CRRT And AKI

Overview

Mostafa Abdel_Salam Mohamed MD

Consultant of Nephrology

bull Sudden interruption of kidney function resulting from obstruction reduced circulation or disease of the renal tissue

bull Results in retention of toxins fluids and end products of metabolism

bull Usually reversible with medical treatment

bull May progress to end stage renal disease uremic syndrome and death without treatment

definitions of AKI

RIFLE criteria for diagnosis of AKI based on The ldquoAcute Dialysis Quality Initiativerdquo

Increase in SCr Urine output

Risk of renal injury

Injury to the kidney

Failure of kidney function

03 mgdl increase

2 X baseline

3 X baseline OR

gt 05 mgdl increase if SCr gt=4 mgdl

lt 05 mlkghr for gt 6 h

lt 05 mlkghr for gt12h

Anuria for gt12 h

Loss of kidney function

End-stage disease

Persistent renal failure for gt 4 weeks

Persistent renal failure for gt 3 months

Am J Kidney Dis 2005 Dec46(6)1038-48

Stage Increase in Serum Creatinine

Urine Output

1 15-2 times baselineOR 03 mgdl increase from baseline

lt05 mlkgh for gt6 h

2 2-3 times baseline lt05 mlkgh for gt12 h

3 3 times baseline OR05 mgdl increase if baselinegt4mgdlORAny RRT given

lt03 mlkgh for gt24 hOR Anuria for gt12 h

Definition of Acute Kidney Injury (AKI) based on ldquoAcute Kidney Injury Networkrdquo

Epidemiology

AKI occurs in

bullasymp 7 of hospitalized patients

bull36ndash67 of critically ill patients(depending on the definition)

bull5-6 of intensive care unite (ICU)patients with AKI require renalreplacement therapy (RRP)

Mortality according to RIFLE

Mortality increases proportionately with increasing severity of AKI (using RIFLE)

Mortality in pts with AKI requiring RRT 50-70

Even small changes in serum creatinine are associated with increased mortality

CRITICALCARENURSE Vol 27 No 2 APRIL 2007

bull In 1977 Kramer in Goumlttingen (Germany)developed the continuousarteriovenous hemofiltration(CAVH) technique which used asystemic arteriovenous pressure difference inan extracorporeal circuit to continuouslyproduce an ultrafiltrate

bull In the 1980s a blood pump such as thoseused in intermittent hemodialysis and adouble-lumen catheter in a large vein wereused to provide a consistent

blood-flow rate without

the risks associated

with the arteriovenous approach

The Acute Disease Quality Initiative (ADQI)

Published online August 26 2016

When should acute RRT be initiated (includes AKI and non-AKI indications)

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

How should RRT be integrated into other extracorporeal therapies

When should transition of modalities be considered (CRRT IRRT hybrid therapy)

How should patients be liberated from RRT

When should acute RRT be initiated

Consensus statement 11

bullAcute RRT should be consideredwhen metabolic and fluiddemands exceed total kidneycapacity

Individual

Renal function

Clinical context

562 We suggest using CRRT rather thanstandard intermittent RRT for hemodynamicallyunstable patients (2B)

563 We suggest using CRRT rather thanintermittent RRT for AKI patients with acute braininjury or other causes of increased intracranialpressure or generalized brain edema (2B)

Indications for CRRT

bullCRRT is an effective method toremove fluid and to achieve a targetfluid balance in patients with fluidoverload including those withcongestive cardiac failure (CCF) oracute lung injury

RRT is also effective at removingbiologically active substancesincluding cytokines butthere is still insufficientevidence to recommend the routineuse of CRRT for the treatment ofsepsis

When should acute RRT be initiated

Consensus statement 12

bullDemand for kidney function isdetermined by non-renalcomorbidities the severity ofthe acute disease and solute andfluid burden

When should acute RRT be initiated

Consensus statement 13

bullTotal kidney function is measuredusing a variety of different methodsChanges in kidney function andduration of kidney dysfunction canbe anticipated by markers of kidneydamage

When should acute RRT be initiated

Consensus statement 14

bullThe demandndashcapacityimbalance is dynamicand should be evaluatedregularly

When should acute RRT be initiated

Consensus statement 15

bullFor patients requiring multipletypes of organ support decisionsabout initiating or withholdingRRT should be consideredtogether with other therapies

When should acute RRT be initiated

Consensus statement 16

bullOnce the decision to initiateRRT has been made thetherapy should be started assoon as possible typicallywithin less than 3 h

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 21

bull Selection of RRT modality depends on thecapabilityavailability of the technology

bull Different RRT modalities provide differentcapabilities

bull different machines may provide some butnot all modalities

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 22

bull CRRT recommended in situations whereshifts in fluid balance and metabolicfluctuations are poorly tolerated

bull Intermittent and prolonged intermittenttypes of RRT have a role when fluid andmetabolic fluctuations can be tolerated

Both CRRT and IHD achieve adequate

metabolic control and neither modality has

been shown to be superior in terms of

survival

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 23

bullAvailability of technologies isdetermined by local regulationslocal resources including stafftheir trainingexperience andlaboratory support and financialconstraints

bullSCUF (slow continuous ultrafiltration)

bullCVVH (continuous veno-venous haemofiltration

bullCVVHD (continuous veno-venous haemodialysis)

bullCVVHDF (continuous veno-venous haemodiafiltration

How should RRT be integrated into other extracorporeal therapies

bull Consensus statement 31

In situations where other extracorporealtherapies are required continuous RRT isrecommended and integrated systems arepreferred over parallel systems

extracorporeal liver assist devices (ELADs)

ECLS in Cardiac Failure

When should transition of modalities be considered (CRRT IRRT hybrid therapy)

Consensus statement 41

bullTransition of modalities should beconsidered if the demandndashcapacityimbalance or treatment prioritieshave changed and can be metbetter by an alternative technique

How should patients be liberated from RRT

RRT should bediscontinued ifkidney functionhas recovered

Consensus statement

51

How should patients be liberated from RRT

Consensus statement 52

bullTo determine sustainedrecovery of kidney functionwe recommend monitoring ofurine output and SCr duringRRT

How should patients be liberated from RRT

C onsensus statement 53

bullFor patients requiring multipletypes of organ supportdecisions about withdrawingRRT should be consideredtogether with other therapies

Before

Before CRRT is started patients should have

a complete nursing assessment

bull Fluid status

bull Fluid input

bull Blood pressure

bull Dosages of any vasopressors

bull Weightbull Presence of edemabull CVPbull NaK and ABGs

Nursing Management

During

Once CRRT is started

bull Blood pressure central venous pressure andweight monitoring

bull The bedside nurse should discuss the possibilityof reducing intake to minimal volumes of fluidsif at all possible and concentrating medicationsand infusions to minimize fluid intake if thetarget not acheived

bull Mechanical failures can occur if alarms are ignored or bypassed without determining the cause of the alarms

bull If scales are not properly calibrated the volumes of fluid administered and removed may not be the programmed volumes

541 We suggest initiating RRT in patients with AKI via an uncuffed non tunneled dialysis catheter rather than a tunneled catheter (2D)

542 When choosing a vein for insertion of a dialysis catheter in patients with AKI consider these preferences (Not Graded)

bull First choice right jugular vein

bull Second choice femoral vein

bull Third choice left jugular vein

bull Last choice subclavian vein with preference for the dominant side

Anticoagulation

CRRT can be performed with or without anticoagulation

The choice of anticoagulant depends on

bull The physicianrsquos preference

bull The patientrsquos condition

bull The familiarity of the nursing staff with anticoagulation regimens

The bedside nurse is responsiblefor monitoring any adverse effectsof anticoagulation includinghemorrhage formation ofhematomas thrombocytopeniaand allergic reactions

Heparin

bull The least expensive anticoagulant

bull Either systemically or regionally

When heparin is used

bull The hemofilter may be flushed with a dilute heparin solution continuously or intermittently

Systemic heparinization includes

bull Infusing heparin into a separate intravenous access or into the arterial side of the CRRT circuit

bull Mixing of the heparin with the blood from the patient before the blood reaches the filter

bull Anticoagulation of the circuit as well as for the patient

Argatroban and lepirudin

bullDirect thrombin inhibitors

bullHIT

Lepirudin is cleared by the kidneys and therefore may not be the drug of choice

for patients in ARF

Argatroban is eliminated by the liver and is therefore more suitable for use in

patients with renal failure

Citrate

excellent anticoagulant ability and potential to prolong circuit life

bull Calcium is an essential component of the clotting cascade

bull Citrate binds to the calcium in the patientrsquos blood within the CRRT system and prevents clotting

Citrate is infused prefilter into the CRRT system and calcium is typically infused via another intravenous line outside the circuit

Ionized calcium levels are routinely monitored

1048708Heparin

bull 250500 Uhr

1048708HIT Argatroban

bull 1048708051 mghr

1048708Bleeding risk

bull 1048708Citrate

bull 1048708No anticoagulation

Dialysate

Conculsions

Critically ill patients AKI occurs in up to 30 of all ICU admissions

CRRT is almost exclusively applied to patients in (ICU)

Restrict monitoring and follow up of the patients during CRRT is mandatory

Well trained nurse is the corner stone of adequate CRRT

bull Sudden interruption of kidney function resulting from obstruction reduced circulation or disease of the renal tissue

bull Results in retention of toxins fluids and end products of metabolism

bull Usually reversible with medical treatment

bull May progress to end stage renal disease uremic syndrome and death without treatment

definitions of AKI

RIFLE criteria for diagnosis of AKI based on The ldquoAcute Dialysis Quality Initiativerdquo

Increase in SCr Urine output

Risk of renal injury

Injury to the kidney

Failure of kidney function

03 mgdl increase

2 X baseline

3 X baseline OR

gt 05 mgdl increase if SCr gt=4 mgdl

lt 05 mlkghr for gt 6 h

lt 05 mlkghr for gt12h

Anuria for gt12 h

Loss of kidney function

End-stage disease

Persistent renal failure for gt 4 weeks

Persistent renal failure for gt 3 months

Am J Kidney Dis 2005 Dec46(6)1038-48

Stage Increase in Serum Creatinine

Urine Output

1 15-2 times baselineOR 03 mgdl increase from baseline

lt05 mlkgh for gt6 h

2 2-3 times baseline lt05 mlkgh for gt12 h

3 3 times baseline OR05 mgdl increase if baselinegt4mgdlORAny RRT given

lt03 mlkgh for gt24 hOR Anuria for gt12 h

Definition of Acute Kidney Injury (AKI) based on ldquoAcute Kidney Injury Networkrdquo

Epidemiology

AKI occurs in

bullasymp 7 of hospitalized patients

bull36ndash67 of critically ill patients(depending on the definition)

bull5-6 of intensive care unite (ICU)patients with AKI require renalreplacement therapy (RRP)

Mortality according to RIFLE

Mortality increases proportionately with increasing severity of AKI (using RIFLE)

Mortality in pts with AKI requiring RRT 50-70

Even small changes in serum creatinine are associated with increased mortality

CRITICALCARENURSE Vol 27 No 2 APRIL 2007

bull In 1977 Kramer in Goumlttingen (Germany)developed the continuousarteriovenous hemofiltration(CAVH) technique which used asystemic arteriovenous pressure difference inan extracorporeal circuit to continuouslyproduce an ultrafiltrate

bull In the 1980s a blood pump such as thoseused in intermittent hemodialysis and adouble-lumen catheter in a large vein wereused to provide a consistent

blood-flow rate without

the risks associated

with the arteriovenous approach

The Acute Disease Quality Initiative (ADQI)

Published online August 26 2016

When should acute RRT be initiated (includes AKI and non-AKI indications)

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

How should RRT be integrated into other extracorporeal therapies

When should transition of modalities be considered (CRRT IRRT hybrid therapy)

How should patients be liberated from RRT

When should acute RRT be initiated

Consensus statement 11

bullAcute RRT should be consideredwhen metabolic and fluiddemands exceed total kidneycapacity

Individual

Renal function

Clinical context

562 We suggest using CRRT rather thanstandard intermittent RRT for hemodynamicallyunstable patients (2B)

563 We suggest using CRRT rather thanintermittent RRT for AKI patients with acute braininjury or other causes of increased intracranialpressure or generalized brain edema (2B)

Indications for CRRT

bullCRRT is an effective method toremove fluid and to achieve a targetfluid balance in patients with fluidoverload including those withcongestive cardiac failure (CCF) oracute lung injury

RRT is also effective at removingbiologically active substancesincluding cytokines butthere is still insufficientevidence to recommend the routineuse of CRRT for the treatment ofsepsis

When should acute RRT be initiated

Consensus statement 12

bullDemand for kidney function isdetermined by non-renalcomorbidities the severity ofthe acute disease and solute andfluid burden

When should acute RRT be initiated

Consensus statement 13

bullTotal kidney function is measuredusing a variety of different methodsChanges in kidney function andduration of kidney dysfunction canbe anticipated by markers of kidneydamage

When should acute RRT be initiated

Consensus statement 14

bullThe demandndashcapacityimbalance is dynamicand should be evaluatedregularly

When should acute RRT be initiated

Consensus statement 15

bullFor patients requiring multipletypes of organ support decisionsabout initiating or withholdingRRT should be consideredtogether with other therapies

When should acute RRT be initiated

Consensus statement 16

bullOnce the decision to initiateRRT has been made thetherapy should be started assoon as possible typicallywithin less than 3 h

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 21

bull Selection of RRT modality depends on thecapabilityavailability of the technology

bull Different RRT modalities provide differentcapabilities

bull different machines may provide some butnot all modalities

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 22

bull CRRT recommended in situations whereshifts in fluid balance and metabolicfluctuations are poorly tolerated

bull Intermittent and prolonged intermittenttypes of RRT have a role when fluid andmetabolic fluctuations can be tolerated

Both CRRT and IHD achieve adequate

metabolic control and neither modality has

been shown to be superior in terms of

survival

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 23

bullAvailability of technologies isdetermined by local regulationslocal resources including stafftheir trainingexperience andlaboratory support and financialconstraints

bullSCUF (slow continuous ultrafiltration)

bullCVVH (continuous veno-venous haemofiltration

bullCVVHD (continuous veno-venous haemodialysis)

bullCVVHDF (continuous veno-venous haemodiafiltration

How should RRT be integrated into other extracorporeal therapies

bull Consensus statement 31

In situations where other extracorporealtherapies are required continuous RRT isrecommended and integrated systems arepreferred over parallel systems

extracorporeal liver assist devices (ELADs)

ECLS in Cardiac Failure

When should transition of modalities be considered (CRRT IRRT hybrid therapy)

Consensus statement 41

bullTransition of modalities should beconsidered if the demandndashcapacityimbalance or treatment prioritieshave changed and can be metbetter by an alternative technique

How should patients be liberated from RRT

RRT should bediscontinued ifkidney functionhas recovered

Consensus statement

51

How should patients be liberated from RRT

Consensus statement 52

bullTo determine sustainedrecovery of kidney functionwe recommend monitoring ofurine output and SCr duringRRT

How should patients be liberated from RRT

C onsensus statement 53

bullFor patients requiring multipletypes of organ supportdecisions about withdrawingRRT should be consideredtogether with other therapies

Before

Before CRRT is started patients should have

a complete nursing assessment

bull Fluid status

bull Fluid input

bull Blood pressure

bull Dosages of any vasopressors

bull Weightbull Presence of edemabull CVPbull NaK and ABGs

Nursing Management

During

Once CRRT is started

bull Blood pressure central venous pressure andweight monitoring

bull The bedside nurse should discuss the possibilityof reducing intake to minimal volumes of fluidsif at all possible and concentrating medicationsand infusions to minimize fluid intake if thetarget not acheived

bull Mechanical failures can occur if alarms are ignored or bypassed without determining the cause of the alarms

bull If scales are not properly calibrated the volumes of fluid administered and removed may not be the programmed volumes

541 We suggest initiating RRT in patients with AKI via an uncuffed non tunneled dialysis catheter rather than a tunneled catheter (2D)

542 When choosing a vein for insertion of a dialysis catheter in patients with AKI consider these preferences (Not Graded)

bull First choice right jugular vein

bull Second choice femoral vein

bull Third choice left jugular vein

bull Last choice subclavian vein with preference for the dominant side

Anticoagulation

CRRT can be performed with or without anticoagulation

The choice of anticoagulant depends on

bull The physicianrsquos preference

bull The patientrsquos condition

bull The familiarity of the nursing staff with anticoagulation regimens

The bedside nurse is responsiblefor monitoring any adverse effectsof anticoagulation includinghemorrhage formation ofhematomas thrombocytopeniaand allergic reactions

Heparin

bull The least expensive anticoagulant

bull Either systemically or regionally

When heparin is used

bull The hemofilter may be flushed with a dilute heparin solution continuously or intermittently

Systemic heparinization includes

bull Infusing heparin into a separate intravenous access or into the arterial side of the CRRT circuit

bull Mixing of the heparin with the blood from the patient before the blood reaches the filter

bull Anticoagulation of the circuit as well as for the patient

Argatroban and lepirudin

bullDirect thrombin inhibitors

bullHIT

Lepirudin is cleared by the kidneys and therefore may not be the drug of choice

for patients in ARF

Argatroban is eliminated by the liver and is therefore more suitable for use in

patients with renal failure

Citrate

excellent anticoagulant ability and potential to prolong circuit life

bull Calcium is an essential component of the clotting cascade

bull Citrate binds to the calcium in the patientrsquos blood within the CRRT system and prevents clotting

Citrate is infused prefilter into the CRRT system and calcium is typically infused via another intravenous line outside the circuit

Ionized calcium levels are routinely monitored

1048708Heparin

bull 250500 Uhr

1048708HIT Argatroban

bull 1048708051 mghr

1048708Bleeding risk

bull 1048708Citrate

bull 1048708No anticoagulation

Dialysate

Conculsions

Critically ill patients AKI occurs in up to 30 of all ICU admissions

CRRT is almost exclusively applied to patients in (ICU)

Restrict monitoring and follow up of the patients during CRRT is mandatory

Well trained nurse is the corner stone of adequate CRRT

RIFLE criteria for diagnosis of AKI based on The ldquoAcute Dialysis Quality Initiativerdquo

Increase in SCr Urine output

Risk of renal injury

Injury to the kidney

Failure of kidney function

03 mgdl increase

2 X baseline

3 X baseline OR

gt 05 mgdl increase if SCr gt=4 mgdl

lt 05 mlkghr for gt 6 h

lt 05 mlkghr for gt12h

Anuria for gt12 h

Loss of kidney function

End-stage disease

Persistent renal failure for gt 4 weeks

Persistent renal failure for gt 3 months

Am J Kidney Dis 2005 Dec46(6)1038-48

Stage Increase in Serum Creatinine

Urine Output

1 15-2 times baselineOR 03 mgdl increase from baseline

lt05 mlkgh for gt6 h

2 2-3 times baseline lt05 mlkgh for gt12 h

3 3 times baseline OR05 mgdl increase if baselinegt4mgdlORAny RRT given

lt03 mlkgh for gt24 hOR Anuria for gt12 h

Definition of Acute Kidney Injury (AKI) based on ldquoAcute Kidney Injury Networkrdquo

Epidemiology

AKI occurs in

bullasymp 7 of hospitalized patients

bull36ndash67 of critically ill patients(depending on the definition)

bull5-6 of intensive care unite (ICU)patients with AKI require renalreplacement therapy (RRP)

Mortality according to RIFLE

Mortality increases proportionately with increasing severity of AKI (using RIFLE)

Mortality in pts with AKI requiring RRT 50-70

Even small changes in serum creatinine are associated with increased mortality

CRITICALCARENURSE Vol 27 No 2 APRIL 2007

bull In 1977 Kramer in Goumlttingen (Germany)developed the continuousarteriovenous hemofiltration(CAVH) technique which used asystemic arteriovenous pressure difference inan extracorporeal circuit to continuouslyproduce an ultrafiltrate

bull In the 1980s a blood pump such as thoseused in intermittent hemodialysis and adouble-lumen catheter in a large vein wereused to provide a consistent

blood-flow rate without

the risks associated

with the arteriovenous approach

The Acute Disease Quality Initiative (ADQI)

Published online August 26 2016

When should acute RRT be initiated (includes AKI and non-AKI indications)

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

How should RRT be integrated into other extracorporeal therapies

When should transition of modalities be considered (CRRT IRRT hybrid therapy)

How should patients be liberated from RRT

When should acute RRT be initiated

Consensus statement 11

bullAcute RRT should be consideredwhen metabolic and fluiddemands exceed total kidneycapacity

Individual

Renal function

Clinical context

562 We suggest using CRRT rather thanstandard intermittent RRT for hemodynamicallyunstable patients (2B)

563 We suggest using CRRT rather thanintermittent RRT for AKI patients with acute braininjury or other causes of increased intracranialpressure or generalized brain edema (2B)

Indications for CRRT

bullCRRT is an effective method toremove fluid and to achieve a targetfluid balance in patients with fluidoverload including those withcongestive cardiac failure (CCF) oracute lung injury

RRT is also effective at removingbiologically active substancesincluding cytokines butthere is still insufficientevidence to recommend the routineuse of CRRT for the treatment ofsepsis

When should acute RRT be initiated

Consensus statement 12

bullDemand for kidney function isdetermined by non-renalcomorbidities the severity ofthe acute disease and solute andfluid burden

When should acute RRT be initiated

Consensus statement 13

bullTotal kidney function is measuredusing a variety of different methodsChanges in kidney function andduration of kidney dysfunction canbe anticipated by markers of kidneydamage

When should acute RRT be initiated

Consensus statement 14

bullThe demandndashcapacityimbalance is dynamicand should be evaluatedregularly

When should acute RRT be initiated

Consensus statement 15

bullFor patients requiring multipletypes of organ support decisionsabout initiating or withholdingRRT should be consideredtogether with other therapies

When should acute RRT be initiated

Consensus statement 16

bullOnce the decision to initiateRRT has been made thetherapy should be started assoon as possible typicallywithin less than 3 h

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 21

bull Selection of RRT modality depends on thecapabilityavailability of the technology

bull Different RRT modalities provide differentcapabilities

bull different machines may provide some butnot all modalities

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 22

bull CRRT recommended in situations whereshifts in fluid balance and metabolicfluctuations are poorly tolerated

bull Intermittent and prolonged intermittenttypes of RRT have a role when fluid andmetabolic fluctuations can be tolerated

Both CRRT and IHD achieve adequate

metabolic control and neither modality has

been shown to be superior in terms of

survival

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 23

bullAvailability of technologies isdetermined by local regulationslocal resources including stafftheir trainingexperience andlaboratory support and financialconstraints

bullSCUF (slow continuous ultrafiltration)

bullCVVH (continuous veno-venous haemofiltration

bullCVVHD (continuous veno-venous haemodialysis)

bullCVVHDF (continuous veno-venous haemodiafiltration

How should RRT be integrated into other extracorporeal therapies

bull Consensus statement 31

In situations where other extracorporealtherapies are required continuous RRT isrecommended and integrated systems arepreferred over parallel systems

extracorporeal liver assist devices (ELADs)

ECLS in Cardiac Failure

When should transition of modalities be considered (CRRT IRRT hybrid therapy)

Consensus statement 41

bullTransition of modalities should beconsidered if the demandndashcapacityimbalance or treatment prioritieshave changed and can be metbetter by an alternative technique

How should patients be liberated from RRT

RRT should bediscontinued ifkidney functionhas recovered

Consensus statement

51

How should patients be liberated from RRT

Consensus statement 52

bullTo determine sustainedrecovery of kidney functionwe recommend monitoring ofurine output and SCr duringRRT

