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RRT IN ICU

RRT IN ICU. DR. NISITH KUMAR MOHANTY. WHEN TO START RRT IN ICU?. CONTROVERSIAL EARLY/LATE RRT COMPLICATION- Bleeding,thrombosis, hypotension , Arrhythmias, infection. YEARS OF WRONG TEACHING. INDICATION OF RRT TEXT BOOK TEACHING- S/S OF UREMIC SYNDROME REFRACTORY HYPERVOLEMIA

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RRT IN ICU

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  1. RRT IN ICU DR. NISITH KUMAR MOHANTY

  2. WHEN TO START RRT IN ICU? • CONTROVERSIAL • EARLY/LATE • RRT COMPLICATION- • Bleeding,thrombosis,hypotension, • Arrhythmias, infection

  3. YEARS OF WRONG TEACHING • INDICATION OF RRT TEXT BOOK TEACHING- • S/S OF UREMIC SYNDROME • REFRACTORY HYPERVOLEMIA • HYPERKALAEMIA • ACIDOSIS • BUN>100

  4. WHY WE SHOULD START EARLY? • 50/M • DM,2ND POD CABG,3 INOTROPES,OLIGURIA -24/H,FEBRILE,TLC COUNT 14000/cmm/Hb 7gm/dl • BU-50mg/Scr/2mg • K-4.5meq/l Na-130meq/l • CXR-SIGN OF UPPER LOBE VESSEL PROMINENCE

  5. EARLY RRT- • TO PREVENT FLUID OVER RATHER THAN TREAT FLUID OVERLOAD • TO PREVENT OR MINIMIZE BIOCHEMICAL ABNORMALITY • NO RCT /BUT NOTHING AGAINST • EPIDEMIOLOGIC STUDIES • PHYSIOLOGIC REASONING

  6. INDIACTION RRT IN ICU • OLIGURIA<200ML/24H • ANURIA<50ML/12H • ACIDOSIS Ph<7.1 • Azotemia>BU>200mg • Hyperkalemia>6.5 • UREMIC ORGAN INVOLEMENT-pericarditis,encephalopathy,neuropathy, myopathy

  7. INDI- • SEVERE DYSNATREMIA->160/<115 • CLINICALLY SIGNIFICANT ORGAN OEDEMA-LUNG • LARGE FLUID REQUIREMENT • DRUG OVER DOSE

  8. WHEN TO STOP? • NO STUDY-SO VARIABLE • ALL CRITERIA FOR INITIATING RRT ABSENT • URINE OUT PUT 1ml/min/24h • No fluid imbalance • Developed complication of RRT

  9. WHICH FORM RRT? • IHD • CRRT • SLEDD

  10. CONCEPT • DIFUSSION • CONVECTION

  11. IHD • Availabity • Low cost of machine and consumable • Easy to operate • Two recent RCT comparing with CRRT • Uehlinger et al—n-125pt • Hemodiaf group—n-175 • Observational study-n-398- CRRT-206,IHD-192

  12. RCT • CONLUSION- • LACK OF DIFFERENCE IN OUTCOME • MORE PT FROM CRRT - >IHD BECAUSE OF COMPLICATION • LESS PRACTICAL PROBLEM EVEN IN UNSTABLE PT

  13. FREQUENCY • CHRONIC DIALYSIS STRATEGIES NOT SUITABLE FOR ARF • DAILY>3 WEEK

  14. 100 90 80 70 60 50 40 72 % 30 54 % 20 10 0 3/wk HD 7/wk HD wKT/V = 3.6 wKT/V = 7.4 Survival vs. Dialysis Dose In IntermittentHaemodialysis Adapted from Shiffl et al. N Engl J Med. 2002;346:305-10.

  15. CRRT • MOST PHYSIOLOGICAL • NEEDS COSTLY REPLACEMENT FLUID/ DISPOSABLE/EQUIPMENT • TYPES

  16. FIRST CRRT

  17. SLEDD • SLOW DAILY EXTENDED DIALYSIS/SUSTAINED LOW EFFICIENCY DIALYSIS • LOW DIALYSATE FLOW/LOW BLOOD FLOW

  18. ADVANTAGE • EFFICIENT CLEARANCE OF SMALL SOLUTE • GOOD HAEMODYNAMIC TOLERABILITY • FLEXIBLE TREATMENT • REDUCED COST

  19. CVVH IDH EFFECT TIME

  20. TAKE HOME MESSAGE • TREAT PT TIMELY AND AGGRESIVELY • TAILER THE RRT FOR THE PARTICULAR PT • DAILY DIALSIS IS BETTER THAN ¾ /WEEK DAILYSIS

  21. THANKS FOR KIND ATTENTION

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