997, dyslipidemia, and tobacco
  use who called 911 for severe chest pain on
  11/01/10. This pain was similar in nature to his
  previous MI.

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ECG in the ambulance
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History

• In the ambulance en route to the emergency room,
  the patient developed two episodes of ventricular
  fibrillation which both successfully responded to
  DC cardioversion. After arrival to the cath lab,
  the patient developed cardiogenic shock and
  recurrent ventricular fibrillation requiring
  multiple shocks (he was shocked 11 times in the
  cath lab prior to intervention) and intubation
  with mechanical ventilation.

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Cath Lab Course

• Coronary angiography showed
• Totally occluded mid LAD with thrombus
• Mild diffuse atherosclerosis of left circumflex
  and right coronary arteries
• Soon after the first injection there was proximal
  propagation of the LAD thrombus which occluded
  the left main coronary artery
• A wire was passed to the distal LAD and an
  AngioJet thrombectomy device was used which
  re-established flow

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Cath Lab Course

• After the Impella device was placed, the patient
  had no further episodes of ventricular
  fibrillation

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Immediately Post Cath

• Patient admitted to the CCU on IV Epinephrine,
  Dobutamine, and Dopamine continuous infusions
• Echocardiogram the next day showed severe
  anterior wall hypokinesis with EF 25
• The patient was placed on CVVH then on SCUF to
  remove excess fluid

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Hospital Course

• Hospital day 3 Impella device was removed
• Hospital Day 6 Repeat echocardiogram, EF 50-55
• Hospital Day 8 Extubated, neurologically intact
• Hospital Day 16 Discharged to home

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Case Study2

• Alan is a 20 year old admitted to a cardiology
  unit with CHF and Situs Inversus. He had SOB ,
  anascara, arrythmias. His blood pressure was
  110/60 mm Hg. He has a serum creatinine of 1.5
  mg/dl. He is in need of a pacemaker but first
  needs 10 liters of fluid removed before placement
  of a pacemaker.
• He is started on furosemide 80 mg every 8 hours
  and metolazone 10mg/d for 2 days. On day three he
  is given mannitol 25 g every eight hours.
• He is putting out 3L of urine a day but has only
  decreased his net fluid loss by 3 L due to lack
  of adherance to his fluid restriciton

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Case StudyContinued

• Because of his need for a pacemaker, the
  decision was made to place the patient on SCUF.
• After three days of therapy the patient was at
  his dry weight and stable and was able to receive
  his pacemaker
• Consideration has to be given related to rate of
  fluid removal and his overall renal function
• Patient was discharged to home with a follow up
  to a nephrologist

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Case Study3

• Mrs. D was admitted to MICU for sepsis. She had
  been hypotensive that required vasopressors.
  During the course of her stay in MICU, she
  developed AKI. To manage her fluid and
  electrolytes, she was started on CRRT. She seemed
  to tolerate CRRT well.
• On her 5th day of therapy, her Serum Creatinine
  was down to 1.2 from 6.9 and her electrolytes
  were stable, her BP was borderline with MAP gt 60
  mmHg and lt 70 mmHg.
• CRRT was discontinued and only to be restarted
  after 2 days when the patient became hypotensive
  again that regular HD was not possible given her
  hemodynamic parameters.
• Patient was started on phenylephrine at 200
  mcg/min and nor-epinephrine at 10 mcg/min. On the
  3rd day of the 2nd therapy, the patient had the
  following data

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Patient Data
Time BP CVP Vasopressor I and O Balance
2/15 2200 125/60 14 Off -100
2/16 0600 110/65 12 Off -250
2/16 1900 73/85 6 ON -1100
2/17 2300 108/55 10 Off -500
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Questions

• What happened in this scenario?
• What should have been considered in setting the
  net fluid removal rate?
• How would we assess for the intravascular vs
  extra-vascular fluid status?
• When will be the right time to advocate for
  discontinuance of CRRT?

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Conclusion

• CRRT therapies can be applied to many clinical
  situations
• The patient goals/outcomes can be enhanced with
  early initiation of this therapy

CRRT IS NOT JUST FOR RENAL FAILURE
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THANK YOU