How should patients be liberated from RRT

C onsensus statement 53

bullFor patients requiring multipletypes of organ supportdecisions about withdrawingRRT should be consideredtogether with other therapies

Before

Before CRRT is started patients should have

a complete nursing assessment

bull Fluid status

bull Fluid input

bull Blood pressure

bull Dosages of any vasopressors

bull Weightbull Presence of edemabull CVPbull NaK and ABGs

Nursing Management

During

Once CRRT is started

bull Blood pressure central venous pressure andweight monitoring

bull The bedside nurse should discuss the possibilityof reducing intake to minimal volumes of fluidsif at all possible and concentrating medicationsand infusions to minimize fluid intake if thetarget not acheived

bull Mechanical failures can occur if alarms are ignored or bypassed without determining the cause of the alarms

bull If scales are not properly calibrated the volumes of fluid administered and removed may not be the programmed volumes

541 We suggest initiating RRT in patients with AKI via an uncuffed non tunneled dialysis catheter rather than a tunneled catheter (2D)

542 When choosing a vein for insertion of a dialysis catheter in patients with AKI consider these preferences (Not Graded)

bull First choice right jugular vein

bull Second choice femoral vein

bull Third choice left jugular vein

bull Last choice subclavian vein with preference for the dominant side

Anticoagulation

CRRT can be performed with or without anticoagulation

The choice of anticoagulant depends on

bull The physicianrsquos preference

bull The patientrsquos condition

bull The familiarity of the nursing staff with anticoagulation regimens

The bedside nurse is responsiblefor monitoring any adverse effectsof anticoagulation includinghemorrhage formation ofhematomas thrombocytopeniaand allergic reactions

Heparin

bull The least expensive anticoagulant

bull Either systemically or regionally

When heparin is used

bull The hemofilter may be flushed with a dilute heparin solution continuously or intermittently

Systemic heparinization includes

bull Infusing heparin into a separate intravenous access or into the arterial side of the CRRT circuit

bull Mixing of the heparin with the blood from the patient before the blood reaches the filter

bull Anticoagulation of the circuit as well as for the patient

Argatroban and lepirudin

bullDirect thrombin inhibitors

bullHIT

Lepirudin is cleared by the kidneys and therefore may not be the drug of choice

for patients in ARF

Argatroban is eliminated by the liver and is therefore more suitable for use in

patients with renal failure

Citrate

excellent anticoagulant ability and potential to prolong circuit life

bull Calcium is an essential component of the clotting cascade

bull Citrate binds to the calcium in the patientrsquos blood within the CRRT system and prevents clotting

Citrate is infused prefilter into the CRRT system and calcium is typically infused via another intravenous line outside the circuit

Ionized calcium levels are routinely monitored

1048708Heparin

bull 250500 Uhr

1048708HIT Argatroban

bull 1048708051 mghr

1048708Bleeding risk

bull 1048708Citrate

bull 1048708No anticoagulation

Dialysate

Conculsions

Critically ill patients AKI occurs in up to 30 of all ICU admissions

CRRT is almost exclusively applied to patients in (ICU)

Restrict monitoring and follow up of the patients during CRRT is mandatory

Well trained nurse is the corner stone of adequate CRRT

Stage Increase in Serum Creatinine

Urine Output

1 15-2 times baselineOR 03 mgdl increase from baseline

lt05 mlkgh for gt6 h

2 2-3 times baseline lt05 mlkgh for gt12 h

3 3 times baseline OR05 mgdl increase if baselinegt4mgdlORAny RRT given

lt03 mlkgh for gt24 hOR Anuria for gt12 h

Definition of Acute Kidney Injury (AKI) based on ldquoAcute Kidney Injury Networkrdquo

Epidemiology

AKI occurs in

bullasymp 7 of hospitalized patients

bull36ndash67 of critically ill patients(depending on the definition)

bull5-6 of intensive care unite (ICU)patients with AKI require renalreplacement therapy (RRP)

Mortality according to RIFLE

Mortality increases proportionately with increasing severity of AKI (using RIFLE)

Mortality in pts with AKI requiring RRT 50-70

Even small changes in serum creatinine are associated with increased mortality

CRITICALCARENURSE Vol 27 No 2 APRIL 2007

bull In 1977 Kramer in Goumlttingen (Germany)developed the continuousarteriovenous hemofiltration(CAVH) technique which used asystemic arteriovenous pressure difference inan extracorporeal circuit to continuouslyproduce an ultrafiltrate

bull In the 1980s a blood pump such as thoseused in intermittent hemodialysis and adouble-lumen catheter in a large vein wereused to provide a consistent

blood-flow rate without

the risks associated

with the arteriovenous approach

The Acute Disease Quality Initiative (ADQI)

Published online August 26 2016

When should acute RRT be initiated (includes AKI and non-AKI indications)

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

How should RRT be integrated into other extracorporeal therapies

When should transition of modalities be considered (CRRT IRRT hybrid therapy)

How should patients be liberated from RRT

When should acute RRT be initiated

Consensus statement 11

bullAcute RRT should be consideredwhen metabolic and fluiddemands exceed total kidneycapacity

Individual

Renal function

Clinical context

562 We suggest using CRRT rather thanstandard intermittent RRT for hemodynamicallyunstable patients (2B)

563 We suggest using CRRT rather thanintermittent RRT for AKI patients with acute braininjury or other causes of increased intracranialpressure or generalized brain edema (2B)

Indications for CRRT

bullCRRT is an effective method toremove fluid and to achieve a targetfluid balance in patients with fluidoverload including those withcongestive cardiac failure (CCF) oracute lung injury

RRT is also effective at removingbiologically active substancesincluding cytokines butthere is still insufficientevidence to recommend the routineuse of CRRT for the treatment ofsepsis

When should acute RRT be initiated

Consensus statement 12

bullDemand for kidney function isdetermined by non-renalcomorbidities the severity ofthe acute disease and solute andfluid burden

When should acute RRT be initiated

Consensus statement 13

bullTotal kidney function is measuredusing a variety of different methodsChanges in kidney function andduration of kidney dysfunction canbe anticipated by markers of kidneydamage

When should acute RRT be initiated

Consensus statement 14

bullThe demandndashcapacityimbalance is dynamicand should be evaluatedregularly

When should acute RRT be initiated

Consensus statement 15

bullFor patients requiring multipletypes of organ support decisionsabout initiating or withholdingRRT should be consideredtogether with other therapies

When should acute RRT be initiated

Consensus statement 16

bullOnce the decision to initiateRRT has been made thetherapy should be started assoon as possible typicallywithin less than 3 h

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 21

bull Selection of RRT modality depends on thecapabilityavailability of the technology

bull Different RRT modalities provide differentcapabilities

bull different machines may provide some butnot all modalities

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 22

bull CRRT recommended in situations whereshifts in fluid balance and metabolicfluctuations are poorly tolerated

bull Intermittent and prolonged intermittenttypes of RRT have a role when fluid andmetabolic fluctuations can be tolerated

Both CRRT and IHD achieve adequate

metabolic control and neither modality has

been shown to be superior in terms of

survival

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 23

bullAvailability of technologies isdetermined by local regulationslocal resources including stafftheir trainingexperience andlaboratory support and financialconstraints

bullSCUF (slow continuous ultrafiltration)

bullCVVH (continuous veno-venous haemofiltration

bullCVVHD (continuous veno-venous haemodialysis)

bullCVVHDF (continuous veno-venous haemodiafiltration

How should RRT be integrated into other extracorporeal therapies

bull Consensus statement 31

In situations where other extracorporealtherapies are required continuous RRT isrecommended and integrated systems arepreferred over parallel systems

extracorporeal liver assist devices (ELADs)

ECLS in Cardiac Failure

When should transition of modalities be considered (CRRT IRRT hybrid therapy)

Consensus statement 41

bullTransition of modalities should beconsidered if the demandndashcapacityimbalance or treatment prioritieshave changed and can be metbetter by an alternative technique

How should patients be liberated from RRT

RRT should bediscontinued ifkidney functionhas recovered

Consensus statement

51

How should patients be liberated from RRT

Consensus statement 52

bullTo determine sustainedrecovery of kidney functionwe recommend monitoring ofurine output and SCr duringRRT

How should patients be liberated from RRT

C onsensus statement 53

bullFor patients requiring multipletypes of organ supportdecisions about withdrawingRRT should be consideredtogether with other therapies

Before

Before CRRT is started patients should have

a complete nursing assessment

bull Fluid status

bull Fluid input

bull Blood pressure

bull Dosages of any vasopressors

bull Weightbull Presence of edemabull CVPbull NaK and ABGs

Nursing Management

During

Once CRRT is started

bull Blood pressure central venous pressure andweight monitoring

bull The bedside nurse should discuss the possibilityof reducing intake to minimal volumes of fluidsif at all possible and concentrating medicationsand infusions to minimize fluid intake if thetarget not acheived

bull Mechanical failures can occur if alarms are ignored or bypassed without determining the cause of the alarms

bull If scales are not properly calibrated the volumes of fluid administered and removed may not be the programmed volumes

541 We suggest initiating RRT in patients with AKI via an uncuffed non tunneled dialysis catheter rather than a tunneled catheter (2D)

542 When choosing a vein for insertion of a dialysis catheter in patients with AKI consider these preferences (Not Graded)

bull First choice right jugular vein

bull Second choice femoral vein

bull Third choice left jugular vein

bull Last choice subclavian vein with preference for the dominant side

Anticoagulation

CRRT can be performed with or without anticoagulation

The choice of anticoagulant depends on

bull The physicianrsquos preference

bull The patientrsquos condition

bull The familiarity of the nursing staff with anticoagulation regimens

The bedside nurse is responsiblefor monitoring any adverse effectsof anticoagulation includinghemorrhage formation ofhematomas thrombocytopeniaand allergic reactions

Heparin

bull The least expensive anticoagulant

bull Either systemically or regionally

When heparin is used

bull The hemofilter may be flushed with a dilute heparin solution continuously or intermittently

Systemic heparinization includes

bull Infusing heparin into a separate intravenous access or into the arterial side of the CRRT circuit

bull Mixing of the heparin with the blood from the patient before the blood reaches the filter

bull Anticoagulation of the circuit as well as for the patient

Argatroban and lepirudin

bullDirect thrombin inhibitors

bullHIT

Lepirudin is cleared by the kidneys and therefore may not be the drug of choice

for patients in ARF

Argatroban is eliminated by the liver and is therefore more suitable for use in

patients with renal failure

Citrate

excellent anticoagulant ability and potential to prolong circuit life

bull Calcium is an essential component of the clotting cascade

bull Citrate binds to the calcium in the patientrsquos blood within the CRRT system and prevents clotting

Citrate is infused prefilter into the CRRT system and calcium is typically infused via another intravenous line outside the circuit

Ionized calcium levels are routinely monitored

1048708Heparin

bull 250500 Uhr

1048708HIT Argatroban

bull 1048708051 mghr

1048708Bleeding risk

bull 1048708Citrate

bull 1048708No anticoagulation

Dialysate

Conculsions

Critically ill patients AKI occurs in up to 30 of all ICU admissions

CRRT is almost exclusively applied to patients in (ICU)

Restrict monitoring and follow up of the patients during CRRT is mandatory

Well trained nurse is the corner stone of adequate CRRT

Epidemiology

AKI occurs in

bullasymp 7 of hospitalized patients

bull36ndash67 of critically ill patients(depending on the definition)

bull5-6 of intensive care unite (ICU)patients with AKI require renalreplacement therapy (RRP)

Mortality according to RIFLE

Mortality increases proportionately with increasing severity of AKI (using RIFLE)

Mortality in pts with AKI requiring RRT 50-70

Even small changes in serum creatinine are associated with increased mortality

CRITICALCARENURSE Vol 27 No 2 APRIL 2007

bull In 1977 Kramer in Goumlttingen (Germany)developed the continuousarteriovenous hemofiltration(CAVH) technique which used asystemic arteriovenous pressure difference inan extracorporeal circuit to continuouslyproduce an ultrafiltrate

bull In the 1980s a blood pump such as thoseused in intermittent hemodialysis and adouble-lumen catheter in a large vein wereused to provide a consistent

blood-flow rate without

the risks associated

with the arteriovenous approach

The Acute Disease Quality Initiative (ADQI)

Published online August 26 2016

When should acute RRT be initiated (includes AKI and non-AKI indications)

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

How should RRT be integrated into other extracorporeal therapies

When should transition of modalities be considered (CRRT IRRT hybrid therapy)

How should patients be liberated from RRT

When should acute RRT be initiated

Consensus statement 11

bullAcute RRT should be consideredwhen metabolic and fluiddemands exceed total kidneycapacity

Individual

Renal function

Clinical context

562 We suggest using CRRT rather thanstandard intermittent RRT for hemodynamicallyunstable patients (2B)

563 We suggest using CRRT rather thanintermittent RRT for AKI patients with acute braininjury or other causes of increased intracranialpressure or generalized brain edema (2B)

Indications for CRRT

bullCRRT is an effective method toremove fluid and to achieve a targetfluid balance in patients with fluidoverload including those withcongestive cardiac failure (CCF) oracute lung injury

RRT is also effective at removingbiologically active substancesincluding cytokines butthere is still insufficientevidence to recommend the routineuse of CRRT for the treatment ofsepsis

When should acute RRT be initiated

Consensus statement 12

bullDemand for kidney function isdetermined by non-renalcomorbidities the severity ofthe acute disease and solute andfluid burden

When should acute RRT be initiated

Consensus statement 13

bullTotal kidney function is measuredusing a variety of different methodsChanges in kidney function andduration of kidney dysfunction canbe anticipated by markers of kidneydamage

When should acute RRT be initiated

Consensus statement 14

bullThe demandndashcapacityimbalance is dynamicand should be evaluatedregularly

When should acute RRT be initiated

Consensus statement 15

bullFor patients requiring multipletypes of organ support decisionsabout initiating or withholdingRRT should be consideredtogether with other therapies

When should acute RRT be initiated

Consensus statement 16

bullOnce the decision to initiateRRT has been made thetherapy should be started assoon as possible typicallywithin less than 3 h

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 21

bull Selection of RRT modality depends on thecapabilityavailability of the technology

bull Different RRT modalities provide differentcapabilities

bull different machines may provide some butnot all modalities

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 22

bull CRRT recommended in situations whereshifts in fluid balance and metabolicfluctuations are poorly tolerated

bull Intermittent and prolonged intermittenttypes of RRT have a role when fluid andmetabolic fluctuations can be tolerated

Both CRRT and IHD achieve adequate

metabolic control and neither modality has

been shown to be superior in terms of

survival

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 23

bullAvailability of technologies isdetermined by local regulationslocal resources including stafftheir trainingexperience andlaboratory support and financialconstraints

bullSCUF (slow continuous ultrafiltration)

bullCVVH (continuous veno-venous haemofiltration

bullCVVHD (continuous veno-venous haemodialysis)

bullCVVHDF (continuous veno-venous haemodiafiltration

How should RRT be integrated into other extracorporeal therapies

bull Consensus statement 31

In situations where other extracorporealtherapies are required continuous RRT isrecommended and integrated systems arepreferred over parallel systems

extracorporeal liver assist devices (ELADs)

ECLS in Cardiac Failure

When should transition of modalities be considered (CRRT IRRT hybrid therapy)

Consensus statement 41

bullTransition of modalities should beconsidered if the demandndashcapacityimbalance or treatment prioritieshave changed and can be metbetter by an alternative technique

How should patients be liberated from RRT

RRT should bediscontinued ifkidney functionhas recovered

Consensus statement

51

How should patients be liberated from RRT

Consensus statement 52

bullTo determine sustainedrecovery of kidney functionwe recommend monitoring ofurine output and SCr duringRRT

How should patients be liberated from RRT

C onsensus statement 53

bullFor patients requiring multipletypes of organ supportdecisions about withdrawingRRT should be consideredtogether with other therapies

Before

Before CRRT is started patients should have

a complete nursing assessment

bull Fluid status

bull Fluid input

bull Blood pressure

bull Dosages of any vasopressors

bull Weightbull Presence of edemabull CVPbull NaK and ABGs

Nursing Management

During

Once CRRT is started

bull Blood pressure central venous pressure andweight monitoring

bull The bedside nurse should discuss the possibilityof reducing intake to minimal volumes of fluidsif at all possible and concentrating medicationsand infusions to minimize fluid intake if thetarget not acheived

bull Mechanical failures can occur if alarms are ignored or bypassed without determining the cause of the alarms

bull If scales are not properly calibrated the volumes of fluid administered and removed may not be the programmed volumes

541 We suggest initiating RRT in patients with AKI via an uncuffed non tunneled dialysis catheter rather than a tunneled catheter (2D)

542 When choosing a vein for insertion of a dialysis catheter in patients with AKI consider these preferences (Not Graded)

bull First choice right jugular vein

bull Second choice femoral vein

bull Third choice left jugular vein

bull Last choice subclavian vein with preference for the dominant side

Anticoagulation

CRRT can be performed with or without anticoagulation

The choice of anticoagulant depends on

bull The physicianrsquos preference

bull The patientrsquos condition

bull The familiarity of the nursing staff with anticoagulation regimens

The bedside nurse is responsiblefor monitoring any adverse effectsof anticoagulation includinghemorrhage formation ofhematomas thrombocytopeniaand allergic reactions

Heparin

bull The least expensive anticoagulant

bull Either systemically or regionally

When heparin is used

bull The hemofilter may be flushed with a dilute heparin solution continuously or intermittently

Systemic heparinization includes

bull Infusing heparin into a separate intravenous access or into the arterial side of the CRRT circuit

bull Mixing of the heparin with the blood from the patient before the blood reaches the filter

bull Anticoagulation of the circuit as well as for the patient

Argatroban and lepirudin

bullDirect thrombin inhibitors

bullHIT

Lepirudin is cleared by the kidneys and therefore may not be the drug of choice

for patients in ARF

Argatroban is eliminated by the liver and is therefore more suitable for use in

patients with renal failure

Citrate

excellent anticoagulant ability and potential to prolong circuit life

bull Calcium is an essential component of the clotting cascade

bull Citrate binds to the calcium in the patientrsquos blood within the CRRT system and prevents clotting

Citrate is infused prefilter into the CRRT system and calcium is typically infused via another intravenous line outside the circuit

Ionized calcium levels are routinely monitored

1048708Heparin

bull 250500 Uhr

1048708HIT Argatroban

bull 1048708051 mghr

1048708Bleeding risk

bull 1048708Citrate

bull 1048708No anticoagulation

Dialysate

Conculsions

Critically ill patients AKI occurs in up to 30 of all ICU admissions

CRRT is almost exclusively applied to patients in (ICU)

Restrict monitoring and follow up of the patients during CRRT is mandatory

Well trained nurse is the corner stone of adequate CRRT

Mortality according to RIFLE

Mortality increases proportionately with increasing severity of AKI (using RIFLE)

Mortality in pts with AKI requiring RRT 50-70

Even small changes in serum creatinine are associated with increased mortality

CRITICALCARENURSE Vol 27 No 2 APRIL 2007

bull In 1977 Kramer in Goumlttingen (Germany)developed the continuousarteriovenous hemofiltration(CAVH) technique which used asystemic arteriovenous pressure difference inan extracorporeal circuit to continuouslyproduce an ultrafiltrate

bull In the 1980s a blood pump such as thoseused in intermittent hemodialysis and adouble-lumen catheter in a large vein wereused to provide a consistent

blood-flow rate without

the risks associated

with the arteriovenous approach

The Acute Disease Quality Initiative (ADQI)

Published online August 26 2016

When should acute RRT be initiated (includes AKI and non-AKI indications)

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

How should RRT be integrated into other extracorporeal therapies

When should transition of modalities be considered (CRRT IRRT hybrid therapy)

How should patients be liberated from RRT

When should acute RRT be initiated

Consensus statement 11

bullAcute RRT should be consideredwhen metabolic and fluiddemands exceed total kidneycapacity

Individual

Renal function

Clinical context

562 We suggest using CRRT rather thanstandard intermittent RRT for hemodynamicallyunstable patients (2B)

563 We suggest using CRRT rather thanintermittent RRT for AKI patients with acute braininjury or other causes of increased intracranialpressure or generalized brain edema (2B)

Indications for CRRT

bullCRRT is an effective method toremove fluid and to achieve a targetfluid balance in patients with fluidoverload including those withcongestive cardiac failure (CCF) oracute lung injury

RRT is also effective at removingbiologically active substancesincluding cytokines butthere is still insufficientevidence to recommend the routineuse of CRRT for the treatment ofsepsis

When should acute RRT be initiated

Consensus statement 12

bullDemand for kidney function isdetermined by non-renalcomorbidities the severity ofthe acute disease and solute andfluid burden

When should acute RRT be initiated

Consensus statement 13

bullTotal kidney function is measuredusing a variety of different methodsChanges in kidney function andduration of kidney dysfunction canbe anticipated by markers of kidneydamage

When should acute RRT be initiated

Consensus statement 14

bullThe demandndashcapacityimbalance is dynamicand should be evaluatedregularly

When should acute RRT be initiated

Consensus statement 15

bullFor patients requiring multipletypes of organ support decisionsabout initiating or withholdingRRT should be consideredtogether with other therapies

When should acute RRT be initiated

Consensus statement 16

bullOnce the decision to initiateRRT has been made thetherapy should be started assoon as possible typicallywithin less than 3 h

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 21

bull Selection of RRT modality depends on thecapabilityavailability of the technology

bull Different RRT modalities provide differentcapabilities

bull different machines may provide some butnot all modalities

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 22

bull CRRT recommended in situations whereshifts in fluid balance and metabolicfluctuations are poorly tolerated

bull Intermittent and prolonged intermittenttypes of RRT have a role when fluid andmetabolic fluctuations can be tolerated

Both CRRT and IHD achieve adequate

metabolic control and neither modality has

been shown to be superior in terms of

survival

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 23

bullAvailability of technologies isdetermined by local regulationslocal resources including stafftheir trainingexperience andlaboratory support and financialconstraints

bullSCUF (slow continuous ultrafiltration)

bullCVVH (continuous veno-venous haemofiltration

bullCVVHD (continuous veno-venous haemodialysis)

bullCVVHDF (continuous veno-venous haemodiafiltration

How should RRT be integrated into other extracorporeal therapies

bull Consensus statement 31

In situations where other extracorporealtherapies are required continuous RRT isrecommended and integrated systems arepreferred over parallel systems

extracorporeal liver assist devices (ELADs)

ECLS in Cardiac Failure

When should transition of modalities be considered (CRRT IRRT hybrid therapy)

Consensus statement 41

bullTransition of modalities should beconsidered if the demandndashcapacityimbalance or treatment prioritieshave changed and can be metbetter by an alternative technique

How should patients be liberated from RRT

RRT should bediscontinued ifkidney functionhas recovered

Consensus statement

51

How should patients be liberated from RRT

Consensus statement 52

bullTo determine sustainedrecovery of kidney functionwe recommend monitoring ofurine output and SCr duringRRT

How should patients be liberated from RRT

C onsensus statement 53

bullFor patients requiring multipletypes of organ supportdecisions about withdrawingRRT should be consideredtogether with other therapies

Before

Before CRRT is started patients should have

a complete nursing assessment

bull Fluid status

bull Fluid input

bull Blood pressure

bull Dosages of any vasopressors

bull Weightbull Presence of edemabull CVPbull NaK and ABGs

Nursing Management

During

Once CRRT is started

bull Blood pressure central venous pressure andweight monitoring

bull The bedside nurse should discuss the possibilityof reducing intake to minimal volumes of fluidsif at all possible and concentrating medicationsand infusions to minimize fluid intake if thetarget not acheived

bull Mechanical failures can occur if alarms are ignored or bypassed without determining the cause of the alarms

bull If scales are not properly calibrated the volumes of fluid administered and removed may not be the programmed volumes

