RRT IN ICU DR. NISITH KUMAR MOHANTY

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

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

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

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

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

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

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

WHICH FORM RRT? IHD IHD CRRT CRRT SLEDD SLEDD

CONCEPT DIFUSSION DIFUSSION CONVECTION CONVECTION

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

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

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

Adapted from Shiffl et al. N Engl J Med. 2002;346: /wk HD wKT/V = 3.6 7/wk HD wKT/V = % 72 % Survival vs. Dialysis Dose In Intermittent Haemodialysis

CRRT MOST PHYSIOLOGICAL MOST PHYSIOLOGICAL NEEDS COSTLY REPLACEMENT FLUID/ DISPOSABLE/EQUIPMENT NEEDS COSTLY REPLACEMENT FLUID/ DISPOSABLE/EQUIPMENT TYPES TYPES

FIRST CRRT

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

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

TIME EFFECT CVVH IDH

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

THANKS FOR KIND ATTENTION