Download 7 CRRT_ It`s Not Just For Renal Failure Anymore Sue Fallone

Objectives

Define Heart Failure

Define Sepsis

Discuss medical management of heart failure and sepsis

Describe indications for CRRT for these disorders

Case Study
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
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

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.

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

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
2. Sympathetic activity:
1. Hypertrophy &
Dilatation
• H.R.
• V.C
• E.D.V
Angiotensin
Aldosterone
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
45–50% and abnormal left ventricular relaxation assessed by
echocardiography
systolic failure is when the left ventricle loses it’s 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.
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 body’s
tissues
Will see edema, SOB, can affect kidney function
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.
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.
Classification of Heart Failure
Functional 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
2. Sympathetic activity:
•  H.R.
• V.C
1. Hypertrophy &
Dilatation
• E.D.V
Angiotensin
Aldosterone
If Resistant to Diuretics
MAY NEED
Ultrafiltration
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).
UNLOAD Study
Results

28% with greater fluid loss with UF

43% reduction in patients being re-hospitalization for HF

63% fewer hospital days for HF
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.
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.
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
Criteria for SIRS
Requires 2 of the following 4 features to be present:

Temp >38.3° or <36.0° C

Tachypnea (RR>20 or MV>10L)

Tachycardia (HR>90, in the absence of intrinsic heart disease)

WBC > 10,000/mm3 or <4,000/mm3 or
>10% band forms on differential
Criteria for Severe SIRS
Must meet criteria for SIRS, plus 1 of the following:

Altered mental status

SBP<90mmHg or fall of >40mmHg from baseline

Impaired gas exchange

Metabolic acidosis (pH<7.30 & lactate > 1.5 x upper
limit of normal)

Oliguria (<0.5mL/kg/hr) or renal failure

Hyperbilirubinemia

Coagulopathy (platelets < 80,000-100,000/mm3, INR
>2.0, PTT >1.5 x control, or elevated fibrin degredation
products)
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
Pathophysiology of Sepsis
continued

C/O decreases

Intravascular fluid loss

Decreased pre load-hypotension

ATN-renal hypoperfusion and ischemic injury

MODS

MOF
Relationship Between SIRS and Sepsis
Adapted from: Marini JJ, et al. Critical Care Medicine, 2nd ed. 1997.
Risk Factors for
SIRS/Sepsis

Age

Indwelling lines/catheters

Immunocompromised states

Malnutrition

Alcoholism

Malignancy

Diabetes

Cirrhosis

Male sex

Genetic predisposition?
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%.
Treatment

Fluid Resuscitation

Vasopressors

Antibiotics

Eradication of infection

Ventilatory support, activated protein C, steroids, glycemic
control, nutrition

CRRT
CONTINUOUS
RENAL
REPLACMENT
THERAPY
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
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
Three Compartment Model
Intracellular
Space
Extracellular
Space
Circulating
Blood Volume
Toxins
Fluid
23 L 17 L
40 Liters
Toxins
Fluid
5 Liters
Dialyzer
Intra2Vascular
Space
Toxins
Fluid
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
Indications
continued

Highly catabolic patients who need increased clearance rates

Patients needing large molecular weight substances
removed

Sepsis
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)
CRRT Modalities
SCUF OR ULTRAFILTRATION - Slow
Continuous UltraFiltration
CVVHD - Continuous Veno-Venous
HemoDialysis
CVVH - Continuous Veno-Venous
Hemofiltration
CVVHDF – Continuous Veno-Venous
Hemodiafiltration
SCUF/Ultrafiltration

Primary therapeutic goal:

Safe management of fluid removal

Patient UF rate ranges up to 2 L/Hr

No dialysate;No replacement fluids

No molecule removal

Large fluid removal via ultrafiltration

Blood Flow rates = 100-200 ml/min
Access
SCUF/ULTRAFILTRATION
Return
Slow
Continuous
UltraFiltration
Effluent
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.
45
Convection – Step 1 Filter Action
Na
Red Cell
Na
H2O
U
K
Red Cell
U
Red Cell
Na
K
U
K
K
U
H2O
K
Red Cell
U
Na
K
Na
H2O
U
H2O
H2O
U
H2O
Na
Red Cell
Na Na
Na
Na
Na
Na
U
H2 O
H2O
U
H2O
Na
H2 O
K
H2O
K
U
Na
K
U
Na
Na
H2O
H2O
Na
Na
Na
U
H2O
H2O
Na
K
K
Solute Removal by
Convection
Convection: The movement of solutes with a water-flow,
“solvent drag”, e.g... the movement of membrane-permeable
solutes with water across the semipermeable membrane
Access
Return
CVVH
Replacement
(pre or post dilution)
Continuous
Veno-Venous
Hemofiltration
Effluent
Molecular Transport Mechanisms

Convection - The movement of solutes with a
water-flow, “solvent drag”, the movement of membranepermeable solutes with water across the semipermeable
membrane
Convection – Step 1 Filter Action
Na
Red Cell
Na
H2O
U
K
Red Cell
U
Red Cell
Na
K
U
K
K
U
H2O
K
Red Cell
U
Na
K
Na
H2O
U
H2O
H2O
U
H2O
Na
Red Cell
Na Na
Na
Na
Na
Na
U
H2 O
H2O
U
H2O
Na
H2 O
K
H2O
K
U
Na
K
U
Na
Na
H2O
H2O
Na
Na
Na
U
H2O
H2O
Na
K
K
Solute Removal by
Convection
Convection: The movement of solutes with a water-flow,
“solvent drag”, e.g... the movement of membrane-permeable
solutes with water across the semipermeable membrane
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.
Diffusion – Filter Action
Na
Na
K
Mg
Mg
Na
H2O
Na
U
Na
U
Na
K
H2O
Mg
U
H2O
H2O
Na
K
H2 O
H2 O
Na
Na
H2 O
H2O
H2O
Na
K
H2O
Mg
U
K
U
H2O
H2O
U
Na
U
Na
Mg
U
U
Na
K
Na
U
U
K
Na
Na
U
K
Na
K
Na
Na
Na
K
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.
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
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.
ECG in the ambulance
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.
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
Cath Lab Course

After the Impella device was placed, the patient had no
further episodes of ventricular fibrillation
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
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
Case Study
#2

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
Case Study
Continued

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
Case Study
#3

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 > 60 mmHg and < 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 norepinephrine at 10 mcg/min. On the 3rd day of the 2nd therapy, the
patient had the following data:
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
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?
Conclusion

CRRT therapies can be applied to many clinical situations

The patient goals/outcomes can be enhanced with early
initiation of this therapy