541 We suggest initiating RRT in patients with AKI via an uncuffed non tunneled dialysis catheter rather than a tunneled catheter (2D)

542 When choosing a vein for insertion of a dialysis catheter in patients with AKI consider these preferences (Not Graded)

bull First choice right jugular vein

bull Second choice femoral vein

bull Third choice left jugular vein

bull Last choice subclavian vein with preference for the dominant side

Anticoagulation

CRRT can be performed with or without anticoagulation

The choice of anticoagulant depends on

bull The physicianrsquos preference

bull The patientrsquos condition

bull The familiarity of the nursing staff with anticoagulation regimens

The bedside nurse is responsiblefor monitoring any adverse effectsof anticoagulation includinghemorrhage formation ofhematomas thrombocytopeniaand allergic reactions

Heparin

bull The least expensive anticoagulant

bull Either systemically or regionally

When heparin is used

bull The hemofilter may be flushed with a dilute heparin solution continuously or intermittently

Systemic heparinization includes

bull Infusing heparin into a separate intravenous access or into the arterial side of the CRRT circuit

bull Mixing of the heparin with the blood from the patient before the blood reaches the filter

bull Anticoagulation of the circuit as well as for the patient

Argatroban and lepirudin

bullDirect thrombin inhibitors

bullHIT

Lepirudin is cleared by the kidneys and therefore may not be the drug of choice

for patients in ARF

Argatroban is eliminated by the liver and is therefore more suitable for use in

patients with renal failure

Citrate

excellent anticoagulant ability and potential to prolong circuit life

bull Calcium is an essential component of the clotting cascade

bull Citrate binds to the calcium in the patientrsquos blood within the CRRT system and prevents clotting

Citrate is infused prefilter into the CRRT system and calcium is typically infused via another intravenous line outside the circuit

Ionized calcium levels are routinely monitored

1048708Heparin

bull 250500 Uhr

1048708HIT Argatroban

bull 1048708051 mghr

1048708Bleeding risk

bull 1048708Citrate

bull 1048708No anticoagulation

Dialysate

Conculsions

Critically ill patients AKI occurs in up to 30 of all ICU admissions

CRRT is almost exclusively applied to patients in (ICU)

Restrict monitoring and follow up of the patients during CRRT is mandatory

Well trained nurse is the corner stone of adequate CRRT

CRITICALCARENURSE Vol 27 No 2 APRIL 2007

bull In 1977 Kramer in Goumlttingen (Germany)developed the continuousarteriovenous hemofiltration(CAVH) technique which used asystemic arteriovenous pressure difference inan extracorporeal circuit to continuouslyproduce an ultrafiltrate

bull In the 1980s a blood pump such as thoseused in intermittent hemodialysis and adouble-lumen catheter in a large vein wereused to provide a consistent

blood-flow rate without

the risks associated

with the arteriovenous approach

The Acute Disease Quality Initiative (ADQI)

Published online August 26 2016

When should acute RRT be initiated (includes AKI and non-AKI indications)

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

How should RRT be integrated into other extracorporeal therapies

When should transition of modalities be considered (CRRT IRRT hybrid therapy)

How should patients be liberated from RRT

When should acute RRT be initiated

Consensus statement 11

bullAcute RRT should be consideredwhen metabolic and fluiddemands exceed total kidneycapacity

Individual

Renal function

Clinical context

562 We suggest using CRRT rather thanstandard intermittent RRT for hemodynamicallyunstable patients (2B)

563 We suggest using CRRT rather thanintermittent RRT for AKI patients with acute braininjury or other causes of increased intracranialpressure or generalized brain edema (2B)

Indications for CRRT

bullCRRT is an effective method toremove fluid and to achieve a targetfluid balance in patients with fluidoverload including those withcongestive cardiac failure (CCF) oracute lung injury

RRT is also effective at removingbiologically active substancesincluding cytokines butthere is still insufficientevidence to recommend the routineuse of CRRT for the treatment ofsepsis

When should acute RRT be initiated

Consensus statement 12

bullDemand for kidney function isdetermined by non-renalcomorbidities the severity ofthe acute disease and solute andfluid burden

When should acute RRT be initiated

Consensus statement 13

bullTotal kidney function is measuredusing a variety of different methodsChanges in kidney function andduration of kidney dysfunction canbe anticipated by markers of kidneydamage

When should acute RRT be initiated

Consensus statement 14

bullThe demandndashcapacityimbalance is dynamicand should be evaluatedregularly

When should acute RRT be initiated

Consensus statement 15

bullFor patients requiring multipletypes of organ support decisionsabout initiating or withholdingRRT should be consideredtogether with other therapies

When should acute RRT be initiated

Consensus statement 16

bullOnce the decision to initiateRRT has been made thetherapy should be started assoon as possible typicallywithin less than 3 h

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 21

bull Selection of RRT modality depends on thecapabilityavailability of the technology

bull Different RRT modalities provide differentcapabilities

bull different machines may provide some butnot all modalities

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 22

bull CRRT recommended in situations whereshifts in fluid balance and metabolicfluctuations are poorly tolerated

bull Intermittent and prolonged intermittenttypes of RRT have a role when fluid andmetabolic fluctuations can be tolerated

Both CRRT and IHD achieve adequate

metabolic control and neither modality has

been shown to be superior in terms of

survival

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 23

bullAvailability of technologies isdetermined by local regulationslocal resources including stafftheir trainingexperience andlaboratory support and financialconstraints

bullSCUF (slow continuous ultrafiltration)

bullCVVH (continuous veno-venous haemofiltration

bullCVVHD (continuous veno-venous haemodialysis)

bullCVVHDF (continuous veno-venous haemodiafiltration

How should RRT be integrated into other extracorporeal therapies

bull Consensus statement 31

In situations where other extracorporealtherapies are required continuous RRT isrecommended and integrated systems arepreferred over parallel systems

extracorporeal liver assist devices (ELADs)

ECLS in Cardiac Failure

When should transition of modalities be considered (CRRT IRRT hybrid therapy)

Consensus statement 41

bullTransition of modalities should beconsidered if the demandndashcapacityimbalance or treatment prioritieshave changed and can be metbetter by an alternative technique

How should patients be liberated from RRT

RRT should bediscontinued ifkidney functionhas recovered

Consensus statement

51

How should patients be liberated from RRT

Consensus statement 52

bullTo determine sustainedrecovery of kidney functionwe recommend monitoring ofurine output and SCr duringRRT

How should patients be liberated from RRT

C onsensus statement 53

bullFor patients requiring multipletypes of organ supportdecisions about withdrawingRRT should be consideredtogether with other therapies

Before

Before CRRT is started patients should have

a complete nursing assessment

bull Fluid status

bull Fluid input

bull Blood pressure

bull Dosages of any vasopressors

bull Weightbull Presence of edemabull CVPbull NaK and ABGs

Nursing Management

During

Once CRRT is started

bull Blood pressure central venous pressure andweight monitoring

bull The bedside nurse should discuss the possibilityof reducing intake to minimal volumes of fluidsif at all possible and concentrating medicationsand infusions to minimize fluid intake if thetarget not acheived

bull Mechanical failures can occur if alarms are ignored or bypassed without determining the cause of the alarms

bull If scales are not properly calibrated the volumes of fluid administered and removed may not be the programmed volumes

541 We suggest initiating RRT in patients with AKI via an uncuffed non tunneled dialysis catheter rather than a tunneled catheter (2D)

542 When choosing a vein for insertion of a dialysis catheter in patients with AKI consider these preferences (Not Graded)

bull First choice right jugular vein

bull Second choice femoral vein

bull Third choice left jugular vein

bull Last choice subclavian vein with preference for the dominant side

Anticoagulation

CRRT can be performed with or without anticoagulation

The choice of anticoagulant depends on

bull The physicianrsquos preference

bull The patientrsquos condition

bull The familiarity of the nursing staff with anticoagulation regimens

The bedside nurse is responsiblefor monitoring any adverse effectsof anticoagulation includinghemorrhage formation ofhematomas thrombocytopeniaand allergic reactions

Heparin

bull The least expensive anticoagulant

bull Either systemically or regionally

When heparin is used

bull The hemofilter may be flushed with a dilute heparin solution continuously or intermittently

Systemic heparinization includes

bull Infusing heparin into a separate intravenous access or into the arterial side of the CRRT circuit

bull Mixing of the heparin with the blood from the patient before the blood reaches the filter

bull Anticoagulation of the circuit as well as for the patient

Argatroban and lepirudin

bullDirect thrombin inhibitors

bullHIT

Lepirudin is cleared by the kidneys and therefore may not be the drug of choice

for patients in ARF

Argatroban is eliminated by the liver and is therefore more suitable for use in

patients with renal failure

Citrate

excellent anticoagulant ability and potential to prolong circuit life

bull Calcium is an essential component of the clotting cascade

bull Citrate binds to the calcium in the patientrsquos blood within the CRRT system and prevents clotting

Citrate is infused prefilter into the CRRT system and calcium is typically infused via another intravenous line outside the circuit

Ionized calcium levels are routinely monitored

1048708Heparin

bull 250500 Uhr

1048708HIT Argatroban

bull 1048708051 mghr

1048708Bleeding risk

bull 1048708Citrate

bull 1048708No anticoagulation

Dialysate

Conculsions

Critically ill patients AKI occurs in up to 30 of all ICU admissions

CRRT is almost exclusively applied to patients in (ICU)

Restrict monitoring and follow up of the patients during CRRT is mandatory

Well trained nurse is the corner stone of adequate CRRT

bull In 1977 Kramer in Goumlttingen (Germany)developed the continuousarteriovenous hemofiltration(CAVH) technique which used asystemic arteriovenous pressure difference inan extracorporeal circuit to continuouslyproduce an ultrafiltrate

bull In the 1980s a blood pump such as thoseused in intermittent hemodialysis and adouble-lumen catheter in a large vein wereused to provide a consistent

blood-flow rate without

the risks associated

with the arteriovenous approach

The Acute Disease Quality Initiative (ADQI)

Published online August 26 2016

When should acute RRT be initiated (includes AKI and non-AKI indications)

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

How should RRT be integrated into other extracorporeal therapies

When should transition of modalities be considered (CRRT IRRT hybrid therapy)

How should patients be liberated from RRT

When should acute RRT be initiated

Consensus statement 11

bullAcute RRT should be consideredwhen metabolic and fluiddemands exceed total kidneycapacity

Individual

Renal function

Clinical context

562 We suggest using CRRT rather thanstandard intermittent RRT for hemodynamicallyunstable patients (2B)

563 We suggest using CRRT rather thanintermittent RRT for AKI patients with acute braininjury or other causes of increased intracranialpressure or generalized brain edema (2B)

Indications for CRRT

bullCRRT is an effective method toremove fluid and to achieve a targetfluid balance in patients with fluidoverload including those withcongestive cardiac failure (CCF) oracute lung injury

RRT is also effective at removingbiologically active substancesincluding cytokines butthere is still insufficientevidence to recommend the routineuse of CRRT for the treatment ofsepsis

When should acute RRT be initiated

Consensus statement 12

bullDemand for kidney function isdetermined by non-renalcomorbidities the severity ofthe acute disease and solute andfluid burden

When should acute RRT be initiated

Consensus statement 13

bullTotal kidney function is measuredusing a variety of different methodsChanges in kidney function andduration of kidney dysfunction canbe anticipated by markers of kidneydamage

When should acute RRT be initiated

Consensus statement 14

bullThe demandndashcapacityimbalance is dynamicand should be evaluatedregularly

When should acute RRT be initiated

Consensus statement 15

bullFor patients requiring multipletypes of organ support decisionsabout initiating or withholdingRRT should be consideredtogether with other therapies

When should acute RRT be initiated

Consensus statement 16

bullOnce the decision to initiateRRT has been made thetherapy should be started assoon as possible typicallywithin less than 3 h

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 21

bull Selection of RRT modality depends on thecapabilityavailability of the technology

bull Different RRT modalities provide differentcapabilities

bull different machines may provide some butnot all modalities

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 22

bull CRRT recommended in situations whereshifts in fluid balance and metabolicfluctuations are poorly tolerated

bull Intermittent and prolonged intermittenttypes of RRT have a role when fluid andmetabolic fluctuations can be tolerated

Both CRRT and IHD achieve adequate

metabolic control and neither modality has

been shown to be superior in terms of

survival

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 23

bullAvailability of technologies isdetermined by local regulationslocal resources including stafftheir trainingexperience andlaboratory support and financialconstraints

bullSCUF (slow continuous ultrafiltration)

bullCVVH (continuous veno-venous haemofiltration

bullCVVHD (continuous veno-venous haemodialysis)

bullCVVHDF (continuous veno-venous haemodiafiltration

How should RRT be integrated into other extracorporeal therapies

bull Consensus statement 31

In situations where other extracorporealtherapies are required continuous RRT isrecommended and integrated systems arepreferred over parallel systems

extracorporeal liver assist devices (ELADs)

ECLS in Cardiac Failure

When should transition of modalities be considered (CRRT IRRT hybrid therapy)

Consensus statement 41

bullTransition of modalities should beconsidered if the demandndashcapacityimbalance or treatment prioritieshave changed and can be metbetter by an alternative technique

How should patients be liberated from RRT

RRT should bediscontinued ifkidney functionhas recovered

Consensus statement

51

How should patients be liberated from RRT

Consensus statement 52

bullTo determine sustainedrecovery of kidney functionwe recommend monitoring ofurine output and SCr duringRRT

How should patients be liberated from RRT

C onsensus statement 53

bullFor patients requiring multipletypes of organ supportdecisions about withdrawingRRT should be consideredtogether with other therapies

Before

Before CRRT is started patients should have

a complete nursing assessment

bull Fluid status

bull Fluid input

bull Blood pressure

bull Dosages of any vasopressors

bull Weightbull Presence of edemabull CVPbull NaK and ABGs

Nursing Management

During

Once CRRT is started

bull Blood pressure central venous pressure andweight monitoring

bull The bedside nurse should discuss the possibilityof reducing intake to minimal volumes of fluidsif at all possible and concentrating medicationsand infusions to minimize fluid intake if thetarget not acheived

bull Mechanical failures can occur if alarms are ignored or bypassed without determining the cause of the alarms

bull If scales are not properly calibrated the volumes of fluid administered and removed may not be the programmed volumes

541 We suggest initiating RRT in patients with AKI via an uncuffed non tunneled dialysis catheter rather than a tunneled catheter (2D)

542 When choosing a vein for insertion of a dialysis catheter in patients with AKI consider these preferences (Not Graded)

bull First choice right jugular vein

bull Second choice femoral vein

bull Third choice left jugular vein

bull Last choice subclavian vein with preference for the dominant side

Anticoagulation

CRRT can be performed with or without anticoagulation

The choice of anticoagulant depends on

bull The physicianrsquos preference

bull The patientrsquos condition

bull The familiarity of the nursing staff with anticoagulation regimens

The bedside nurse is responsiblefor monitoring any adverse effectsof anticoagulation includinghemorrhage formation ofhematomas thrombocytopeniaand allergic reactions

Heparin

bull The least expensive anticoagulant

bull Either systemically or regionally

When heparin is used

bull The hemofilter may be flushed with a dilute heparin solution continuously or intermittently

Systemic heparinization includes

bull Infusing heparin into a separate intravenous access or into the arterial side of the CRRT circuit

bull Mixing of the heparin with the blood from the patient before the blood reaches the filter

bull Anticoagulation of the circuit as well as for the patient

Argatroban and lepirudin

bullDirect thrombin inhibitors

bullHIT

Lepirudin is cleared by the kidneys and therefore may not be the drug of choice

for patients in ARF

Argatroban is eliminated by the liver and is therefore more suitable for use in

patients with renal failure

Citrate

excellent anticoagulant ability and potential to prolong circuit life

bull Calcium is an essential component of the clotting cascade

bull Citrate binds to the calcium in the patientrsquos blood within the CRRT system and prevents clotting

Citrate is infused prefilter into the CRRT system and calcium is typically infused via another intravenous line outside the circuit

Ionized calcium levels are routinely monitored

1048708Heparin

bull 250500 Uhr

1048708HIT Argatroban

bull 1048708051 mghr

1048708Bleeding risk

bull 1048708Citrate

bull 1048708No anticoagulation

Dialysate

Conculsions

Critically ill patients AKI occurs in up to 30 of all ICU admissions

CRRT is almost exclusively applied to patients in (ICU)

Restrict monitoring and follow up of the patients during CRRT is mandatory

Well trained nurse is the corner stone of adequate CRRT

bull In the 1980s a blood pump such as thoseused in intermittent hemodialysis and adouble-lumen catheter in a large vein wereused to provide a consistent

blood-flow rate without

the risks associated

with the arteriovenous approach

The Acute Disease Quality Initiative (ADQI)

Published online August 26 2016

When should acute RRT be initiated (includes AKI and non-AKI indications)

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

How should RRT be integrated into other extracorporeal therapies

When should transition of modalities be considered (CRRT IRRT hybrid therapy)

How should patients be liberated from RRT

When should acute RRT be initiated

Consensus statement 11

bullAcute RRT should be consideredwhen metabolic and fluiddemands exceed total kidneycapacity

Individual

Renal function

Clinical context

562 We suggest using CRRT rather thanstandard intermittent RRT for hemodynamicallyunstable patients (2B)

563 We suggest using CRRT rather thanintermittent RRT for AKI patients with acute braininjury or other causes of increased intracranialpressure or generalized brain edema (2B)

Indications for CRRT

bullCRRT is an effective method toremove fluid and to achieve a targetfluid balance in patients with fluidoverload including those withcongestive cardiac failure (CCF) oracute lung injury

RRT is also effective at removingbiologically active substancesincluding cytokines butthere is still insufficientevidence to recommend the routineuse of CRRT for the treatment ofsepsis

When should acute RRT be initiated

Consensus statement 12

bullDemand for kidney function isdetermined by non-renalcomorbidities the severity ofthe acute disease and solute andfluid burden

When should acute RRT be initiated

Consensus statement 13

bullTotal kidney function is measuredusing a variety of different methodsChanges in kidney function andduration of kidney dysfunction canbe anticipated by markers of kidneydamage

When should acute RRT be initiated

Consensus statement 14

bullThe demandndashcapacityimbalance is dynamicand should be evaluatedregularly

When should acute RRT be initiated

Consensus statement 15

bullFor patients requiring multipletypes of organ support decisionsabout initiating or withholdingRRT should be consideredtogether with other therapies

When should acute RRT be initiated

Consensus statement 16

bullOnce the decision to initiateRRT has been made thetherapy should be started assoon as possible typicallywithin less than 3 h

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 21

bull Selection of RRT modality depends on thecapabilityavailability of the technology

bull Different RRT modalities provide differentcapabilities

bull different machines may provide some butnot all modalities

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 22

bull CRRT recommended in situations whereshifts in fluid balance and metabolicfluctuations are poorly tolerated

bull Intermittent and prolonged intermittenttypes of RRT have a role when fluid andmetabolic fluctuations can be tolerated

Both CRRT and IHD achieve adequate

metabolic control and neither modality has

been shown to be superior in terms of

survival

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 23

bullAvailability of technologies isdetermined by local regulationslocal resources including stafftheir trainingexperience andlaboratory support and financialconstraints

bullSCUF (slow continuous ultrafiltration)

bullCVVH (continuous veno-venous haemofiltration

bullCVVHD (continuous veno-venous haemodialysis)

bullCVVHDF (continuous veno-venous haemodiafiltration

How should RRT be integrated into other extracorporeal therapies

bull Consensus statement 31

In situations where other extracorporealtherapies are required continuous RRT isrecommended and integrated systems arepreferred over parallel systems

extracorporeal liver assist devices (ELADs)

ECLS in Cardiac Failure

When should transition of modalities be considered (CRRT IRRT hybrid therapy)

Consensus statement 41

bullTransition of modalities should beconsidered if the demandndashcapacityimbalance or treatment prioritieshave changed and can be metbetter by an alternative technique

How should patients be liberated from RRT

RRT should bediscontinued ifkidney functionhas recovered

Consensus statement

51

How should patients be liberated from RRT

Consensus statement 52

bullTo determine sustainedrecovery of kidney functionwe recommend monitoring ofurine output and SCr duringRRT

How should patients be liberated from RRT

C onsensus statement 53

bullFor patients requiring multipletypes of organ supportdecisions about withdrawingRRT should be consideredtogether with other therapies

Before

Before CRRT is started patients should have

a complete nursing assessment

bull Fluid status

bull Fluid input

bull Blood pressure

bull Dosages of any vasopressors

bull Weightbull Presence of edemabull CVPbull NaK and ABGs

Nursing Management

During

Once CRRT is started

bull Blood pressure central venous pressure andweight monitoring

bull The bedside nurse should discuss the possibilityof reducing intake to minimal volumes of fluidsif at all possible and concentrating medicationsand infusions to minimize fluid intake if thetarget not acheived

bull Mechanical failures can occur if alarms are ignored or bypassed without determining the cause of the alarms

bull If scales are not properly calibrated the volumes of fluid administered and removed may not be the programmed volumes

541 We suggest initiating RRT in patients with AKI via an uncuffed non tunneled dialysis catheter rather than a tunneled catheter (2D)

542 When choosing a vein for insertion of a dialysis catheter in patients with AKI consider these preferences (Not Graded)

bull First choice right jugular vein

bull Second choice femoral vein

bull Third choice left jugular vein

bull Last choice subclavian vein with preference for the dominant side

Anticoagulation

CRRT can be performed with or without anticoagulation

The choice of anticoagulant depends on

bull The physicianrsquos preference

bull The patientrsquos condition

bull The familiarity of the nursing staff with anticoagulation regimens

The bedside nurse is responsiblefor monitoring any adverse effectsof anticoagulation includinghemorrhage formation ofhematomas thrombocytopeniaand allergic reactions

Heparin

bull The least expensive anticoagulant

bull Either systemically or regionally

When heparin is used

bull The hemofilter may be flushed with a dilute heparin solution continuously or intermittently

Systemic heparinization includes

bull Infusing heparin into a separate intravenous access or into the arterial side of the CRRT circuit

bull Mixing of the heparin with the blood from the patient before the blood reaches the filter

bull Anticoagulation of the circuit as well as for the patient

Argatroban and lepirudin

bullDirect thrombin inhibitors

bullHIT

Lepirudin is cleared by the kidneys and therefore may not be the drug of choice

for patients in ARF

Argatroban is eliminated by the liver and is therefore more suitable for use in

patients with renal failure

Citrate

excellent anticoagulant ability and potential to prolong circuit life

bull Calcium is an essential component of the clotting cascade

bull Citrate binds to the calcium in the patientrsquos blood within the CRRT system and prevents clotting

Citrate is infused prefilter into the CRRT system and calcium is typically infused via another intravenous line outside the circuit

Ionized calcium levels are routinely monitored

1048708Heparin

bull 250500 Uhr

1048708HIT Argatroban

bull 1048708051 mghr

1048708Bleeding risk

bull 1048708Citrate

bull 1048708No anticoagulation

Dialysate

Conculsions

Critically ill patients AKI occurs in up to 30 of all ICU admissions

CRRT is almost exclusively applied to patients in (ICU)

Restrict monitoring and follow up of the patients during CRRT is mandatory

Well trained nurse is the corner stone of adequate CRRT

The Acute Disease Quality Initiative (ADQI)

Published online August 26 2016

When should acute RRT be initiated (includes AKI and non-AKI indications)

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

How should RRT be integrated into other extracorporeal therapies

When should transition of modalities be considered (CRRT IRRT hybrid therapy)

