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Intensive care conference: management of acid-base disorders with CRRT -- 2011 International Society of Nephrology. 主講人 : R2 顏介立. Introduction. 1. acid-base homeostasis  challenge in ICU 2. Focus on CRRT (Continuous renal replacement therapies ) in critical patient with AKI

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R2

Intensive care conference:management of acid-base disorders with CRRT--2011 International Society of Nephrology

主講人: R2 顏介立


Introduction

Introduction

1. acid-base homeostasis challenge in ICU

2. Focus on CRRT (Continuous renal replacement therapies ) in critical patient

with AKI

3. hypercapnic acidosis and lactic acidosis

for example


Crrt continuous renal replacement therapies

CRRT (Continuous renal replacement therapies )

- called "go slow dialysis”

  • The major advantage of continuous therapy is the slower rate of solute or fluid removal per unit of time

  • CVVHD (Continuousveno-venous hemodialysis)

  • CVVHF (Continuousveno-venous hemofiltration)

  • CVVHDF


Crrt continuous renal replacement therapies1

CRRT (Continuous renal replacement therapies )


Hypercapnic acidosis

Hypercapnic acidosis

1. Cause

  • Increase CO2 production or decrease

    CO2 elimination

    2. Physiological compensatory:

    lung:

    hypercapnia stimulate cental and paripheral chemoreceptors=>increase ventilation


Hypercapnic acidosis1

Hypercapnic acidosis

2. Physiological compensatory:

kidney: 3-5 days (in animal model)

** but this mechanism is limited in AKI patient


Hypercapnic acidosis2

Hypercapnic acidosis

3. Management

  • ALI/ARDS treatment: CO2 retention permission

    =>low tidal volume(4-6ml/kg) and low pressure(<30)

    =>maintain adequate oxygenation

    =>PaCO2=66.5mmhg/ PH decrease to 7.2

  • Acidosis would “well tolerated” if fair tissue perfusion

    and oxygen


Hypercapnic acidosis3

Hypercapnic acidosis

3. Management

  • Hypercapnic acidosis controversies:

    Advantage:

    improve arterial and tissue oxygenation,

    reduce oxidative stress, anti-inflammatory effect

    Disadvantage:

    vasodilating effect, increase capillary permeability

    (may worsen brain edema) =>ICH

    may cause myocardial depression, pulmonary hypertension

    Conclusion:

    patient with advanced age and multiple comorbidities,

    lung-protective stragegies may disadvantage


Hypercapnic acidosis4

Hypercapnic acidosis

3. Management

sodium bicarbonate :

  • Worsen exisiting hypercapnia

  • Worsen heart failure due to volume expansion, hyperosmolality, decrease ionized calcium plasma concentration

  • Hypercapnic acidosis treat by sodium bicarbonate

    is not recommended unless metabolic acidosis co-exist


Hypercapnic acidosis5

Hypercapnic acidosis

3. Management

-Intermittent hemodialysis:

rapid flux of bicarbonate => excess CO2=>

required hyperventilation

-CRRT:

much slower buffer delivery=>

correct combined respiratory and metabolic acidosis

by CRRT in case reports.


Hypercapnic acidosis6

Hypercapnic acidosis

3. Management

  • Convective hemofiltration:

    use hemofiltration with replacement fluid contain

    NaOH can remove half of CO2 production

    =>50% reduction in minute ventilation and keep

    PaCO2 level 35-38 with stable blood PH

  • CVVHF may an effective adjunctive treatment

    for acidosis in respiratory failure patient

    => avoid intubation and ventilator induced ALI or

    infection


Lactic acidosis

Lactic acidosis

  • pathophysiology: - Pyruvate: precursor of lactate

    PDH


Lactic acidosis1

Lactic acidosis

2. Classification of lactic acidosis:

  • Type A: inadequate oxygen supply

  • Type B: dysregulation of metabolism rather than

    hypoxia

    B1: liver disease, malignancy

    B2: drug induced: metformin, aspirin, propofol……

    B3: congenital

    - Sepsis induced lactic acidosis


Lactic acidosis2

Lactic acidosis

3. Clinical application of lactate:

- Lactate acidosis is related to high mortality

  • Lactate is a prognosis indicator

    surviving sepsis campaign regard lactate level>4mmol/L need aggressive treatment protocols

    - Treat underlying disease


Lactic acidosis3

Lactic acidosis

4. Treatment of lactic acidosis:

- Treatment underlying disease

  • Sodium bicarbonate:

    may worsen oxygen delivery, increase lactate production (especially when hypoxia=>induce glycolysis), decrease portal vein flow

  • The surviving sepsis campaign recommended hold

    sodium bicarbonate unless ph<7.15

    -two randonmized trials


Lactic acidosis4

Lactic acidosis

4. Treatment of lactic acidosis

  • CRRT

    Type A lactic acidosis:

    small observational studies showed efficient

    management of severe type A lactic acidosis=>

    CRRT vs sodium bicarbonate infusion


Lactic acidosis5

Lactic acidosis

4. Treatment of lactic acidosis

  • CRRT

    Drug-induced lactic acidosis: metformin

    - shock and overdose

    @ increase intestinal lactic acid production, impaired gluconeogensis, glycogenolysis, mitocondrial respiration and phophorylation=>mortality rate>30%

    @metformin is sliminated by kidney and highly water

    soluble


Lactic acidosis6

Lactic acidosis

4. Treatment of lactic acidosis

  • CRRT

    -Drug induced lactic acidosis

    Hemodialysis and CRRT=>

    Correct acidosis and remove metformin from plasma

    -NRTI-induced lactic acidosis

    -Summary:

    CRRT are useful in uncontrollable acidemia with

    multiple organ failure, and removal causative toxin


Anticoagulation

Anticoagulation

  • heparin:

    Heparin is the most commonly utilized anticoagulant

    @ risk of systemic bleeding and heparin-induced

    thrombocytopenia


Anticoagulation1

Anticoagulation

Citrate:

  • chelating ionized calcium=> anticoagulation

    @decrease risk of systemic bleeding

    @systemic calcium infusion

  • Citrate=>bicarbonate (carbonic anhydrase)

    @liver, skeletal muscle, kidney (high mitochondria)

  • Citrate toxicity=> in liver failure patient

    @ metabolic acidosis=> because bicarbonate loss

    and citrate can’t metabolize bicarbonate

    @ ca2+ decrease but total plasma calcium increase


Conclusion

Conclusion

  • Hypercapnic acidosis and lactic acidosis

  • Bicarbonate infusion vs addition bicarbonate

    during CRRT

    - Need further prospective controlled study


R2

  • Thanks for your attention ~~

  • Any question?


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