How should patients be liberated from RRT

When should acute RRT be initiated

Consensus statement 11

bullAcute RRT should be consideredwhen metabolic and fluiddemands exceed total kidneycapacity

Individual

Renal function

Clinical context

562 We suggest using CRRT rather thanstandard intermittent RRT for hemodynamicallyunstable patients (2B)

563 We suggest using CRRT rather thanintermittent RRT for AKI patients with acute braininjury or other causes of increased intracranialpressure or generalized brain edema (2B)

Indications for CRRT

bullCRRT is an effective method toremove fluid and to achieve a targetfluid balance in patients with fluidoverload including those withcongestive cardiac failure (CCF) oracute lung injury

RRT is also effective at removingbiologically active substancesincluding cytokines butthere is still insufficientevidence to recommend the routineuse of CRRT for the treatment ofsepsis

When should acute RRT be initiated

Consensus statement 12

bullDemand for kidney function isdetermined by non-renalcomorbidities the severity ofthe acute disease and solute andfluid burden

When should acute RRT be initiated

Consensus statement 13

bullTotal kidney function is measuredusing a variety of different methodsChanges in kidney function andduration of kidney dysfunction canbe anticipated by markers of kidneydamage

When should acute RRT be initiated

Consensus statement 14

bullThe demandndashcapacityimbalance is dynamicand should be evaluatedregularly

When should acute RRT be initiated

Consensus statement 15

bullFor patients requiring multipletypes of organ support decisionsabout initiating or withholdingRRT should be consideredtogether with other therapies

When should acute RRT be initiated

Consensus statement 16

bullOnce the decision to initiateRRT has been made thetherapy should be started assoon as possible typicallywithin less than 3 h

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 21

bull Selection of RRT modality depends on thecapabilityavailability of the technology

bull Different RRT modalities provide differentcapabilities

bull different machines may provide some butnot all modalities

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 22

bull CRRT recommended in situations whereshifts in fluid balance and metabolicfluctuations are poorly tolerated

bull Intermittent and prolonged intermittenttypes of RRT have a role when fluid andmetabolic fluctuations can be tolerated

Both CRRT and IHD achieve adequate

metabolic control and neither modality has

been shown to be superior in terms of

survival

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 23

bullAvailability of technologies isdetermined by local regulationslocal resources including stafftheir trainingexperience andlaboratory support and financialconstraints

bullSCUF (slow continuous ultrafiltration)

bullCVVH (continuous veno-venous haemofiltration

bullCVVHD (continuous veno-venous haemodialysis)

bullCVVHDF (continuous veno-venous haemodiafiltration

How should RRT be integrated into other extracorporeal therapies

bull Consensus statement 31

In situations where other extracorporealtherapies are required continuous RRT isrecommended and integrated systems arepreferred over parallel systems

extracorporeal liver assist devices (ELADs)

ECLS in Cardiac Failure

When should transition of modalities be considered (CRRT IRRT hybrid therapy)

Consensus statement 41

bullTransition of modalities should beconsidered if the demandndashcapacityimbalance or treatment prioritieshave changed and can be metbetter by an alternative technique

How should patients be liberated from RRT

RRT should bediscontinued ifkidney functionhas recovered

Consensus statement

51

How should patients be liberated from RRT

Consensus statement 52

bullTo determine sustainedrecovery of kidney functionwe recommend monitoring ofurine output and SCr duringRRT

How should patients be liberated from RRT

C onsensus statement 53

bullFor patients requiring multipletypes of organ supportdecisions about withdrawingRRT should be consideredtogether with other therapies

Before

Before CRRT is started patients should have

a complete nursing assessment

bull Fluid status

bull Fluid input

bull Blood pressure

bull Dosages of any vasopressors

bull Weightbull Presence of edemabull CVPbull NaK and ABGs

Nursing Management

During

Once CRRT is started

bull Blood pressure central venous pressure andweight monitoring

bull The bedside nurse should discuss the possibilityof reducing intake to minimal volumes of fluidsif at all possible and concentrating medicationsand infusions to minimize fluid intake if thetarget not acheived

bull Mechanical failures can occur if alarms are ignored or bypassed without determining the cause of the alarms

bull If scales are not properly calibrated the volumes of fluid administered and removed may not be the programmed volumes

541 We suggest initiating RRT in patients with AKI via an uncuffed non tunneled dialysis catheter rather than a tunneled catheter (2D)

542 When choosing a vein for insertion of a dialysis catheter in patients with AKI consider these preferences (Not Graded)

bull First choice right jugular vein

bull Second choice femoral vein

bull Third choice left jugular vein

bull Last choice subclavian vein with preference for the dominant side

Anticoagulation

CRRT can be performed with or without anticoagulation

The choice of anticoagulant depends on

bull The physicianrsquos preference

bull The patientrsquos condition

bull The familiarity of the nursing staff with anticoagulation regimens

The bedside nurse is responsiblefor monitoring any adverse effectsof anticoagulation includinghemorrhage formation ofhematomas thrombocytopeniaand allergic reactions

Heparin

bull The least expensive anticoagulant

bull Either systemically or regionally

When heparin is used

bull The hemofilter may be flushed with a dilute heparin solution continuously or intermittently

Systemic heparinization includes

bull Infusing heparin into a separate intravenous access or into the arterial side of the CRRT circuit

bull Mixing of the heparin with the blood from the patient before the blood reaches the filter

bull Anticoagulation of the circuit as well as for the patient

Argatroban and lepirudin

bullDirect thrombin inhibitors

bullHIT

Lepirudin is cleared by the kidneys and therefore may not be the drug of choice

for patients in ARF

Argatroban is eliminated by the liver and is therefore more suitable for use in

patients with renal failure

Citrate

excellent anticoagulant ability and potential to prolong circuit life

bull Calcium is an essential component of the clotting cascade

bull Citrate binds to the calcium in the patientrsquos blood within the CRRT system and prevents clotting

Citrate is infused prefilter into the CRRT system and calcium is typically infused via another intravenous line outside the circuit

Ionized calcium levels are routinely monitored

1048708Heparin

bull 250500 Uhr

1048708HIT Argatroban

bull 1048708051 mghr

1048708Bleeding risk

bull 1048708Citrate

bull 1048708No anticoagulation

Dialysate

Conculsions

Critically ill patients AKI occurs in up to 30 of all ICU admissions

CRRT is almost exclusively applied to patients in (ICU)

Restrict monitoring and follow up of the patients during CRRT is mandatory

Well trained nurse is the corner stone of adequate CRRT

When should acute RRT be initiated (includes AKI and non-AKI indications)

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

How should RRT be integrated into other extracorporeal therapies

When should transition of modalities be considered (CRRT IRRT hybrid therapy)

How should patients be liberated from RRT

When should acute RRT be initiated

Consensus statement 11

bullAcute RRT should be consideredwhen metabolic and fluiddemands exceed total kidneycapacity

Individual

Renal function

Clinical context

562 We suggest using CRRT rather thanstandard intermittent RRT for hemodynamicallyunstable patients (2B)

563 We suggest using CRRT rather thanintermittent RRT for AKI patients with acute braininjury or other causes of increased intracranialpressure or generalized brain edema (2B)

Indications for CRRT

bullCRRT is an effective method toremove fluid and to achieve a targetfluid balance in patients with fluidoverload including those withcongestive cardiac failure (CCF) oracute lung injury

RRT is also effective at removingbiologically active substancesincluding cytokines butthere is still insufficientevidence to recommend the routineuse of CRRT for the treatment ofsepsis

When should acute RRT be initiated

Consensus statement 12

bullDemand for kidney function isdetermined by non-renalcomorbidities the severity ofthe acute disease and solute andfluid burden

When should acute RRT be initiated

Consensus statement 13

bullTotal kidney function is measuredusing a variety of different methodsChanges in kidney function andduration of kidney dysfunction canbe anticipated by markers of kidneydamage

When should acute RRT be initiated

Consensus statement 14

bullThe demandndashcapacityimbalance is dynamicand should be evaluatedregularly

When should acute RRT be initiated

Consensus statement 15

bullFor patients requiring multipletypes of organ support decisionsabout initiating or withholdingRRT should be consideredtogether with other therapies

When should acute RRT be initiated

Consensus statement 16

bullOnce the decision to initiateRRT has been made thetherapy should be started assoon as possible typicallywithin less than 3 h

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 21

bull Selection of RRT modality depends on thecapabilityavailability of the technology

bull Different RRT modalities provide differentcapabilities

bull different machines may provide some butnot all modalities

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 22

bull CRRT recommended in situations whereshifts in fluid balance and metabolicfluctuations are poorly tolerated

bull Intermittent and prolonged intermittenttypes of RRT have a role when fluid andmetabolic fluctuations can be tolerated

Both CRRT and IHD achieve adequate

metabolic control and neither modality has

been shown to be superior in terms of

survival

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 23

bullAvailability of technologies isdetermined by local regulationslocal resources including stafftheir trainingexperience andlaboratory support and financialconstraints

bullSCUF (slow continuous ultrafiltration)

bullCVVH (continuous veno-venous haemofiltration

bullCVVHD (continuous veno-venous haemodialysis)

bullCVVHDF (continuous veno-venous haemodiafiltration

How should RRT be integrated into other extracorporeal therapies

bull Consensus statement 31

In situations where other extracorporealtherapies are required continuous RRT isrecommended and integrated systems arepreferred over parallel systems

extracorporeal liver assist devices (ELADs)

ECLS in Cardiac Failure

When should transition of modalities be considered (CRRT IRRT hybrid therapy)

Consensus statement 41

bullTransition of modalities should beconsidered if the demandndashcapacityimbalance or treatment prioritieshave changed and can be metbetter by an alternative technique

How should patients be liberated from RRT

RRT should bediscontinued ifkidney functionhas recovered

Consensus statement

51

How should patients be liberated from RRT

Consensus statement 52

bullTo determine sustainedrecovery of kidney functionwe recommend monitoring ofurine output and SCr duringRRT

How should patients be liberated from RRT

C onsensus statement 53

bullFor patients requiring multipletypes of organ supportdecisions about withdrawingRRT should be consideredtogether with other therapies

Before

Before CRRT is started patients should have

a complete nursing assessment

bull Fluid status

bull Fluid input

bull Blood pressure

bull Dosages of any vasopressors

bull Weightbull Presence of edemabull CVPbull NaK and ABGs

Nursing Management

During

Once CRRT is started

bull Blood pressure central venous pressure andweight monitoring

bull The bedside nurse should discuss the possibilityof reducing intake to minimal volumes of fluidsif at all possible and concentrating medicationsand infusions to minimize fluid intake if thetarget not acheived

bull Mechanical failures can occur if alarms are ignored or bypassed without determining the cause of the alarms

bull If scales are not properly calibrated the volumes of fluid administered and removed may not be the programmed volumes

541 We suggest initiating RRT in patients with AKI via an uncuffed non tunneled dialysis catheter rather than a tunneled catheter (2D)

542 When choosing a vein for insertion of a dialysis catheter in patients with AKI consider these preferences (Not Graded)

bull First choice right jugular vein

bull Second choice femoral vein

bull Third choice left jugular vein

bull Last choice subclavian vein with preference for the dominant side

Anticoagulation

CRRT can be performed with or without anticoagulation

The choice of anticoagulant depends on

bull The physicianrsquos preference

bull The patientrsquos condition

bull The familiarity of the nursing staff with anticoagulation regimens

The bedside nurse is responsiblefor monitoring any adverse effectsof anticoagulation includinghemorrhage formation ofhematomas thrombocytopeniaand allergic reactions

Heparin

bull The least expensive anticoagulant

bull Either systemically or regionally

When heparin is used

bull The hemofilter may be flushed with a dilute heparin solution continuously or intermittently

Systemic heparinization includes

bull Infusing heparin into a separate intravenous access or into the arterial side of the CRRT circuit

bull Mixing of the heparin with the blood from the patient before the blood reaches the filter

bull Anticoagulation of the circuit as well as for the patient

Argatroban and lepirudin

bullDirect thrombin inhibitors

bullHIT

Lepirudin is cleared by the kidneys and therefore may not be the drug of choice

for patients in ARF

Argatroban is eliminated by the liver and is therefore more suitable for use in

patients with renal failure

Citrate

excellent anticoagulant ability and potential to prolong circuit life

bull Calcium is an essential component of the clotting cascade

bull Citrate binds to the calcium in the patientrsquos blood within the CRRT system and prevents clotting

Citrate is infused prefilter into the CRRT system and calcium is typically infused via another intravenous line outside the circuit

Ionized calcium levels are routinely monitored

1048708Heparin

bull 250500 Uhr

1048708HIT Argatroban

bull 1048708051 mghr

1048708Bleeding risk

bull 1048708Citrate

bull 1048708No anticoagulation

Dialysate

Conculsions

Critically ill patients AKI occurs in up to 30 of all ICU admissions

CRRT is almost exclusively applied to patients in (ICU)

Restrict monitoring and follow up of the patients during CRRT is mandatory

Well trained nurse is the corner stone of adequate CRRT

When should acute RRT be initiated

Consensus statement 11

bullAcute RRT should be consideredwhen metabolic and fluiddemands exceed total kidneycapacity

Individual

Renal function

Clinical context

562 We suggest using CRRT rather thanstandard intermittent RRT for hemodynamicallyunstable patients (2B)

563 We suggest using CRRT rather thanintermittent RRT for AKI patients with acute braininjury or other causes of increased intracranialpressure or generalized brain edema (2B)

Indications for CRRT

bullCRRT is an effective method toremove fluid and to achieve a targetfluid balance in patients with fluidoverload including those withcongestive cardiac failure (CCF) oracute lung injury

RRT is also effective at removingbiologically active substancesincluding cytokines butthere is still insufficientevidence to recommend the routineuse of CRRT for the treatment ofsepsis

When should acute RRT be initiated

Consensus statement 12

bullDemand for kidney function isdetermined by non-renalcomorbidities the severity ofthe acute disease and solute andfluid burden

When should acute RRT be initiated

Consensus statement 13

bullTotal kidney function is measuredusing a variety of different methodsChanges in kidney function andduration of kidney dysfunction canbe anticipated by markers of kidneydamage

When should acute RRT be initiated

Consensus statement 14

bullThe demandndashcapacityimbalance is dynamicand should be evaluatedregularly

When should acute RRT be initiated

Consensus statement 15

bullFor patients requiring multipletypes of organ support decisionsabout initiating or withholdingRRT should be consideredtogether with other therapies

When should acute RRT be initiated

Consensus statement 16

bullOnce the decision to initiateRRT has been made thetherapy should be started assoon as possible typicallywithin less than 3 h

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 21

bull Selection of RRT modality depends on thecapabilityavailability of the technology

bull Different RRT modalities provide differentcapabilities

bull different machines may provide some butnot all modalities

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 22

bull CRRT recommended in situations whereshifts in fluid balance and metabolicfluctuations are poorly tolerated

bull Intermittent and prolonged intermittenttypes of RRT have a role when fluid andmetabolic fluctuations can be tolerated

Both CRRT and IHD achieve adequate

metabolic control and neither modality has

been shown to be superior in terms of

survival

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 23

bullAvailability of technologies isdetermined by local regulationslocal resources including stafftheir trainingexperience andlaboratory support and financialconstraints

bullSCUF (slow continuous ultrafiltration)

bullCVVH (continuous veno-venous haemofiltration

bullCVVHD (continuous veno-venous haemodialysis)

bullCVVHDF (continuous veno-venous haemodiafiltration

How should RRT be integrated into other extracorporeal therapies

bull Consensus statement 31

In situations where other extracorporealtherapies are required continuous RRT isrecommended and integrated systems arepreferred over parallel systems

extracorporeal liver assist devices (ELADs)

ECLS in Cardiac Failure

When should transition of modalities be considered (CRRT IRRT hybrid therapy)

Consensus statement 41

bullTransition of modalities should beconsidered if the demandndashcapacityimbalance or treatment prioritieshave changed and can be metbetter by an alternative technique

How should patients be liberated from RRT

RRT should bediscontinued ifkidney functionhas recovered

Consensus statement

51

How should patients be liberated from RRT

Consensus statement 52

bullTo determine sustainedrecovery of kidney functionwe recommend monitoring ofurine output and SCr duringRRT

How should patients be liberated from RRT

C onsensus statement 53

bullFor patients requiring multipletypes of organ supportdecisions about withdrawingRRT should be consideredtogether with other therapies

Before

Before CRRT is started patients should have

a complete nursing assessment

bull Fluid status

bull Fluid input

bull Blood pressure

bull Dosages of any vasopressors

bull Weightbull Presence of edemabull CVPbull NaK and ABGs

Nursing Management

During

Once CRRT is started

bull Blood pressure central venous pressure andweight monitoring

bull The bedside nurse should discuss the possibilityof reducing intake to minimal volumes of fluidsif at all possible and concentrating medicationsand infusions to minimize fluid intake if thetarget not acheived

bull Mechanical failures can occur if alarms are ignored or bypassed without determining the cause of the alarms

bull If scales are not properly calibrated the volumes of fluid administered and removed may not be the programmed volumes

541 We suggest initiating RRT in patients with AKI via an uncuffed non tunneled dialysis catheter rather than a tunneled catheter (2D)

542 When choosing a vein for insertion of a dialysis catheter in patients with AKI consider these preferences (Not Graded)

bull First choice right jugular vein

bull Second choice femoral vein

bull Third choice left jugular vein

bull Last choice subclavian vein with preference for the dominant side

Anticoagulation

CRRT can be performed with or without anticoagulation

The choice of anticoagulant depends on

bull The physicianrsquos preference

bull The patientrsquos condition

bull The familiarity of the nursing staff with anticoagulation regimens

The bedside nurse is responsiblefor monitoring any adverse effectsof anticoagulation includinghemorrhage formation ofhematomas thrombocytopeniaand allergic reactions

Heparin

bull The least expensive anticoagulant

bull Either systemically or regionally

When heparin is used

bull The hemofilter may be flushed with a dilute heparin solution continuously or intermittently

Systemic heparinization includes

bull Infusing heparin into a separate intravenous access or into the arterial side of the CRRT circuit

bull Mixing of the heparin with the blood from the patient before the blood reaches the filter

bull Anticoagulation of the circuit as well as for the patient

Argatroban and lepirudin

bullDirect thrombin inhibitors

bullHIT

Lepirudin is cleared by the kidneys and therefore may not be the drug of choice

for patients in ARF

Argatroban is eliminated by the liver and is therefore more suitable for use in

patients with renal failure

Citrate

excellent anticoagulant ability and potential to prolong circuit life

bull Calcium is an essential component of the clotting cascade

bull Citrate binds to the calcium in the patientrsquos blood within the CRRT system and prevents clotting

Citrate is infused prefilter into the CRRT system and calcium is typically infused via another intravenous line outside the circuit

Ionized calcium levels are routinely monitored

1048708Heparin

bull 250500 Uhr

1048708HIT Argatroban

bull 1048708051 mghr

1048708Bleeding risk

bull 1048708Citrate

bull 1048708No anticoagulation

Dialysate

Conculsions

Critically ill patients AKI occurs in up to 30 of all ICU admissions

CRRT is almost exclusively applied to patients in (ICU)

Restrict monitoring and follow up of the patients during CRRT is mandatory

Well trained nurse is the corner stone of adequate CRRT

Individual

Renal function

Clinical context

562 We suggest using CRRT rather thanstandard intermittent RRT for hemodynamicallyunstable patients (2B)

563 We suggest using CRRT rather thanintermittent RRT for AKI patients with acute braininjury or other causes of increased intracranialpressure or generalized brain edema (2B)

Indications for CRRT

bullCRRT is an effective method toremove fluid and to achieve a targetfluid balance in patients with fluidoverload including those withcongestive cardiac failure (CCF) oracute lung injury

RRT is also effective at removingbiologically active substancesincluding cytokines butthere is still insufficientevidence to recommend the routineuse of CRRT for the treatment ofsepsis

When should acute RRT be initiated

Consensus statement 12

bullDemand for kidney function isdetermined by non-renalcomorbidities the severity ofthe acute disease and solute andfluid burden

When should acute RRT be initiated

Consensus statement 13

bullTotal kidney function is measuredusing a variety of different methodsChanges in kidney function andduration of kidney dysfunction canbe anticipated by markers of kidneydamage

When should acute RRT be initiated

Consensus statement 14

bullThe demandndashcapacityimbalance is dynamicand should be evaluatedregularly

When should acute RRT be initiated

Consensus statement 15

bullFor patients requiring multipletypes of organ support decisionsabout initiating or withholdingRRT should be consideredtogether with other therapies

When should acute RRT be initiated

Consensus statement 16

bullOnce the decision to initiateRRT has been made thetherapy should be started assoon as possible typicallywithin less than 3 h

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 21

bull Selection of RRT modality depends on thecapabilityavailability of the technology

bull Different RRT modalities provide differentcapabilities

bull different machines may provide some butnot all modalities

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 22

bull CRRT recommended in situations whereshifts in fluid balance and metabolicfluctuations are poorly tolerated

bull Intermittent and prolonged intermittenttypes of RRT have a role when fluid andmetabolic fluctuations can be tolerated

Both CRRT and IHD achieve adequate

metabolic control and neither modality has

been shown to be superior in terms of

survival

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 23

bullAvailability of technologies isdetermined by local regulationslocal resources including stafftheir trainingexperience andlaboratory support and financialconstraints

bullSCUF (slow continuous ultrafiltration)

bullCVVH (continuous veno-venous haemofiltration

bullCVVHD (continuous veno-venous haemodialysis)

bullCVVHDF (continuous veno-venous haemodiafiltration

How should RRT be integrated into other extracorporeal therapies

bull Consensus statement 31

In situations where other extracorporealtherapies are required continuous RRT isrecommended and integrated systems arepreferred over parallel systems

extracorporeal liver assist devices (ELADs)

ECLS in Cardiac Failure

When should transition of modalities be considered (CRRT IRRT hybrid therapy)

Consensus statement 41

bullTransition of modalities should beconsidered if the demandndashcapacityimbalance or treatment prioritieshave changed and can be metbetter by an alternative technique

How should patients be liberated from RRT

RRT should bediscontinued ifkidney functionhas recovered

Consensus statement

51

How should patients be liberated from RRT

Consensus statement 52

bullTo determine sustainedrecovery of kidney functionwe recommend monitoring ofurine output and SCr duringRRT

How should patients be liberated from RRT

C onsensus statement 53

bullFor patients requiring multipletypes of organ supportdecisions about withdrawingRRT should be consideredtogether with other therapies

Before

Before CRRT is started patients should have

a complete nursing assessment

bull Fluid status

bull Fluid input

bull Blood pressure

bull Dosages of any vasopressors

bull Weightbull Presence of edemabull CVPbull NaK and ABGs

Nursing Management

During

Once CRRT is started

bull Blood pressure central venous pressure andweight monitoring

bull The bedside nurse should discuss the possibilityof reducing intake to minimal volumes of fluidsif at all possible and concentrating medicationsand infusions to minimize fluid intake if thetarget not acheived

bull Mechanical failures can occur if alarms are ignored or bypassed without determining the cause of the alarms

bull If scales are not properly calibrated the volumes of fluid administered and removed may not be the programmed volumes

541 We suggest initiating RRT in patients with AKI via an uncuffed non tunneled dialysis catheter rather than a tunneled catheter (2D)

542 When choosing a vein for insertion of a dialysis catheter in patients with AKI consider these preferences (Not Graded)

bull First choice right jugular vein

bull Second choice femoral vein

bull Third choice left jugular vein

bull Last choice subclavian vein with preference for the dominant side

Anticoagulation

CRRT can be performed with or without anticoagulation

The choice of anticoagulant depends on

bull The physicianrsquos preference

bull The patientrsquos condition

bull The familiarity of the nursing staff with anticoagulation regimens

The bedside nurse is responsiblefor monitoring any adverse effectsof anticoagulation includinghemorrhage formation ofhematomas thrombocytopeniaand allergic reactions

Heparin

bull The least expensive anticoagulant

bull Either systemically or regionally

When heparin is used

bull The hemofilter may be flushed with a dilute heparin solution continuously or intermittently

Systemic heparinization includes

bull Infusing heparin into a separate intravenous access or into the arterial side of the CRRT circuit

bull Mixing of the heparin with the blood from the patient before the blood reaches the filter

bull Anticoagulation of the circuit as well as for the patient

Argatroban and lepirudin

bullDirect thrombin inhibitors

bullHIT

Lepirudin is cleared by the kidneys and therefore may not be the drug of choice

for patients in ARF

Argatroban is eliminated by the liver and is therefore more suitable for use in

patients with renal failure

Citrate

excellent anticoagulant ability and potential to prolong circuit life

bull Calcium is an essential component of the clotting cascade

bull Citrate binds to the calcium in the patientrsquos blood within the CRRT system and prevents clotting

Citrate is infused prefilter into the CRRT system and calcium is typically infused via another intravenous line outside the circuit

Ionized calcium levels are routinely monitored

1048708Heparin

bull 250500 Uhr

1048708HIT Argatroban

bull 1048708051 mghr

1048708Bleeding risk

bull 1048708Citrate

bull 1048708No anticoagulation

Dialysate

Conculsions

Critically ill patients AKI occurs in up to 30 of all ICU admissions

CRRT is almost exclusively applied to patients in (ICU)

Restrict monitoring and follow up of the patients during CRRT is mandatory

Well trained nurse is the corner stone of adequate CRRT

562 We suggest using CRRT rather thanstandard intermittent RRT for hemodynamicallyunstable patients (2B)

563 We suggest using CRRT rather thanintermittent RRT for AKI patients with acute braininjury or other causes of increased intracranialpressure or generalized brain edema (2B)

Indications for CRRT

bullCRRT is an effective method toremove fluid and to achieve a targetfluid balance in patients with fluidoverload including those withcongestive cardiac failure (CCF) oracute lung injury

RRT is also effective at removingbiologically active substancesincluding cytokines butthere is still insufficientevidence to recommend the routineuse of CRRT for the treatment ofsepsis

When should acute RRT be initiated

Consensus statement 12

bullDemand for kidney function isdetermined by non-renalcomorbidities the severity ofthe acute disease and solute andfluid burden

When should acute RRT be initiated

Consensus statement 13

bullTotal kidney function is measuredusing a variety of different methodsChanges in kidney function andduration of kidney dysfunction canbe anticipated by markers of kidneydamage

When should acute RRT be initiated

Consensus statement 14

bullThe demandndashcapacityimbalance is dynamicand should be evaluatedregularly

When should acute RRT be initiated

Consensus statement 15

bullFor patients requiring multipletypes of organ support decisionsabout initiating or withholdingRRT should be consideredtogether with other therapies

When should acute RRT be initiated

Consensus statement 16

bullOnce the decision to initiateRRT has been made thetherapy should be started assoon as possible typicallywithin less than 3 h

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 21

bull Selection of RRT modality depends on thecapabilityavailability of the technology

bull Different RRT modalities provide differentcapabilities

bull different machines may provide some butnot all modalities

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 22

bull CRRT recommended in situations whereshifts in fluid balance and metabolicfluctuations are poorly tolerated

bull Intermittent and prolonged intermittenttypes of RRT have a role when fluid andmetabolic fluctuations can be tolerated

Both CRRT and IHD achieve adequate

metabolic control and neither modality has

been shown to be superior in terms of

survival

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 23

bullAvailability of technologies isdetermined by local regulationslocal resources including stafftheir trainingexperience andlaboratory support and financialconstraints

bullSCUF (slow continuous ultrafiltration)

bullCVVH (continuous veno-venous haemofiltration

bullCVVHD (continuous veno-venous haemodialysis)

bullCVVHDF (continuous veno-venous haemodiafiltration

How should RRT be integrated into other extracorporeal therapies

bull Consensus statement 31

In situations where other extracorporealtherapies are required continuous RRT isrecommended and integrated systems arepreferred over parallel systems

extracorporeal liver assist devices (ELADs)

ECLS in Cardiac Failure

When should transition of modalities be considered (CRRT IRRT hybrid therapy)

Consensus statement 41

bullTransition of modalities should beconsidered if the demandndashcapacityimbalance or treatment prioritieshave changed and can be metbetter by an alternative technique

How should patients be liberated from RRT

RRT should bediscontinued ifkidney functionhas recovered

Consensus statement

51

How should patients be liberated from RRT

Consensus statement 52

bullTo determine sustainedrecovery of kidney functionwe recommend monitoring ofurine output and SCr duringRRT

How should patients be liberated from RRT

C onsensus statement 53

bullFor patients requiring multipletypes of organ supportdecisions about withdrawingRRT should be consideredtogether with other therapies

Before

Before CRRT is started patients should have

a complete nursing assessment

bull Fluid status

bull Fluid input

bull Blood pressure

bull Dosages of any vasopressors

bull Weightbull Presence of edemabull CVPbull NaK and ABGs

Nursing Management

During

Once CRRT is started

bull Blood pressure central venous pressure andweight monitoring

bull The bedside nurse should discuss the possibilityof reducing intake to minimal volumes of fluidsif at all possible and concentrating medicationsand infusions to minimize fluid intake if thetarget not acheived

bull Mechanical failures can occur if alarms are ignored or bypassed without determining the cause of the alarms

bull If scales are not properly calibrated the volumes of fluid administered and removed may not be the programmed volumes

541 We suggest initiating RRT in patients with AKI via an uncuffed non tunneled dialysis catheter rather than a tunneled catheter (2D)

542 When choosing a vein for insertion of a dialysis catheter in patients with AKI consider these preferences (Not Graded)

bull First choice right jugular vein

bull Second choice femoral vein

bull Third choice left jugular vein

bull Last choice subclavian vein with preference for the dominant side

Anticoagulation

CRRT can be performed with or without anticoagulation

The choice of anticoagulant depends on

bull The physicianrsquos preference

bull The patientrsquos condition

bull The familiarity of the nursing staff with anticoagulation regimens

The bedside nurse is responsiblefor monitoring any adverse effectsof anticoagulation includinghemorrhage formation ofhematomas thrombocytopeniaand allergic reactions

Heparin

bull The least expensive anticoagulant

bull Either systemically or regionally

When heparin is used

bull The hemofilter may be flushed with a dilute heparin solution continuously or intermittently

Systemic heparinization includes

bull Infusing heparin into a separate intravenous access or into the arterial side of the CRRT circuit

bull Mixing of the heparin with the blood from the patient before the blood reaches the filter

bull Anticoagulation of the circuit as well as for the patient

Argatroban and lepirudin

bullDirect thrombin inhibitors

bullHIT

Lepirudin is cleared by the kidneys and therefore may not be the drug of choice

for patients in ARF

Argatroban is eliminated by the liver and is therefore more suitable for use in

patients with renal failure

Citrate

excellent anticoagulant ability and potential to prolong circuit life

bull Calcium is an essential component of the clotting cascade

bull Citrate binds to the calcium in the patientrsquos blood within the CRRT system and prevents clotting

Citrate is infused prefilter into the CRRT system and calcium is typically infused via another intravenous line outside the circuit

Ionized calcium levels are routinely monitored

1048708Heparin

bull 250500 Uhr

1048708HIT Argatroban

bull 1048708051 mghr

1048708Bleeding risk

bull 1048708Citrate

bull 1048708No anticoagulation

Dialysate

Conculsions

Critically ill patients AKI occurs in up to 30 of all ICU admissions

CRRT is almost exclusively applied to patients in (ICU)

Restrict monitoring and follow up of the patients during CRRT is mandatory

Well trained nurse is the corner stone of adequate CRRT

Indications for CRRT

bullCRRT is an effective method toremove fluid and to achieve a targetfluid balance in patients with fluidoverload including those withcongestive cardiac failure (CCF) oracute lung injury

RRT is also effective at removingbiologically active substancesincluding cytokines butthere is still insufficientevidence to recommend the routineuse of CRRT for the treatment ofsepsis

When should acute RRT be initiated

Consensus statement 12

bullDemand for kidney function isdetermined by non-renalcomorbidities the severity ofthe acute disease and solute andfluid burden

When should acute RRT be initiated

Consensus statement 13

bullTotal kidney function is measuredusing a variety of different methodsChanges in kidney function andduration of kidney dysfunction canbe anticipated by markers of kidneydamage

When should acute RRT be initiated

Consensus statement 14

bullThe demandndashcapacityimbalance is dynamicand should be evaluatedregularly

When should acute RRT be initiated

Consensus statement 15

bullFor patients requiring multipletypes of organ support decisionsabout initiating or withholdingRRT should be consideredtogether with other therapies

When should acute RRT be initiated

Consensus statement 16

bullOnce the decision to initiateRRT has been made thetherapy should be started assoon as possible typicallywithin less than 3 h

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 21

bull Selection of RRT modality depends on thecapabilityavailability of the technology

bull Different RRT modalities provide differentcapabilities

bull different machines may provide some butnot all modalities

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 22

bull CRRT recommended in situations whereshifts in fluid balance and metabolicfluctuations are poorly tolerated

bull Intermittent and prolonged intermittenttypes of RRT have a role when fluid andmetabolic fluctuations can be tolerated

Both CRRT and IHD achieve adequate

metabolic control and neither modality has

been shown to be superior in terms of

survival

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 23

bullAvailability of technologies isdetermined by local regulationslocal resources including stafftheir trainingexperience andlaboratory support and financialconstraints

bullSCUF (slow continuous ultrafiltration)

bullCVVH (continuous veno-venous haemofiltration

bullCVVHD (continuous veno-venous haemodialysis)

bullCVVHDF (continuous veno-venous haemodiafiltration

How should RRT be integrated into other extracorporeal therapies

bull Consensus statement 31

In situations where other extracorporealtherapies are required continuous RRT isrecommended and integrated systems arepreferred over parallel systems

extracorporeal liver assist devices (ELADs)

ECLS in Cardiac Failure

When should transition of modalities be considered (CRRT IRRT hybrid therapy)

Consensus statement 41

bullTransition of modalities should beconsidered if the demandndashcapacityimbalance or treatment prioritieshave changed and can be metbetter by an alternative technique

How should patients be liberated from RRT

RRT should bediscontinued ifkidney functionhas recovered

Consensus statement

51

How should patients be liberated from RRT

Consensus statement 52

bullTo determine sustainedrecovery of kidney functionwe recommend monitoring ofurine output and SCr duringRRT

How should patients be liberated from RRT

C onsensus statement 53

bullFor patients requiring multipletypes of organ supportdecisions about withdrawingRRT should be consideredtogether with other therapies

Before

Before CRRT is started patients should have

a complete nursing assessment

bull Fluid status

bull Fluid input

bull Blood pressure

bull Dosages of any vasopressors

bull Weightbull Presence of edemabull CVPbull NaK and ABGs

Nursing Management

During

Once CRRT is started

bull Blood pressure central venous pressure andweight monitoring

bull The bedside nurse should discuss the possibilityof reducing intake to minimal volumes of fluidsif at all possible and concentrating medicationsand infusions to minimize fluid intake if thetarget not acheived

bull Mechanical failures can occur if alarms are ignored or bypassed without determining the cause of the alarms

bull If scales are not properly calibrated the volumes of fluid administered and removed may not be the programmed volumes

541 We suggest initiating RRT in patients with AKI via an uncuffed non tunneled dialysis catheter rather than a tunneled catheter (2D)

542 When choosing a vein for insertion of a dialysis catheter in patients with AKI consider these preferences (Not Graded)

bull First choice right jugular vein

bull Second choice femoral vein

bull Third choice left jugular vein

bull Last choice subclavian vein with preference for the dominant side

Anticoagulation

CRRT can be performed with or without anticoagulation

The choice of anticoagulant depends on

bull The physicianrsquos preference

bull The patientrsquos condition

bull The familiarity of the nursing staff with anticoagulation regimens

The bedside nurse is responsiblefor monitoring any adverse effectsof anticoagulation includinghemorrhage formation ofhematomas thrombocytopeniaand allergic reactions

Heparin

bull The least expensive anticoagulant

bull Either systemically or regionally

When heparin is used

bull The hemofilter may be flushed with a dilute heparin solution continuously or intermittently

Systemic heparinization includes

bull Infusing heparin into a separate intravenous access or into the arterial side of the CRRT circuit

bull Mixing of the heparin with the blood from the patient before the blood reaches the filter

bull Anticoagulation of the circuit as well as for the patient

Argatroban and lepirudin

bullDirect thrombin inhibitors

bullHIT

Lepirudin is cleared by the kidneys and therefore may not be the drug of choice

for patients in ARF

Argatroban is eliminated by the liver and is therefore more suitable for use in

patients with renal failure

Citrate

excellent anticoagulant ability and potential to prolong circuit life

bull Calcium is an essential component of the clotting cascade

bull Citrate binds to the calcium in the patientrsquos blood within the CRRT system and prevents clotting

Citrate is infused prefilter into the CRRT system and calcium is typically infused via another intravenous line outside the circuit

Ionized calcium levels are routinely monitored

1048708Heparin

bull 250500 Uhr

1048708HIT Argatroban

bull 1048708051 mghr

1048708Bleeding risk

bull 1048708Citrate

bull 1048708No anticoagulation

Dialysate

Conculsions

Critically ill patients AKI occurs in up to 30 of all ICU admissions

CRRT is almost exclusively applied to patients in (ICU)

Restrict monitoring and follow up of the patients during CRRT is mandatory

Well trained nurse is the corner stone of adequate CRRT

RRT is also effective at removingbiologically active substancesincluding cytokines butthere is still insufficientevidence to recommend the routineuse of CRRT for the treatment ofsepsis

When should acute RRT be initiated

Consensus statement 12

bullDemand for kidney function isdetermined by non-renalcomorbidities the severity ofthe acute disease and solute andfluid burden

When should acute RRT be initiated

Consensus statement 13

bullTotal kidney function is measuredusing a variety of different methodsChanges in kidney function andduration of kidney dysfunction canbe anticipated by markers of kidneydamage

When should acute RRT be initiated

Consensus statement 14

bullThe demandndashcapacityimbalance is dynamicand should be evaluatedregularly

When should acute RRT be initiated

Consensus statement 15

bullFor patients requiring multipletypes of organ support decisionsabout initiating or withholdingRRT should be consideredtogether with other therapies

When should acute RRT be initiated

Consensus statement 16

bullOnce the decision to initiateRRT has been made thetherapy should be started assoon as possible typicallywithin less than 3 h

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 21

bull Selection of RRT modality depends on thecapabilityavailability of the technology

bull Different RRT modalities provide differentcapabilities

bull different machines may provide some butnot all modalities

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 22

bull CRRT recommended in situations whereshifts in fluid balance and metabolicfluctuations are poorly tolerated

bull Intermittent and prolonged intermittenttypes of RRT have a role when fluid andmetabolic fluctuations can be tolerated

Both CRRT and IHD achieve adequate

metabolic control and neither modality has

been shown to be superior in terms of

survival

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 23

bullAvailability of technologies isdetermined by local regulationslocal resources including stafftheir trainingexperience andlaboratory support and financialconstraints

bullSCUF (slow continuous ultrafiltration)

bullCVVH (continuous veno-venous haemofiltration

bullCVVHD (continuous veno-venous haemodialysis)

bullCVVHDF (continuous veno-venous haemodiafiltration

How should RRT be integrated into other extracorporeal therapies

bull Consensus statement 31

In situations where other extracorporealtherapies are required continuous RRT isrecommended and integrated systems arepreferred over parallel systems

extracorporeal liver assist devices (ELADs)

ECLS in Cardiac Failure

When should transition of modalities be considered (CRRT IRRT hybrid therapy)

Consensus statement 41

bullTransition of modalities should beconsidered if the demandndashcapacityimbalance or treatment prioritieshave changed and can be metbetter by an alternative technique

How should patients be liberated from RRT

RRT should bediscontinued ifkidney functionhas recovered

Consensus statement

51

How should patients be liberated from RRT

Consensus statement 52

bullTo determine sustainedrecovery of kidney functionwe recommend monitoring ofurine output and SCr duringRRT

How should patients be liberated from RRT

C onsensus statement 53

bullFor patients requiring multipletypes of organ supportdecisions about withdrawingRRT should be consideredtogether with other therapies

Before

Before CRRT is started patients should have

a complete nursing assessment

bull Fluid status

bull Fluid input

bull Blood pressure

bull Dosages of any vasopressors

bull Weightbull Presence of edemabull CVPbull NaK and ABGs

Nursing Management

During

Once CRRT is started

bull Blood pressure central venous pressure andweight monitoring

bull The bedside nurse should discuss the possibilityof reducing intake to minimal volumes of fluidsif at all possible and concentrating medicationsand infusions to minimize fluid intake if thetarget not acheived

bull Mechanical failures can occur if alarms are ignored or bypassed without determining the cause of the alarms

bull If scales are not properly calibrated the volumes of fluid administered and removed may not be the programmed volumes

541 We suggest initiating RRT in patients with AKI via an uncuffed non tunneled dialysis catheter rather than a tunneled catheter (2D)

542 When choosing a vein for insertion of a dialysis catheter in patients with AKI consider these preferences (Not Graded)

bull First choice right jugular vein

bull Second choice femoral vein

bull Third choice left jugular vein

bull Last choice subclavian vein with preference for the dominant side

Anticoagulation

CRRT can be performed with or without anticoagulation

The choice of anticoagulant depends on

bull The physicianrsquos preference

bull The patientrsquos condition

bull The familiarity of the nursing staff with anticoagulation regimens

The bedside nurse is responsiblefor monitoring any adverse effectsof anticoagulation includinghemorrhage formation ofhematomas thrombocytopeniaand allergic reactions

Heparin

bull The least expensive anticoagulant

bull Either systemically or regionally

When heparin is used

bull The hemofilter may be flushed with a dilute heparin solution continuously or intermittently

Systemic heparinization includes

bull Infusing heparin into a separate intravenous access or into the arterial side of the CRRT circuit

bull Mixing of the heparin with the blood from the patient before the blood reaches the filter

bull Anticoagulation of the circuit as well as for the patient

Argatroban and lepirudin

bullDirect thrombin inhibitors

bullHIT

Lepirudin is cleared by the kidneys and therefore may not be the drug of choice

for patients in ARF

Argatroban is eliminated by the liver and is therefore more suitable for use in

patients with renal failure

Citrate

excellent anticoagulant ability and potential to prolong circuit life

bull Calcium is an essential component of the clotting cascade

bull Citrate binds to the calcium in the patientrsquos blood within the CRRT system and prevents clotting

Citrate is infused prefilter into the CRRT system and calcium is typically infused via another intravenous line outside the circuit

Ionized calcium levels are routinely monitored

1048708Heparin

bull 250500 Uhr

1048708HIT Argatroban

bull 1048708051 mghr

1048708Bleeding risk

bull 1048708Citrate

bull 1048708No anticoagulation

Dialysate

Conculsions

Critically ill patients AKI occurs in up to 30 of all ICU admissions

CRRT is almost exclusively applied to patients in (ICU)

Restrict monitoring and follow up of the patients during CRRT is mandatory

Well trained nurse is the corner stone of adequate CRRT

When should acute RRT be initiated

Consensus statement 12

bullDemand for kidney function isdetermined by non-renalcomorbidities the severity ofthe acute disease and solute andfluid burden

When should acute RRT be initiated

Consensus statement 13

bullTotal kidney function is measuredusing a variety of different methodsChanges in kidney function andduration of kidney dysfunction canbe anticipated by markers of kidneydamage

When should acute RRT be initiated

Consensus statement 14

bullThe demandndashcapacityimbalance is dynamicand should be evaluatedregularly

When should acute RRT be initiated

Consensus statement 15

bullFor patients requiring multipletypes of organ support decisionsabout initiating or withholdingRRT should be consideredtogether with other therapies

When should acute RRT be initiated

Consensus statement 16

bullOnce the decision to initiateRRT has been made thetherapy should be started assoon as possible typicallywithin less than 3 h

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 21

bull Selection of RRT modality depends on thecapabilityavailability of the technology

bull Different RRT modalities provide differentcapabilities

bull different machines may provide some butnot all modalities

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 22

bull CRRT recommended in situations whereshifts in fluid balance and metabolicfluctuations are poorly tolerated

bull Intermittent and prolonged intermittenttypes of RRT have a role when fluid andmetabolic fluctuations can be tolerated

Both CRRT and IHD achieve adequate

metabolic control and neither modality has

been shown to be superior in terms of

survival

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 23

bullAvailability of technologies isdetermined by local regulationslocal resources including stafftheir trainingexperience andlaboratory support and financialconstraints

bullSCUF (slow continuous ultrafiltration)

bullCVVH (continuous veno-venous haemofiltration

bullCVVHD (continuous veno-venous haemodialysis)

bullCVVHDF (continuous veno-venous haemodiafiltration

How should RRT be integrated into other extracorporeal therapies

bull Consensus statement 31

In situations where other extracorporealtherapies are required continuous RRT isrecommended and integrated systems arepreferred over parallel systems

extracorporeal liver assist devices (ELADs)

ECLS in Cardiac Failure

When should transition of modalities be considered (CRRT IRRT hybrid therapy)

Consensus statement 41

bullTransition of modalities should beconsidered if the demandndashcapacityimbalance or treatment prioritieshave changed and can be metbetter by an alternative technique

How should patients be liberated from RRT

RRT should bediscontinued ifkidney functionhas recovered

Consensus statement

51

How should patients be liberated from RRT

Consensus statement 52

bullTo determine sustainedrecovery of kidney functionwe recommend monitoring ofurine output and SCr duringRRT

How should patients be liberated from RRT

C onsensus statement 53

bullFor patients requiring multipletypes of organ supportdecisions about withdrawingRRT should be consideredtogether with other therapies

Before

Before CRRT is started patients should have

a complete nursing assessment

bull Fluid status

bull Fluid input

bull Blood pressure

bull Dosages of any vasopressors

bull Weightbull Presence of edemabull CVPbull NaK and ABGs

Nursing Management

During

Once CRRT is started

bull Blood pressure central venous pressure andweight monitoring

bull The bedside nurse should discuss the possibilityof reducing intake to minimal volumes of fluidsif at all possible and concentrating medicationsand infusions to minimize fluid intake if thetarget not acheived

bull Mechanical failures can occur if alarms are ignored or bypassed without determining the cause of the alarms

bull If scales are not properly calibrated the volumes of fluid administered and removed may not be the programmed volumes

541 We suggest initiating RRT in patients with AKI via an uncuffed non tunneled dialysis catheter rather than a tunneled catheter (2D)

542 When choosing a vein for insertion of a dialysis catheter in patients with AKI consider these preferences (Not Graded)

bull First choice right jugular vein

bull Second choice femoral vein

bull Third choice left jugular vein

bull Last choice subclavian vein with preference for the dominant side

Anticoagulation

CRRT can be performed with or without anticoagulation

The choice of anticoagulant depends on

bull The physicianrsquos preference

bull The patientrsquos condition

bull The familiarity of the nursing staff with anticoagulation regimens

The bedside nurse is responsiblefor monitoring any adverse effectsof anticoagulation includinghemorrhage formation ofhematomas thrombocytopeniaand allergic reactions

Heparin

bull The least expensive anticoagulant

bull Either systemically or regionally

When heparin is used

bull The hemofilter may be flushed with a dilute heparin solution continuously or intermittently

Systemic heparinization includes

bull Infusing heparin into a separate intravenous access or into the arterial side of the CRRT circuit

bull Mixing of the heparin with the blood from the patient before the blood reaches the filter

bull Anticoagulation of the circuit as well as for the patient

Argatroban and lepirudin

bullDirect thrombin inhibitors

bullHIT

Lepirudin is cleared by the kidneys and therefore may not be the drug of choice

for patients in ARF

Argatroban is eliminated by the liver and is therefore more suitable for use in

patients with renal failure

Citrate

excellent anticoagulant ability and potential to prolong circuit life

bull Calcium is an essential component of the clotting cascade

bull Citrate binds to the calcium in the patientrsquos blood within the CRRT system and prevents clotting

Citrate is infused prefilter into the CRRT system and calcium is typically infused via another intravenous line outside the circuit

Ionized calcium levels are routinely monitored

1048708Heparin

bull 250500 Uhr

1048708HIT Argatroban

bull 1048708051 mghr

1048708Bleeding risk

bull 1048708Citrate

bull 1048708No anticoagulation

Dialysate

Conculsions

Critically ill patients AKI occurs in up to 30 of all ICU admissions

CRRT is almost exclusively applied to patients in (ICU)

Restrict monitoring and follow up of the patients during CRRT is mandatory

Well trained nurse is the corner stone of adequate CRRT

When should acute RRT be initiated

Consensus statement 13

bullTotal kidney function is measuredusing a variety of different methodsChanges in kidney function andduration of kidney dysfunction canbe anticipated by markers of kidneydamage

When should acute RRT be initiated

Consensus statement 14

bullThe demandndashcapacityimbalance is dynamicand should be evaluatedregularly

When should acute RRT be initiated

Consensus statement 15

bullFor patients requiring multipletypes of organ support decisionsabout initiating or withholdingRRT should be consideredtogether with other therapies

When should acute RRT be initiated

Consensus statement 16

bullOnce the decision to initiateRRT has been made thetherapy should be started assoon as possible typicallywithin less than 3 h

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 21

bull Selection of RRT modality depends on thecapabilityavailability of the technology

bull Different RRT modalities provide differentcapabilities

bull different machines may provide some butnot all modalities

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 22

bull CRRT recommended in situations whereshifts in fluid balance and metabolicfluctuations are poorly tolerated

bull Intermittent and prolonged intermittenttypes of RRT have a role when fluid andmetabolic fluctuations can be tolerated

Both CRRT and IHD achieve adequate

metabolic control and neither modality has

been shown to be superior in terms of

survival

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 23

bullAvailability of technologies isdetermined by local regulationslocal resources including stafftheir trainingexperience andlaboratory support and financialconstraints

bullSCUF (slow continuous ultrafiltration)

bullCVVH (continuous veno-venous haemofiltration

bullCVVHD (continuous veno-venous haemodialysis)

bullCVVHDF (continuous veno-venous haemodiafiltration

How should RRT be integrated into other extracorporeal therapies

bull Consensus statement 31

In situations where other extracorporealtherapies are required continuous RRT isrecommended and integrated systems arepreferred over parallel systems

extracorporeal liver assist devices (ELADs)

ECLS in Cardiac Failure

When should transition of modalities be considered (CRRT IRRT hybrid therapy)

Consensus statement 41

bullTransition of modalities should beconsidered if the demandndashcapacityimbalance or treatment prioritieshave changed and can be metbetter by an alternative technique

How should patients be liberated from RRT

RRT should bediscontinued ifkidney functionhas recovered

Consensus statement

51

How should patients be liberated from RRT

Consensus statement 52

bullTo determine sustainedrecovery of kidney functionwe recommend monitoring ofurine output and SCr duringRRT

How should patients be liberated from RRT

C onsensus statement 53

bullFor patients requiring multipletypes of organ supportdecisions about withdrawingRRT should be consideredtogether with other therapies

Before

Before CRRT is started patients should have

a complete nursing assessment

bull Fluid status

bull Fluid input

bull Blood pressure

bull Dosages of any vasopressors

bull Weightbull Presence of edemabull CVPbull NaK and ABGs

Nursing Management

During

Once CRRT is started

bull Blood pressure central venous pressure andweight monitoring

bull The bedside nurse should discuss the possibilityof reducing intake to minimal volumes of fluidsif at all possible and concentrating medicationsand infusions to minimize fluid intake if thetarget not acheived

bull Mechanical failures can occur if alarms are ignored or bypassed without determining the cause of the alarms

bull If scales are not properly calibrated the volumes of fluid administered and removed may not be the programmed volumes

541 We suggest initiating RRT in patients with AKI via an uncuffed non tunneled dialysis catheter rather than a tunneled catheter (2D)

542 When choosing a vein for insertion of a dialysis catheter in patients with AKI consider these preferences (Not Graded)

bull First choice right jugular vein

bull Second choice femoral vein

bull Third choice left jugular vein

bull Last choice subclavian vein with preference for the dominant side

Anticoagulation

CRRT can be performed with or without anticoagulation

The choice of anticoagulant depends on

bull The physicianrsquos preference

bull The patientrsquos condition

bull The familiarity of the nursing staff with anticoagulation regimens

The bedside nurse is responsiblefor monitoring any adverse effectsof anticoagulation includinghemorrhage formation ofhematomas thrombocytopeniaand allergic reactions

Heparin

bull The least expensive anticoagulant

bull Either systemically or regionally

When heparin is used

bull The hemofilter may be flushed with a dilute heparin solution continuously or intermittently

Systemic heparinization includes

bull Infusing heparin into a separate intravenous access or into the arterial side of the CRRT circuit

bull Mixing of the heparin with the blood from the patient before the blood reaches the filter

bull Anticoagulation of the circuit as well as for the patient

Argatroban and lepirudin

bullDirect thrombin inhibitors

bullHIT

Lepirudin is cleared by the kidneys and therefore may not be the drug of choice

for patients in ARF

Argatroban is eliminated by the liver and is therefore more suitable for use in

patients with renal failure

Citrate

excellent anticoagulant ability and potential to prolong circuit life

bull Calcium is an essential component of the clotting cascade

bull Citrate binds to the calcium in the patientrsquos blood within the CRRT system and prevents clotting

Citrate is infused prefilter into the CRRT system and calcium is typically infused via another intravenous line outside the circuit

Ionized calcium levels are routinely monitored

1048708Heparin

bull 250500 Uhr

1048708HIT Argatroban

bull 1048708051 mghr

1048708Bleeding risk

bull 1048708Citrate

bull 1048708No anticoagulation

Dialysate

Conculsions

Critically ill patients AKI occurs in up to 30 of all ICU admissions

CRRT is almost exclusively applied to patients in (ICU)

Restrict monitoring and follow up of the patients during CRRT is mandatory

Well trained nurse is the corner stone of adequate CRRT

When should acute RRT be initiated

Consensus statement 14

bullThe demandndashcapacityimbalance is dynamicand should be evaluatedregularly

When should acute RRT be initiated

Consensus statement 15

bullFor patients requiring multipletypes of organ support decisionsabout initiating or withholdingRRT should be consideredtogether with other therapies

When should acute RRT be initiated

Consensus statement 16

bullOnce the decision to initiateRRT has been made thetherapy should be started assoon as possible typicallywithin less than 3 h

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 21

bull Selection of RRT modality depends on thecapabilityavailability of the technology

bull Different RRT modalities provide differentcapabilities

bull different machines may provide some butnot all modalities

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 22

bull CRRT recommended in situations whereshifts in fluid balance and metabolicfluctuations are poorly tolerated

bull Intermittent and prolonged intermittenttypes of RRT have a role when fluid andmetabolic fluctuations can be tolerated

Both CRRT and IHD achieve adequate

metabolic control and neither modality has

been shown to be superior in terms of

survival

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 23

bullAvailability of technologies isdetermined by local regulationslocal resources including stafftheir trainingexperience andlaboratory support and financialconstraints

bullSCUF (slow continuous ultrafiltration)

bullCVVH (continuous veno-venous haemofiltration

bullCVVHD (continuous veno-venous haemodialysis)

bullCVVHDF (continuous veno-venous haemodiafiltration

How should RRT be integrated into other extracorporeal therapies

bull Consensus statement 31

In situations where other extracorporealtherapies are required continuous RRT isrecommended and integrated systems arepreferred over parallel systems

extracorporeal liver assist devices (ELADs)

ECLS in Cardiac Failure

When should transition of modalities be considered (CRRT IRRT hybrid therapy)

Consensus statement 41

bullTransition of modalities should beconsidered if the demandndashcapacityimbalance or treatment prioritieshave changed and can be metbetter by an alternative technique

How should patients be liberated from RRT

RRT should bediscontinued ifkidney functionhas recovered

Consensus statement

51

How should patients be liberated from RRT

Consensus statement 52

bullTo determine sustainedrecovery of kidney functionwe recommend monitoring ofurine output and SCr duringRRT

How should patients be liberated from RRT

C onsensus statement 53

bullFor patients requiring multipletypes of organ supportdecisions about withdrawingRRT should be consideredtogether with other therapies

Before

Before CRRT is started patients should have

a complete nursing assessment

bull Fluid status

bull Fluid input

bull Blood pressure

bull Dosages of any vasopressors

bull Weightbull Presence of edemabull CVPbull NaK and ABGs

Nursing Management

During

Once CRRT is started

bull Blood pressure central venous pressure andweight monitoring

bull The bedside nurse should discuss the possibilityof reducing intake to minimal volumes of fluidsif at all possible and concentrating medicationsand infusions to minimize fluid intake if thetarget not acheived

bull Mechanical failures can occur if alarms are ignored or bypassed without determining the cause of the alarms

bull If scales are not properly calibrated the volumes of fluid administered and removed may not be the programmed volumes

541 We suggest initiating RRT in patients with AKI via an uncuffed non tunneled dialysis catheter rather than a tunneled catheter (2D)

542 When choosing a vein for insertion of a dialysis catheter in patients with AKI consider these preferences (Not Graded)

bull First choice right jugular vein

bull Second choice femoral vein

bull Third choice left jugular vein

bull Last choice subclavian vein with preference for the dominant side

Anticoagulation

CRRT can be performed with or without anticoagulation

The choice of anticoagulant depends on

bull The physicianrsquos preference

bull The patientrsquos condition

bull The familiarity of the nursing staff with anticoagulation regimens

The bedside nurse is responsiblefor monitoring any adverse effectsof anticoagulation includinghemorrhage formation ofhematomas thrombocytopeniaand allergic reactions

Heparin

bull The least expensive anticoagulant

bull Either systemically or regionally

When heparin is used

bull The hemofilter may be flushed with a dilute heparin solution continuously or intermittently

Systemic heparinization includes

bull Infusing heparin into a separate intravenous access or into the arterial side of the CRRT circuit

bull Mixing of the heparin with the blood from the patient before the blood reaches the filter

bull Anticoagulation of the circuit as well as for the patient

Argatroban and lepirudin

bullDirect thrombin inhibitors

bullHIT

Lepirudin is cleared by the kidneys and therefore may not be the drug of choice

for patients in ARF

Argatroban is eliminated by the liver and is therefore more suitable for use in

patients with renal failure

Citrate

excellent anticoagulant ability and potential to prolong circuit life

bull Calcium is an essential component of the clotting cascade

bull Citrate binds to the calcium in the patientrsquos blood within the CRRT system and prevents clotting

Citrate is infused prefilter into the CRRT system and calcium is typically infused via another intravenous line outside the circuit

Ionized calcium levels are routinely monitored

1048708Heparin

bull 250500 Uhr

1048708HIT Argatroban

bull 1048708051 mghr

1048708Bleeding risk

bull 1048708Citrate

bull 1048708No anticoagulation

Dialysate

Conculsions

Critically ill patients AKI occurs in up to 30 of all ICU admissions

CRRT is almost exclusively applied to patients in (ICU)

Restrict monitoring and follow up of the patients during CRRT is mandatory

Well trained nurse is the corner stone of adequate CRRT

When should acute RRT be initiated

Consensus statement 15

bullFor patients requiring multipletypes of organ support decisionsabout initiating or withholdingRRT should be consideredtogether with other therapies

When should acute RRT be initiated

Consensus statement 16

bullOnce the decision to initiateRRT has been made thetherapy should be started assoon as possible typicallywithin less than 3 h

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 21

bull Selection of RRT modality depends on thecapabilityavailability of the technology

bull Different RRT modalities provide differentcapabilities

bull different machines may provide some butnot all modalities

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 22

bull CRRT recommended in situations whereshifts in fluid balance and metabolicfluctuations are poorly tolerated

bull Intermittent and prolonged intermittenttypes of RRT have a role when fluid andmetabolic fluctuations can be tolerated

Both CRRT and IHD achieve adequate

metabolic control and neither modality has

been shown to be superior in terms of

survival

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 23

bullAvailability of technologies isdetermined by local regulationslocal resources including stafftheir trainingexperience andlaboratory support and financialconstraints

bullSCUF (slow continuous ultrafiltration)

bullCVVH (continuous veno-venous haemofiltration

bullCVVHD (continuous veno-venous haemodialysis)

bullCVVHDF (continuous veno-venous haemodiafiltration

How should RRT be integrated into other extracorporeal therapies

bull Consensus statement 31

In situations where other extracorporealtherapies are required continuous RRT isrecommended and integrated systems arepreferred over parallel systems

extracorporeal liver assist devices (ELADs)

ECLS in Cardiac Failure

When should transition of modalities be considered (CRRT IRRT hybrid therapy)

Consensus statement 41

bullTransition of modalities should beconsidered if the demandndashcapacityimbalance or treatment prioritieshave changed and can be metbetter by an alternative technique

How should patients be liberated from RRT

RRT should bediscontinued ifkidney functionhas recovered

Consensus statement

51

How should patients be liberated from RRT

Consensus statement 52

bullTo determine sustainedrecovery of kidney functionwe recommend monitoring ofurine output and SCr duringRRT

How should patients be liberated from RRT

C onsensus statement 53

bullFor patients requiring multipletypes of organ supportdecisions about withdrawingRRT should be consideredtogether with other therapies

Before

Before CRRT is started patients should have

a complete nursing assessment

bull Fluid status

bull Fluid input

bull Blood pressure

bull Dosages of any vasopressors

bull Weightbull Presence of edemabull CVPbull NaK and ABGs

Nursing Management

During

Once CRRT is started

bull Blood pressure central venous pressure andweight monitoring

bull The bedside nurse should discuss the possibilityof reducing intake to minimal volumes of fluidsif at all possible and concentrating medicationsand infusions to minimize fluid intake if thetarget not acheived

bull Mechanical failures can occur if alarms are ignored or bypassed without determining the cause of the alarms

bull If scales are not properly calibrated the volumes of fluid administered and removed may not be the programmed volumes

541 We suggest initiating RRT in patients with AKI via an uncuffed non tunneled dialysis catheter rather than a tunneled catheter (2D)

542 When choosing a vein for insertion of a dialysis catheter in patients with AKI consider these preferences (Not Graded)

bull First choice right jugular vein

bull Second choice femoral vein

bull Third choice left jugular vein

bull Last choice subclavian vein with preference for the dominant side

Anticoagulation

CRRT can be performed with or without anticoagulation

The choice of anticoagulant depends on

bull The physicianrsquos preference

bull The patientrsquos condition

bull The familiarity of the nursing staff with anticoagulation regimens

The bedside nurse is responsiblefor monitoring any adverse effectsof anticoagulation includinghemorrhage formation ofhematomas thrombocytopeniaand allergic reactions

Heparin

bull The least expensive anticoagulant

bull Either systemically or regionally

When heparin is used

bull The hemofilter may be flushed with a dilute heparin solution continuously or intermittently

Systemic heparinization includes

bull Infusing heparin into a separate intravenous access or into the arterial side of the CRRT circuit

bull Mixing of the heparin with the blood from the patient before the blood reaches the filter

bull Anticoagulation of the circuit as well as for the patient

Argatroban and lepirudin

bullDirect thrombin inhibitors

bullHIT

Lepirudin is cleared by the kidneys and therefore may not be the drug of choice

for patients in ARF

Argatroban is eliminated by the liver and is therefore more suitable for use in

patients with renal failure

Citrate

excellent anticoagulant ability and potential to prolong circuit life

bull Calcium is an essential component of the clotting cascade

bull Citrate binds to the calcium in the patientrsquos blood within the CRRT system and prevents clotting

Citrate is infused prefilter into the CRRT system and calcium is typically infused via another intravenous line outside the circuit

Ionized calcium levels are routinely monitored

1048708Heparin

bull 250500 Uhr

1048708HIT Argatroban

bull 1048708051 mghr

1048708Bleeding risk

bull 1048708Citrate

bull 1048708No anticoagulation

Dialysate

Conculsions

Critically ill patients AKI occurs in up to 30 of all ICU admissions

CRRT is almost exclusively applied to patients in (ICU)

Restrict monitoring and follow up of the patients during CRRT is mandatory

Well trained nurse is the corner stone of adequate CRRT

When should acute RRT be initiated

Consensus statement 16

bullOnce the decision to initiateRRT has been made thetherapy should be started assoon as possible typicallywithin less than 3 h

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 21

bull Selection of RRT modality depends on thecapabilityavailability of the technology

bull Different RRT modalities provide differentcapabilities

bull different machines may provide some butnot all modalities

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 22

bull CRRT recommended in situations whereshifts in fluid balance and metabolicfluctuations are poorly tolerated

bull Intermittent and prolonged intermittenttypes of RRT have a role when fluid andmetabolic fluctuations can be tolerated

Both CRRT and IHD achieve adequate

metabolic control and neither modality has

been shown to be superior in terms of

survival

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 23

bullAvailability of technologies isdetermined by local regulationslocal resources including stafftheir trainingexperience andlaboratory support and financialconstraints

bullSCUF (slow continuous ultrafiltration)

bullCVVH (continuous veno-venous haemofiltration

bullCVVHD (continuous veno-venous haemodialysis)

bullCVVHDF (continuous veno-venous haemodiafiltration

How should RRT be integrated into other extracorporeal therapies

bull Consensus statement 31

In situations where other extracorporealtherapies are required continuous RRT isrecommended and integrated systems arepreferred over parallel systems

extracorporeal liver assist devices (ELADs)

ECLS in Cardiac Failure

When should transition of modalities be considered (CRRT IRRT hybrid therapy)

Consensus statement 41

bullTransition of modalities should beconsidered if the demandndashcapacityimbalance or treatment prioritieshave changed and can be metbetter by an alternative technique

How should patients be liberated from RRT

RRT should bediscontinued ifkidney functionhas recovered

Consensus statement

51

How should patients be liberated from RRT

Consensus statement 52

bullTo determine sustainedrecovery of kidney functionwe recommend monitoring ofurine output and SCr duringRRT

How should patients be liberated from RRT

C onsensus statement 53

bullFor patients requiring multipletypes of organ supportdecisions about withdrawingRRT should be consideredtogether with other therapies

Before

Before CRRT is started patients should have

a complete nursing assessment

bull Fluid status

bull Fluid input

bull Blood pressure

bull Dosages of any vasopressors

bull Weightbull Presence of edemabull CVPbull NaK and ABGs

Nursing Management

During

Once CRRT is started

bull Blood pressure central venous pressure andweight monitoring

bull The bedside nurse should discuss the possibilityof reducing intake to minimal volumes of fluidsif at all possible and concentrating medicationsand infusions to minimize fluid intake if thetarget not acheived

bull Mechanical failures can occur if alarms are ignored or bypassed without determining the cause of the alarms

bull If scales are not properly calibrated the volumes of fluid administered and removed may not be the programmed volumes

541 We suggest initiating RRT in patients with AKI via an uncuffed non tunneled dialysis catheter rather than a tunneled catheter (2D)

542 When choosing a vein for insertion of a dialysis catheter in patients with AKI consider these preferences (Not Graded)

bull First choice right jugular vein

bull Second choice femoral vein

bull Third choice left jugular vein

bull Last choice subclavian vein with preference for the dominant side

Anticoagulation

CRRT can be performed with or without anticoagulation

The choice of anticoagulant depends on

bull The physicianrsquos preference

bull The patientrsquos condition

bull The familiarity of the nursing staff with anticoagulation regimens

The bedside nurse is responsiblefor monitoring any adverse effectsof anticoagulation includinghemorrhage formation ofhematomas thrombocytopeniaand allergic reactions

Heparin

bull The least expensive anticoagulant

bull Either systemically or regionally

When heparin is used

bull The hemofilter may be flushed with a dilute heparin solution continuously or intermittently

Systemic heparinization includes

bull Infusing heparin into a separate intravenous access or into the arterial side of the CRRT circuit

bull Mixing of the heparin with the blood from the patient before the blood reaches the filter

bull Anticoagulation of the circuit as well as for the patient

Argatroban and lepirudin

bullDirect thrombin inhibitors

bullHIT

Lepirudin is cleared by the kidneys and therefore may not be the drug of choice

for patients in ARF

Argatroban is eliminated by the liver and is therefore more suitable for use in

patients with renal failure

Citrate

excellent anticoagulant ability and potential to prolong circuit life

bull Calcium is an essential component of the clotting cascade

bull Citrate binds to the calcium in the patientrsquos blood within the CRRT system and prevents clotting

Citrate is infused prefilter into the CRRT system and calcium is typically infused via another intravenous line outside the circuit

Ionized calcium levels are routinely monitored

1048708Heparin

bull 250500 Uhr

1048708HIT Argatroban

bull 1048708051 mghr

1048708Bleeding risk

bull 1048708Citrate

bull 1048708No anticoagulation

Dialysate

Conculsions

Critically ill patients AKI occurs in up to 30 of all ICU admissions

CRRT is almost exclusively applied to patients in (ICU)

Restrict monitoring and follow up of the patients during CRRT is mandatory

Well trained nurse is the corner stone of adequate CRRT

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 21

bull Selection of RRT modality depends on thecapabilityavailability of the technology

bull Different RRT modalities provide differentcapabilities

bull different machines may provide some butnot all modalities

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 22

bull CRRT recommended in situations whereshifts in fluid balance and metabolicfluctuations are poorly tolerated

bull Intermittent and prolonged intermittenttypes of RRT have a role when fluid andmetabolic fluctuations can be tolerated

Both CRRT and IHD achieve adequate

metabolic control and neither modality has

been shown to be superior in terms of

survival

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 23

bullAvailability of technologies isdetermined by local regulationslocal resources including stafftheir trainingexperience andlaboratory support and financialconstraints

bullSCUF (slow continuous ultrafiltration)

bullCVVH (continuous veno-venous haemofiltration

bullCVVHD (continuous veno-venous haemodialysis)

bullCVVHDF (continuous veno-venous haemodiafiltration

How should RRT be integrated into other extracorporeal therapies

bull Consensus statement 31

In situations where other extracorporealtherapies are required continuous RRT isrecommended and integrated systems arepreferred over parallel systems

extracorporeal liver assist devices (ELADs)

ECLS in Cardiac Failure

When should transition of modalities be considered (CRRT IRRT hybrid therapy)

Consensus statement 41

bullTransition of modalities should beconsidered if the demandndashcapacityimbalance or treatment prioritieshave changed and can be metbetter by an alternative technique

How should patients be liberated from RRT

RRT should bediscontinued ifkidney functionhas recovered

Consensus statement

51

How should patients be liberated from RRT

Consensus statement 52

bullTo determine sustainedrecovery of kidney functionwe recommend monitoring ofurine output and SCr duringRRT

How should patients be liberated from RRT

C onsensus statement 53

bullFor patients requiring multipletypes of organ supportdecisions about withdrawingRRT should be consideredtogether with other therapies

Before

Before CRRT is started patients should have

a complete nursing assessment

bull Fluid status

bull Fluid input

bull Blood pressure

bull Dosages of any vasopressors

bull Weightbull Presence of edemabull CVPbull NaK and ABGs

Nursing Management

During

Once CRRT is started

bull Blood pressure central venous pressure andweight monitoring

bull The bedside nurse should discuss the possibilityof reducing intake to minimal volumes of fluidsif at all possible and concentrating medicationsand infusions to minimize fluid intake if thetarget not acheived

bull Mechanical failures can occur if alarms are ignored or bypassed without determining the cause of the alarms

bull If scales are not properly calibrated the volumes of fluid administered and removed may not be the programmed volumes

541 We suggest initiating RRT in patients with AKI via an uncuffed non tunneled dialysis catheter rather than a tunneled catheter (2D)

542 When choosing a vein for insertion of a dialysis catheter in patients with AKI consider these preferences (Not Graded)

bull First choice right jugular vein

bull Second choice femoral vein

bull Third choice left jugular vein

bull Last choice subclavian vein with preference for the dominant side

Anticoagulation

CRRT can be performed with or without anticoagulation

The choice of anticoagulant depends on

bull The physicianrsquos preference

bull The patientrsquos condition

bull The familiarity of the nursing staff with anticoagulation regimens

The bedside nurse is responsiblefor monitoring any adverse effectsof anticoagulation includinghemorrhage formation ofhematomas thrombocytopeniaand allergic reactions

Heparin

bull The least expensive anticoagulant

bull Either systemically or regionally

When heparin is used

bull The hemofilter may be flushed with a dilute heparin solution continuously or intermittently

Systemic heparinization includes

bull Infusing heparin into a separate intravenous access or into the arterial side of the CRRT circuit

bull Mixing of the heparin with the blood from the patient before the blood reaches the filter

bull Anticoagulation of the circuit as well as for the patient

Argatroban and lepirudin

bullDirect thrombin inhibitors

bullHIT

Lepirudin is cleared by the kidneys and therefore may not be the drug of choice

for patients in ARF

Argatroban is eliminated by the liver and is therefore more suitable for use in

patients with renal failure

Citrate

excellent anticoagulant ability and potential to prolong circuit life

bull Calcium is an essential component of the clotting cascade

bull Citrate binds to the calcium in the patientrsquos blood within the CRRT system and prevents clotting

Citrate is infused prefilter into the CRRT system and calcium is typically infused via another intravenous line outside the circuit

Ionized calcium levels are routinely monitored

1048708Heparin

bull 250500 Uhr

1048708HIT Argatroban

bull 1048708051 mghr

1048708Bleeding risk

bull 1048708Citrate

bull 1048708No anticoagulation

Dialysate

Conculsions

Critically ill patients AKI occurs in up to 30 of all ICU admissions

CRRT is almost exclusively applied to patients in (ICU)

Restrict monitoring and follow up of the patients during CRRT is mandatory

Well trained nurse is the corner stone of adequate CRRT

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 22

bull CRRT recommended in situations whereshifts in fluid balance and metabolicfluctuations are poorly tolerated

bull Intermittent and prolonged intermittenttypes of RRT have a role when fluid andmetabolic fluctuations can be tolerated

Both CRRT and IHD achieve adequate

metabolic control and neither modality has

been shown to be superior in terms of

survival

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 23

bullAvailability of technologies isdetermined by local regulationslocal resources including stafftheir trainingexperience andlaboratory support and financialconstraints

bullSCUF (slow continuous ultrafiltration)

bullCVVH (continuous veno-venous haemofiltration

bullCVVHD (continuous veno-venous haemodialysis)

bullCVVHDF (continuous veno-venous haemodiafiltration

How should RRT be integrated into other extracorporeal therapies

bull Consensus statement 31

In situations where other extracorporealtherapies are required continuous RRT isrecommended and integrated systems arepreferred over parallel systems

extracorporeal liver assist devices (ELADs)

ECLS in Cardiac Failure

When should transition of modalities be considered (CRRT IRRT hybrid therapy)

Consensus statement 41

bullTransition of modalities should beconsidered if the demandndashcapacityimbalance or treatment prioritieshave changed and can be metbetter by an alternative technique

How should patients be liberated from RRT

RRT should bediscontinued ifkidney functionhas recovered

Consensus statement

51

How should patients be liberated from RRT

Consensus statement 52

bullTo determine sustainedrecovery of kidney functionwe recommend monitoring ofurine output and SCr duringRRT

How should patients be liberated from RRT

C onsensus statement 53

bullFor patients requiring multipletypes of organ supportdecisions about withdrawingRRT should be consideredtogether with other therapies

Before

Before CRRT is started patients should have

a complete nursing assessment

bull Fluid status

bull Fluid input

bull Blood pressure

bull Dosages of any vasopressors

bull Weightbull Presence of edemabull CVPbull NaK and ABGs

Nursing Management

During

Once CRRT is started

bull Blood pressure central venous pressure andweight monitoring

bull The bedside nurse should discuss the possibilityof reducing intake to minimal volumes of fluidsif at all possible and concentrating medicationsand infusions to minimize fluid intake if thetarget not acheived

bull Mechanical failures can occur if alarms are ignored or bypassed without determining the cause of the alarms

bull If scales are not properly calibrated the volumes of fluid administered and removed may not be the programmed volumes

541 We suggest initiating RRT in patients with AKI via an uncuffed non tunneled dialysis catheter rather than a tunneled catheter (2D)

542 When choosing a vein for insertion of a dialysis catheter in patients with AKI consider these preferences (Not Graded)

bull First choice right jugular vein

bull Second choice femoral vein

bull Third choice left jugular vein

bull Last choice subclavian vein with preference for the dominant side

Anticoagulation

CRRT can be performed with or without anticoagulation

The choice of anticoagulant depends on

bull The physicianrsquos preference

bull The patientrsquos condition

bull The familiarity of the nursing staff with anticoagulation regimens

The bedside nurse is responsiblefor monitoring any adverse effectsof anticoagulation includinghemorrhage formation ofhematomas thrombocytopeniaand allergic reactions

Heparin

bull The least expensive anticoagulant

bull Either systemically or regionally

When heparin is used

bull The hemofilter may be flushed with a dilute heparin solution continuously or intermittently

Systemic heparinization includes

bull Infusing heparin into a separate intravenous access or into the arterial side of the CRRT circuit

bull Mixing of the heparin with the blood from the patient before the blood reaches the filter

bull Anticoagulation of the circuit as well as for the patient

Argatroban and lepirudin

bullDirect thrombin inhibitors

bullHIT

Lepirudin is cleared by the kidneys and therefore may not be the drug of choice

for patients in ARF

Argatroban is eliminated by the liver and is therefore more suitable for use in

patients with renal failure

Citrate

excellent anticoagulant ability and potential to prolong circuit life

bull Calcium is an essential component of the clotting cascade

bull Citrate binds to the calcium in the patientrsquos blood within the CRRT system and prevents clotting

Citrate is infused prefilter into the CRRT system and calcium is typically infused via another intravenous line outside the circuit

Ionized calcium levels are routinely monitored

1048708Heparin

bull 250500 Uhr

1048708HIT Argatroban

bull 1048708051 mghr

1048708Bleeding risk

bull 1048708Citrate

bull 1048708No anticoagulation

Dialysate

Conculsions

Critically ill patients AKI occurs in up to 30 of all ICU admissions

CRRT is almost exclusively applied to patients in (ICU)

Restrict monitoring and follow up of the patients during CRRT is mandatory

Well trained nurse is the corner stone of adequate CRRT

Both CRRT and IHD achieve adequate

metabolic control and neither modality has

been shown to be superior in terms of

survival

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 23

bullAvailability of technologies isdetermined by local regulationslocal resources including stafftheir trainingexperience andlaboratory support and financialconstraints

bullSCUF (slow continuous ultrafiltration)

bullCVVH (continuous veno-venous haemofiltration

bullCVVHD (continuous veno-venous haemodialysis)

bullCVVHDF (continuous veno-venous haemodiafiltration

How should RRT be integrated into other extracorporeal therapies

bull Consensus statement 31

In situations where other extracorporealtherapies are required continuous RRT isrecommended and integrated systems arepreferred over parallel systems

extracorporeal liver assist devices (ELADs)

ECLS in Cardiac Failure

When should transition of modalities be considered (CRRT IRRT hybrid therapy)

Consensus statement 41

bullTransition of modalities should beconsidered if the demandndashcapacityimbalance or treatment prioritieshave changed and can be metbetter by an alternative technique

How should patients be liberated from RRT

RRT should bediscontinued ifkidney functionhas recovered

Consensus statement

51

How should patients be liberated from RRT

Consensus statement 52

bullTo determine sustainedrecovery of kidney functionwe recommend monitoring ofurine output and SCr duringRRT

How should patients be liberated from RRT

C onsensus statement 53

bullFor patients requiring multipletypes of organ supportdecisions about withdrawingRRT should be consideredtogether with other therapies

Before

Before CRRT is started patients should have

a complete nursing assessment

bull Fluid status

bull Fluid input

bull Blood pressure

bull Dosages of any vasopressors

bull Weightbull Presence of edemabull CVPbull NaK and ABGs

Nursing Management

During

Once CRRT is started

bull Blood pressure central venous pressure andweight monitoring

bull The bedside nurse should discuss the possibilityof reducing intake to minimal volumes of fluidsif at all possible and concentrating medicationsand infusions to minimize fluid intake if thetarget not acheived

bull Mechanical failures can occur if alarms are ignored or bypassed without determining the cause of the alarms

bull If scales are not properly calibrated the volumes of fluid administered and removed may not be the programmed volumes

541 We suggest initiating RRT in patients with AKI via an uncuffed non tunneled dialysis catheter rather than a tunneled catheter (2D)

542 When choosing a vein for insertion of a dialysis catheter in patients with AKI consider these preferences (Not Graded)

bull First choice right jugular vein

bull Second choice femoral vein

bull Third choice left jugular vein

bull Last choice subclavian vein with preference for the dominant side

Anticoagulation

CRRT can be performed with or without anticoagulation

The choice of anticoagulant depends on

bull The physicianrsquos preference

bull The patientrsquos condition

bull The familiarity of the nursing staff with anticoagulation regimens

The bedside nurse is responsiblefor monitoring any adverse effectsof anticoagulation includinghemorrhage formation ofhematomas thrombocytopeniaand allergic reactions

Heparin

bull The least expensive anticoagulant

bull Either systemically or regionally

When heparin is used

bull The hemofilter may be flushed with a dilute heparin solution continuously or intermittently

Systemic heparinization includes

bull Infusing heparin into a separate intravenous access or into the arterial side of the CRRT circuit

bull Mixing of the heparin with the blood from the patient before the blood reaches the filter

bull Anticoagulation of the circuit as well as for the patient

Argatroban and lepirudin

bullDirect thrombin inhibitors

bullHIT

Lepirudin is cleared by the kidneys and therefore may not be the drug of choice

for patients in ARF

Argatroban is eliminated by the liver and is therefore more suitable for use in

patients with renal failure

Citrate

excellent anticoagulant ability and potential to prolong circuit life

bull Calcium is an essential component of the clotting cascade

bull Citrate binds to the calcium in the patientrsquos blood within the CRRT system and prevents clotting

Citrate is infused prefilter into the CRRT system and calcium is typically infused via another intravenous line outside the circuit

Ionized calcium levels are routinely monitored

1048708Heparin

bull 250500 Uhr

1048708HIT Argatroban

bull 1048708051 mghr

1048708Bleeding risk

bull 1048708Citrate

bull 1048708No anticoagulation

Dialysate

Conculsions

Critically ill patients AKI occurs in up to 30 of all ICU admissions

CRRT is almost exclusively applied to patients in (ICU)

Restrict monitoring and follow up of the patients during CRRT is mandatory

Well trained nurse is the corner stone of adequate CRRT

What is the most appropriate therapy to meet a demandndashcapacity imbalance for a specific patient

Consensus statement 23

bullAvailability of technologies isdetermined by local regulationslocal resources including stafftheir trainingexperience andlaboratory support and financialconstraints

bullSCUF (slow continuous ultrafiltration)

bullCVVH (continuous veno-venous haemofiltration

bullCVVHD (continuous veno-venous haemodialysis)

bullCVVHDF (continuous veno-venous haemodiafiltration

How should RRT be integrated into other extracorporeal therapies

bull Consensus statement 31

In situations where other extracorporealtherapies are required continuous RRT isrecommended and integrated systems arepreferred over parallel systems

extracorporeal liver assist devices (ELADs)

ECLS in Cardiac Failure

When should transition of modalities be considered (CRRT IRRT hybrid therapy)

Consensus statement 41

bullTransition of modalities should beconsidered if the demandndashcapacityimbalance or treatment prioritieshave changed and can be metbetter by an alternative technique

How should patients be liberated from RRT

RRT should bediscontinued ifkidney functionhas recovered

Consensus statement

51

How should patients be liberated from RRT

Consensus statement 52

bullTo determine sustainedrecovery of kidney functionwe recommend monitoring ofurine output and SCr duringRRT

How should patients be liberated from RRT

C onsensus statement 53

bullFor patients requiring multipletypes of organ supportdecisions about withdrawingRRT should be consideredtogether with other therapies

Before

Before CRRT is started patients should have

a complete nursing assessment

bull Fluid status

bull Fluid input

bull Blood pressure

bull Dosages of any vasopressors

bull Weightbull Presence of edemabull CVPbull NaK and ABGs

Nursing Management

During

Once CRRT is started

bull Blood pressure central venous pressure andweight monitoring

bull The bedside nurse should discuss the possibilityof reducing intake to minimal volumes of fluidsif at all possible and concentrating medicationsand infusions to minimize fluid intake if thetarget not acheived

bull Mechanical failures can occur if alarms are ignored or bypassed without determining the cause of the alarms

bull If scales are not properly calibrated the volumes of fluid administered and removed may not be the programmed volumes

541 We suggest initiating RRT in patients with AKI via an uncuffed non tunneled dialysis catheter rather than a tunneled catheter (2D)

542 When choosing a vein for insertion of a dialysis catheter in patients with AKI consider these preferences (Not Graded)

bull First choice right jugular vein

bull Second choice femoral vein

bull Third choice left jugular vein

bull Last choice subclavian vein with preference for the dominant side

Anticoagulation

CRRT can be performed with or without anticoagulation

The choice of anticoagulant depends on

bull The physicianrsquos preference

bull The patientrsquos condition

bull The familiarity of the nursing staff with anticoagulation regimens

The bedside nurse is responsiblefor monitoring any adverse effectsof anticoagulation includinghemorrhage formation ofhematomas thrombocytopeniaand allergic reactions

Heparin

bull The least expensive anticoagulant

bull Either systemically or regionally

When heparin is used

bull The hemofilter may be flushed with a dilute heparin solution continuously or intermittently

Systemic heparinization includes

bull Infusing heparin into a separate intravenous access or into the arterial side of the CRRT circuit

bull Mixing of the heparin with the blood from the patient before the blood reaches the filter

bull Anticoagulation of the circuit as well as for the patient

Argatroban and lepirudin

bullDirect thrombin inhibitors

bullHIT

Lepirudin is cleared by the kidneys and therefore may not be the drug of choice

for patients in ARF

Argatroban is eliminated by the liver and is therefore more suitable for use in

patients with renal failure

Citrate

excellent anticoagulant ability and potential to prolong circuit life

bull Calcium is an essential component of the clotting cascade

bull Citrate binds to the calcium in the patientrsquos blood within the CRRT system and prevents clotting

Citrate is infused prefilter into the CRRT system and calcium is typically infused via another intravenous line outside the circuit

Ionized calcium levels are routinely monitored

1048708Heparin

bull 250500 Uhr

1048708HIT Argatroban

bull 1048708051 mghr

1048708Bleeding risk

bull 1048708Citrate

bull 1048708No anticoagulation

Dialysate

Conculsions

Critically ill patients AKI occurs in up to 30 of all ICU admissions

CRRT is almost exclusively applied to patients in (ICU)

Restrict monitoring and follow up of the patients during CRRT is mandatory

Well trained nurse is the corner stone of adequate CRRT

bullSCUF (slow continuous ultrafiltration)

bullCVVH (continuous veno-venous haemofiltration

bullCVVHD (continuous veno-venous haemodialysis)

bullCVVHDF (continuous veno-venous haemodiafiltration

How should RRT be integrated into other extracorporeal therapies

bull Consensus statement 31

In situations where other extracorporealtherapies are required continuous RRT isrecommended and integrated systems arepreferred over parallel systems

extracorporeal liver assist devices (ELADs)

ECLS in Cardiac Failure

When should transition of modalities be considered (CRRT IRRT hybrid therapy)

Consensus statement 41

bullTransition of modalities should beconsidered if the demandndashcapacityimbalance or treatment prioritieshave changed and can be metbetter by an alternative technique

How should patients be liberated from RRT

RRT should bediscontinued ifkidney functionhas recovered

Consensus statement

51

How should patients be liberated from RRT

Consensus statement 52

bullTo determine sustainedrecovery of kidney functionwe recommend monitoring ofurine output and SCr duringRRT

How should patients be liberated from RRT

C onsensus statement 53

bullFor patients requiring multipletypes of organ supportdecisions about withdrawingRRT should be consideredtogether with other therapies

Before

Before CRRT is started patients should have

a complete nursing assessment

bull Fluid status

bull Fluid input

bull Blood pressure

bull Dosages of any vasopressors

bull Weightbull Presence of edemabull CVPbull NaK and ABGs

Nursing Management

During

Once CRRT is started

bull Blood pressure central venous pressure andweight monitoring

bull The bedside nurse should discuss the possibilityof reducing intake to minimal volumes of fluidsif at all possible and concentrating medicationsand infusions to minimize fluid intake if thetarget not acheived

bull Mechanical failures can occur if alarms are ignored or bypassed without determining the cause of the alarms

bull If scales are not properly calibrated the volumes of fluid administered and removed may not be the programmed volumes

541 We suggest initiating RRT in patients with AKI via an uncuffed non tunneled dialysis catheter rather than a tunneled catheter (2D)

542 When choosing a vein for insertion of a dialysis catheter in patients with AKI consider these preferences (Not Graded)

bull First choice right jugular vein

bull Second choice femoral vein

bull Third choice left jugular vein

bull Last choice subclavian vein with preference for the dominant side

Anticoagulation

CRRT can be performed with or without anticoagulation

The choice of anticoagulant depends on

bull The physicianrsquos preference

bull The patientrsquos condition

bull The familiarity of the nursing staff with anticoagulation regimens

The bedside nurse is responsiblefor monitoring any adverse effectsof anticoagulation includinghemorrhage formation ofhematomas thrombocytopeniaand allergic reactions

Heparin

bull The least expensive anticoagulant

bull Either systemically or regionally

When heparin is used

bull The hemofilter may be flushed with a dilute heparin solution continuously or intermittently

Systemic heparinization includes

bull Infusing heparin into a separate intravenous access or into the arterial side of the CRRT circuit

bull Mixing of the heparin with the blood from the patient before the blood reaches the filter

bull Anticoagulation of the circuit as well as for the patient

Argatroban and lepirudin

bullDirect thrombin inhibitors

bullHIT

Lepirudin is cleared by the kidneys and therefore may not be the drug of choice

for patients in ARF

Argatroban is eliminated by the liver and is therefore more suitable for use in

patients with renal failure

Citrate

excellent anticoagulant ability and potential to prolong circuit life

bull Calcium is an essential component of the clotting cascade

bull Citrate binds to the calcium in the patientrsquos blood within the CRRT system and prevents clotting

Citrate is infused prefilter into the CRRT system and calcium is typically infused via another intravenous line outside the circuit

Ionized calcium levels are routinely monitored

1048708Heparin

bull 250500 Uhr

1048708HIT Argatroban

bull 1048708051 mghr

1048708Bleeding risk

bull 1048708Citrate

bull 1048708No anticoagulation

Dialysate

Conculsions

Critically ill patients AKI occurs in up to 30 of all ICU admissions

CRRT is almost exclusively applied to patients in (ICU)

Restrict monitoring and follow up of the patients during CRRT is mandatory

Well trained nurse is the corner stone of adequate CRRT

How should RRT be integrated into other extracorporeal therapies

bull Consensus statement 31

In situations where other extracorporealtherapies are required continuous RRT isrecommended and integrated systems arepreferred over parallel systems

extracorporeal liver assist devices (ELADs)

ECLS in Cardiac Failure

When should transition of modalities be considered (CRRT IRRT hybrid therapy)

Consensus statement 41

bullTransition of modalities should beconsidered if the demandndashcapacityimbalance or treatment prioritieshave changed and can be metbetter by an alternative technique

How should patients be liberated from RRT

RRT should bediscontinued ifkidney functionhas recovered

Consensus statement

51

How should patients be liberated from RRT

Consensus statement 52

bullTo determine sustainedrecovery of kidney functionwe recommend monitoring ofurine output and SCr duringRRT

How should patients be liberated from RRT

C onsensus statement 53

bullFor patients requiring multipletypes of organ supportdecisions about withdrawingRRT should be consideredtogether with other therapies

Before

Before CRRT is started patients should have

a complete nursing assessment

bull Fluid status

bull Fluid input

bull Blood pressure

bull Dosages of any vasopressors

bull Weightbull Presence of edemabull CVPbull NaK and ABGs

Nursing Management

During

Once CRRT is started

bull Blood pressure central venous pressure andweight monitoring

bull The bedside nurse should discuss the possibilityof reducing intake to minimal volumes of fluidsif at all possible and concentrating medicationsand infusions to minimize fluid intake if thetarget not acheived

bull Mechanical failures can occur if alarms are ignored or bypassed without determining the cause of the alarms

bull If scales are not properly calibrated the volumes of fluid administered and removed may not be the programmed volumes

541 We suggest initiating RRT in patients with AKI via an uncuffed non tunneled dialysis catheter rather than a tunneled catheter (2D)

542 When choosing a vein for insertion of a dialysis catheter in patients with AKI consider these preferences (Not Graded)

bull First choice right jugular vein

bull Second choice femoral vein

bull Third choice left jugular vein

bull Last choice subclavian vein with preference for the dominant side

Anticoagulation

CRRT can be performed with or without anticoagulation

The choice of anticoagulant depends on

bull The physicianrsquos preference

bull The patientrsquos condition

bull The familiarity of the nursing staff with anticoagulation regimens

The bedside nurse is responsiblefor monitoring any adverse effectsof anticoagulation includinghemorrhage formation ofhematomas thrombocytopeniaand allergic reactions

Heparin

bull The least expensive anticoagulant

bull Either systemically or regionally

When heparin is used

bull The hemofilter may be flushed with a dilute heparin solution continuously or intermittently

Systemic heparinization includes

bull Infusing heparin into a separate intravenous access or into the arterial side of the CRRT circuit

bull Mixing of the heparin with the blood from the patient before the blood reaches the filter

bull Anticoagulation of the circuit as well as for the patient

Argatroban and lepirudin

bullDirect thrombin inhibitors

bullHIT

Lepirudin is cleared by the kidneys and therefore may not be the drug of choice

for patients in ARF

Argatroban is eliminated by the liver and is therefore more suitable for use in

patients with renal failure

Citrate

excellent anticoagulant ability and potential to prolong circuit life

bull Calcium is an essential component of the clotting cascade

bull Citrate binds to the calcium in the patientrsquos blood within the CRRT system and prevents clotting

Citrate is infused prefilter into the CRRT system and calcium is typically infused via another intravenous line outside the circuit

Ionized calcium levels are routinely monitored

1048708Heparin

bull 250500 Uhr

1048708HIT Argatroban

bull 1048708051 mghr

1048708Bleeding risk

bull 1048708Citrate

bull 1048708No anticoagulation

Dialysate

Conculsions

Critically ill patients AKI occurs in up to 30 of all ICU admissions

CRRT is almost exclusively applied to patients in (ICU)

Restrict monitoring and follow up of the patients during CRRT is mandatory

Well trained nurse is the corner stone of adequate CRRT

When should transition of modalities be considered (CRRT IRRT hybrid therapy)

Consensus statement 41

bullTransition of modalities should beconsidered if the demandndashcapacityimbalance or treatment prioritieshave changed and can be metbetter by an alternative technique

How should patients be liberated from RRT

RRT should bediscontinued ifkidney functionhas recovered

Consensus statement

51

How should patients be liberated from RRT

Consensus statement 52

bullTo determine sustainedrecovery of kidney functionwe recommend monitoring ofurine output and SCr duringRRT

How should patients be liberated from RRT

C onsensus statement 53

bullFor patients requiring multipletypes of organ supportdecisions about withdrawingRRT should be consideredtogether with other therapies

Before

Before CRRT is started patients should have

a complete nursing assessment

bull Fluid status

bull Fluid input

bull Blood pressure

bull Dosages of any vasopressors

bull Weightbull Presence of edemabull CVPbull NaK and ABGs

Nursing Management

During

Once CRRT is started

bull Blood pressure central venous pressure andweight monitoring

bull The bedside nurse should discuss the possibilityof reducing intake to minimal volumes of fluidsif at all possible and concentrating medicationsand infusions to minimize fluid intake if thetarget not acheived

bull Mechanical failures can occur if alarms are ignored or bypassed without determining the cause of the alarms

bull If scales are not properly calibrated the volumes of fluid administered and removed may not be the programmed volumes

541 We suggest initiating RRT in patients with AKI via an uncuffed non tunneled dialysis catheter rather than a tunneled catheter (2D)

542 When choosing a vein for insertion of a dialysis catheter in patients with AKI consider these preferences (Not Graded)

bull First choice right jugular vein

bull Second choice femoral vein

bull Third choice left jugular vein

bull Last choice subclavian vein with preference for the dominant side

Anticoagulation

CRRT can be performed with or without anticoagulation

The choice of anticoagulant depends on

bull The physicianrsquos preference

bull The patientrsquos condition

bull The familiarity of the nursing staff with anticoagulation regimens

The bedside nurse is responsiblefor monitoring any adverse effectsof anticoagulation includinghemorrhage formation ofhematomas thrombocytopeniaand allergic reactions

Heparin

bull The least expensive anticoagulant

bull Either systemically or regionally

When heparin is used

bull The hemofilter may be flushed with a dilute heparin solution continuously or intermittently

Systemic heparinization includes

bull Infusing heparin into a separate intravenous access or into the arterial side of the CRRT circuit

bull Mixing of the heparin with the blood from the patient before the blood reaches the filter

bull Anticoagulation of the circuit as well as for the patient

Argatroban and lepirudin

bullDirect thrombin inhibitors

bullHIT

Lepirudin is cleared by the kidneys and therefore may not be the drug of choice

for patients in ARF

Argatroban is eliminated by the liver and is therefore more suitable for use in

patients with renal failure

Citrate

excellent anticoagulant ability and potential to prolong circuit life

bull Calcium is an essential component of the clotting cascade

bull Citrate binds to the calcium in the patientrsquos blood within the CRRT system and prevents clotting

Citrate is infused prefilter into the CRRT system and calcium is typically infused via another intravenous line outside the circuit

Ionized calcium levels are routinely monitored

1048708Heparin

bull 250500 Uhr

1048708HIT Argatroban

bull 1048708051 mghr

1048708Bleeding risk

bull 1048708Citrate

bull 1048708No anticoagulation

Dialysate

Conculsions

Critically ill patients AKI occurs in up to 30 of all ICU admissions

CRRT is almost exclusively applied to patients in (ICU)

Restrict monitoring and follow up of the patients during CRRT is mandatory

Well trained nurse is the corner stone of adequate CRRT

How should patients be liberated from RRT

RRT should bediscontinued ifkidney functionhas recovered

Consensus statement

51

How should patients be liberated from RRT

Consensus statement 52

bullTo determine sustainedrecovery of kidney functionwe recommend monitoring ofurine output and SCr duringRRT

How should patients be liberated from RRT

C onsensus statement 53

bullFor patients requiring multipletypes of organ supportdecisions about withdrawingRRT should be consideredtogether with other therapies

Before

Before CRRT is started patients should have

a complete nursing assessment

bull Fluid status

bull Fluid input

bull Blood pressure

bull Dosages of any vasopressors

bull Weightbull Presence of edemabull CVPbull NaK and ABGs

Nursing Management

During

Once CRRT is started

bull Blood pressure central venous pressure andweight monitoring

bull The bedside nurse should discuss the possibilityof reducing intake to minimal volumes of fluidsif at all possible and concentrating medicationsand infusions to minimize fluid intake if thetarget not acheived

bull Mechanical failures can occur if alarms are ignored or bypassed without determining the cause of the alarms

bull If scales are not properly calibrated the volumes of fluid administered and removed may not be the programmed volumes

541 We suggest initiating RRT in patients with AKI via an uncuffed non tunneled dialysis catheter rather than a tunneled catheter (2D)

542 When choosing a vein for insertion of a dialysis catheter in patients with AKI consider these preferences (Not Graded)

bull First choice right jugular vein

bull Second choice femoral vein

bull Third choice left jugular vein

bull Last choice subclavian vein with preference for the dominant side

Anticoagulation

CRRT can be performed with or without anticoagulation

The choice of anticoagulant depends on

bull The physicianrsquos preference

bull The patientrsquos condition

bull The familiarity of the nursing staff with anticoagulation regimens

The bedside nurse is responsiblefor monitoring any adverse effectsof anticoagulation includinghemorrhage formation ofhematomas thrombocytopeniaand allergic reactions

Heparin

bull The least expensive anticoagulant

bull Either systemically or regionally

When heparin is used

bull The hemofilter may be flushed with a dilute heparin solution continuously or intermittently

Systemic heparinization includes

bull Infusing heparin into a separate intravenous access or into the arterial side of the CRRT circuit

bull Mixing of the heparin with the blood from the patient before the blood reaches the filter

bull Anticoagulation of the circuit as well as for the patient

Argatroban and lepirudin

bullDirect thrombin inhibitors

bullHIT

Lepirudin is cleared by the kidneys and therefore may not be the drug of choice

for patients in ARF

Argatroban is eliminated by the liver and is therefore more suitable for use in

patients with renal failure

Citrate

excellent anticoagulant ability and potential to prolong circuit life

bull Calcium is an essential component of the clotting cascade

bull Citrate binds to the calcium in the patientrsquos blood within the CRRT system and prevents clotting

Citrate is infused prefilter into the CRRT system and calcium is typically infused via another intravenous line outside the circuit

Ionized calcium levels are routinely monitored

1048708Heparin

bull 250500 Uhr

1048708HIT Argatroban

bull 1048708051 mghr

1048708Bleeding risk

bull 1048708Citrate

bull 1048708No anticoagulation

Dialysate

Conculsions

Critically ill patients AKI occurs in up to 30 of all ICU admissions

CRRT is almost exclusively applied to patients in (ICU)

Restrict monitoring and follow up of the patients during CRRT is mandatory

Well trained nurse is the corner stone of adequate CRRT

How should patients be liberated from RRT

Consensus statement 52

bullTo determine sustainedrecovery of kidney functionwe recommend monitoring ofurine output and SCr duringRRT

How should patients be liberated from RRT

C onsensus statement 53

bullFor patients requiring multipletypes of organ supportdecisions about withdrawingRRT should be consideredtogether with other therapies

Before

Before CRRT is started patients should have

a complete nursing assessment

bull Fluid status

bull Fluid input

bull Blood pressure

bull Dosages of any vasopressors

bull Weightbull Presence of edemabull CVPbull NaK and ABGs

Nursing Management

During

Once CRRT is started

bull Blood pressure central venous pressure andweight monitoring

bull The bedside nurse should discuss the possibilityof reducing intake to minimal volumes of fluidsif at all possible and concentrating medicationsand infusions to minimize fluid intake if thetarget not acheived

bull Mechanical failures can occur if alarms are ignored or bypassed without determining the cause of the alarms

bull If scales are not properly calibrated the volumes of fluid administered and removed may not be the programmed volumes

541 We suggest initiating RRT in patients with AKI via an uncuffed non tunneled dialysis catheter rather than a tunneled catheter (2D)

542 When choosing a vein for insertion of a dialysis catheter in patients with AKI consider these preferences (Not Graded)

bull First choice right jugular vein

bull Second choice femoral vein

bull Third choice left jugular vein

bull Last choice subclavian vein with preference for the dominant side

Anticoagulation

CRRT can be performed with or without anticoagulation

The choice of anticoagulant depends on

bull The physicianrsquos preference

bull The patientrsquos condition

bull The familiarity of the nursing staff with anticoagulation regimens

The bedside nurse is responsiblefor monitoring any adverse effectsof anticoagulation includinghemorrhage formation ofhematomas thrombocytopeniaand allergic reactions

Heparin

bull The least expensive anticoagulant

bull Either systemically or regionally

When heparin is used

bull The hemofilter may be flushed with a dilute heparin solution continuously or intermittently

Systemic heparinization includes

bull Infusing heparin into a separate intravenous access or into the arterial side of the CRRT circuit

bull Mixing of the heparin with the blood from the patient before the blood reaches the filter

bull Anticoagulation of the circuit as well as for the patient

Argatroban and lepirudin

bullDirect thrombin inhibitors

bullHIT

Lepirudin is cleared by the kidneys and therefore may not be the drug of choice

for patients in ARF

Argatroban is eliminated by the liver and is therefore more suitable for use in

patients with renal failure

Citrate

excellent anticoagulant ability and potential to prolong circuit life

bull Calcium is an essential component of the clotting cascade

bull Citrate binds to the calcium in the patientrsquos blood within the CRRT system and prevents clotting

Citrate is infused prefilter into the CRRT system and calcium is typically infused via another intravenous line outside the circuit

Ionized calcium levels are routinely monitored

1048708Heparin

bull 250500 Uhr

1048708HIT Argatroban

bull 1048708051 mghr

1048708Bleeding risk

bull 1048708Citrate

bull 1048708No anticoagulation

Dialysate

Conculsions

Critically ill patients AKI occurs in up to 30 of all ICU admissions

CRRT is almost exclusively applied to patients in (ICU)

Restrict monitoring and follow up of the patients during CRRT is mandatory

Well trained nurse is the corner stone of adequate CRRT

How should patients be liberated from RRT

C onsensus statement 53

bullFor patients requiring multipletypes of organ supportdecisions about withdrawingRRT should be consideredtogether with other therapies

Before

Before CRRT is started patients should have

a complete nursing assessment

bull Fluid status

bull Fluid input

bull Blood pressure

bull Dosages of any vasopressors

bull Weightbull Presence of edemabull CVPbull NaK and ABGs

Nursing Management

During

Once CRRT is started

bull Blood pressure central venous pressure andweight monitoring

bull The bedside nurse should discuss the possibilityof reducing intake to minimal volumes of fluidsif at all possible and concentrating medicationsand infusions to minimize fluid intake if thetarget not acheived

bull Mechanical failures can occur if alarms are ignored or bypassed without determining the cause of the alarms

bull If scales are not properly calibrated the volumes of fluid administered and removed may not be the programmed volumes

541 We suggest initiating RRT in patients with AKI via an uncuffed non tunneled dialysis catheter rather than a tunneled catheter (2D)

542 When choosing a vein for insertion of a dialysis catheter in patients with AKI consider these preferences (Not Graded)

bull First choice right jugular vein

bull Second choice femoral vein

bull Third choice left jugular vein

bull Last choice subclavian vein with preference for the dominant side

Anticoagulation

CRRT can be performed with or without anticoagulation

The choice of anticoagulant depends on

bull The physicianrsquos preference

bull The patientrsquos condition

bull The familiarity of the nursing staff with anticoagulation regimens

The bedside nurse is responsiblefor monitoring any adverse effectsof anticoagulation includinghemorrhage formation ofhematomas thrombocytopeniaand allergic reactions

Heparin

bull The least expensive anticoagulant

bull Either systemically or regionally

When heparin is used

bull The hemofilter may be flushed with a dilute heparin solution continuously or intermittently

Systemic heparinization includes

bull Infusing heparin into a separate intravenous access or into the arterial side of the CRRT circuit

bull Mixing of the heparin with the blood from the patient before the blood reaches the filter

bull Anticoagulation of the circuit as well as for the patient

Argatroban and lepirudin

bullDirect thrombin inhibitors

bullHIT

Lepirudin is cleared by the kidneys and therefore may not be the drug of choice

for patients in ARF

Argatroban is eliminated by the liver and is therefore more suitable for use in

patients with renal failure

Citrate

excellent anticoagulant ability and potential to prolong circuit life

bull Calcium is an essential component of the clotting cascade

bull Citrate binds to the calcium in the patientrsquos blood within the CRRT system and prevents clotting

Citrate is infused prefilter into the CRRT system and calcium is typically infused via another intravenous line outside the circuit

Ionized calcium levels are routinely monitored

1048708Heparin

bull 250500 Uhr

1048708HIT Argatroban

bull 1048708051 mghr

1048708Bleeding risk

bull 1048708Citrate

bull 1048708No anticoagulation

Dialysate

Conculsions

Critically ill patients AKI occurs in up to 30 of all ICU admissions

CRRT is almost exclusively applied to patients in (ICU)

Restrict monitoring and follow up of the patients during CRRT is mandatory

Well trained nurse is the corner stone of adequate CRRT

Before

Before CRRT is started patients should have

a complete nursing assessment

bull Fluid status

bull Fluid input

bull Blood pressure

bull Dosages of any vasopressors

bull Weightbull Presence of edemabull CVPbull NaK and ABGs

Nursing Management

During

Once CRRT is started

bull Blood pressure central venous pressure andweight monitoring

bull The bedside nurse should discuss the possibilityof reducing intake to minimal volumes of fluidsif at all possible and concentrating medicationsand infusions to minimize fluid intake if thetarget not acheived

bull Mechanical failures can occur if alarms are ignored or bypassed without determining the cause of the alarms

bull If scales are not properly calibrated the volumes of fluid administered and removed may not be the programmed volumes

541 We suggest initiating RRT in patients with AKI via an uncuffed non tunneled dialysis catheter rather than a tunneled catheter (2D)

542 When choosing a vein for insertion of a dialysis catheter in patients with AKI consider these preferences (Not Graded)

bull First choice right jugular vein

bull Second choice femoral vein

bull Third choice left jugular vein

bull Last choice subclavian vein with preference for the dominant side

Anticoagulation

CRRT can be performed with or without anticoagulation

The choice of anticoagulant depends on

bull The physicianrsquos preference

bull The patientrsquos condition

bull The familiarity of the nursing staff with anticoagulation regimens

The bedside nurse is responsiblefor monitoring any adverse effectsof anticoagulation includinghemorrhage formation ofhematomas thrombocytopeniaand allergic reactions

Heparin

bull The least expensive anticoagulant

bull Either systemically or regionally

When heparin is used

bull The hemofilter may be flushed with a dilute heparin solution continuously or intermittently

Systemic heparinization includes

bull Infusing heparin into a separate intravenous access or into the arterial side of the CRRT circuit

bull Mixing of the heparin with the blood from the patient before the blood reaches the filter

bull Anticoagulation of the circuit as well as for the patient

Argatroban and lepirudin

bullDirect thrombin inhibitors

bullHIT

Lepirudin is cleared by the kidneys and therefore may not be the drug of choice

for patients in ARF

Argatroban is eliminated by the liver and is therefore more suitable for use in

patients with renal failure

Citrate

excellent anticoagulant ability and potential to prolong circuit life

bull Calcium is an essential component of the clotting cascade

bull Citrate binds to the calcium in the patientrsquos blood within the CRRT system and prevents clotting

Citrate is infused prefilter into the CRRT system and calcium is typically infused via another intravenous line outside the circuit

Ionized calcium levels are routinely monitored

1048708Heparin

bull 250500 Uhr

1048708HIT Argatroban

bull 1048708051 mghr

1048708Bleeding risk

bull 1048708Citrate

bull 1048708No anticoagulation

Dialysate

Conculsions

Critically ill patients AKI occurs in up to 30 of all ICU admissions

CRRT is almost exclusively applied to patients in (ICU)

Restrict monitoring and follow up of the patients during CRRT is mandatory

Well trained nurse is the corner stone of adequate CRRT

Nursing Management

During

Once CRRT is started

bull Blood pressure central venous pressure andweight monitoring

bull The bedside nurse should discuss the possibilityof reducing intake to minimal volumes of fluidsif at all possible and concentrating medicationsand infusions to minimize fluid intake if thetarget not acheived

bull Mechanical failures can occur if alarms are ignored or bypassed without determining the cause of the alarms

bull If scales are not properly calibrated the volumes of fluid administered and removed may not be the programmed volumes

541 We suggest initiating RRT in patients with AKI via an uncuffed non tunneled dialysis catheter rather than a tunneled catheter (2D)

542 When choosing a vein for insertion of a dialysis catheter in patients with AKI consider these preferences (Not Graded)

bull First choice right jugular vein

bull Second choice femoral vein

bull Third choice left jugular vein

bull Last choice subclavian vein with preference for the dominant side

Anticoagulation

CRRT can be performed with or without anticoagulation

The choice of anticoagulant depends on

bull The physicianrsquos preference

bull The patientrsquos condition

bull The familiarity of the nursing staff with anticoagulation regimens

The bedside nurse is responsiblefor monitoring any adverse effectsof anticoagulation includinghemorrhage formation ofhematomas thrombocytopeniaand allergic reactions

Heparin

bull The least expensive anticoagulant

bull Either systemically or regionally

When heparin is used

bull The hemofilter may be flushed with a dilute heparin solution continuously or intermittently

Systemic heparinization includes

bull Infusing heparin into a separate intravenous access or into the arterial side of the CRRT circuit

bull Mixing of the heparin with the blood from the patient before the blood reaches the filter

bull Anticoagulation of the circuit as well as for the patient

Argatroban and lepirudin

bullDirect thrombin inhibitors

bullHIT

Lepirudin is cleared by the kidneys and therefore may not be the drug of choice

for patients in ARF

Argatroban is eliminated by the liver and is therefore more suitable for use in

patients with renal failure

Citrate

excellent anticoagulant ability and potential to prolong circuit life

bull Calcium is an essential component of the clotting cascade

bull Citrate binds to the calcium in the patientrsquos blood within the CRRT system and prevents clotting

Citrate is infused prefilter into the CRRT system and calcium is typically infused via another intravenous line outside the circuit

Ionized calcium levels are routinely monitored

1048708Heparin

bull 250500 Uhr

1048708HIT Argatroban

bull 1048708051 mghr

1048708Bleeding risk

bull 1048708Citrate

bull 1048708No anticoagulation

Dialysate

Conculsions

Critically ill patients AKI occurs in up to 30 of all ICU admissions

CRRT is almost exclusively applied to patients in (ICU)

Restrict monitoring and follow up of the patients during CRRT is mandatory

Well trained nurse is the corner stone of adequate CRRT

During

Once CRRT is started

bull Blood pressure central venous pressure andweight monitoring

bull The bedside nurse should discuss the possibilityof reducing intake to minimal volumes of fluidsif at all possible and concentrating medicationsand infusions to minimize fluid intake if thetarget not acheived

bull Mechanical failures can occur if alarms are ignored or bypassed without determining the cause of the alarms

bull If scales are not properly calibrated the volumes of fluid administered and removed may not be the programmed volumes

541 We suggest initiating RRT in patients with AKI via an uncuffed non tunneled dialysis catheter rather than a tunneled catheter (2D)

542 When choosing a vein for insertion of a dialysis catheter in patients with AKI consider these preferences (Not Graded)

bull First choice right jugular vein

bull Second choice femoral vein

bull Third choice left jugular vein

bull Last choice subclavian vein with preference for the dominant side

Anticoagulation

CRRT can be performed with or without anticoagulation

The choice of anticoagulant depends on

bull The physicianrsquos preference

bull The patientrsquos condition

bull The familiarity of the nursing staff with anticoagulation regimens

The bedside nurse is responsiblefor monitoring any adverse effectsof anticoagulation includinghemorrhage formation ofhematomas thrombocytopeniaand allergic reactions

Heparin

bull The least expensive anticoagulant

bull Either systemically or regionally

When heparin is used

bull The hemofilter may be flushed with a dilute heparin solution continuously or intermittently

Systemic heparinization includes

bull Infusing heparin into a separate intravenous access or into the arterial side of the CRRT circuit

bull Mixing of the heparin with the blood from the patient before the blood reaches the filter

bull Anticoagulation of the circuit as well as for the patient

Argatroban and lepirudin

bullDirect thrombin inhibitors

bullHIT

Lepirudin is cleared by the kidneys and therefore may not be the drug of choice

for patients in ARF

Argatroban is eliminated by the liver and is therefore more suitable for use in

patients with renal failure

Citrate

excellent anticoagulant ability and potential to prolong circuit life

bull Calcium is an essential component of the clotting cascade

bull Citrate binds to the calcium in the patientrsquos blood within the CRRT system and prevents clotting

Citrate is infused prefilter into the CRRT system and calcium is typically infused via another intravenous line outside the circuit

Ionized calcium levels are routinely monitored

1048708Heparin

bull 250500 Uhr

1048708HIT Argatroban

bull 1048708051 mghr

1048708Bleeding risk

bull 1048708Citrate

bull 1048708No anticoagulation

Dialysate

Conculsions

Critically ill patients AKI occurs in up to 30 of all ICU admissions

CRRT is almost exclusively applied to patients in (ICU)

Restrict monitoring and follow up of the patients during CRRT is mandatory

Well trained nurse is the corner stone of adequate CRRT

bull Mechanical failures can occur if alarms are ignored or bypassed without determining the cause of the alarms

bull If scales are not properly calibrated the volumes of fluid administered and removed may not be the programmed volumes

541 We suggest initiating RRT in patients with AKI via an uncuffed non tunneled dialysis catheter rather than a tunneled catheter (2D)

542 When choosing a vein for insertion of a dialysis catheter in patients with AKI consider these preferences (Not Graded)

bull First choice right jugular vein

bull Second choice femoral vein

bull Third choice left jugular vein

bull Last choice subclavian vein with preference for the dominant side

Anticoagulation

CRRT can be performed with or without anticoagulation

The choice of anticoagulant depends on

bull The physicianrsquos preference

bull The patientrsquos condition

bull The familiarity of the nursing staff with anticoagulation regimens

The bedside nurse is responsiblefor monitoring any adverse effectsof anticoagulation includinghemorrhage formation ofhematomas thrombocytopeniaand allergic reactions

Heparin

bull The least expensive anticoagulant

bull Either systemically or regionally

When heparin is used

bull The hemofilter may be flushed with a dilute heparin solution continuously or intermittently

Systemic heparinization includes

bull Infusing heparin into a separate intravenous access or into the arterial side of the CRRT circuit

bull Mixing of the heparin with the blood from the patient before the blood reaches the filter

bull Anticoagulation of the circuit as well as for the patient

Argatroban and lepirudin

bullDirect thrombin inhibitors

bullHIT

Lepirudin is cleared by the kidneys and therefore may not be the drug of choice

for patients in ARF

Argatroban is eliminated by the liver and is therefore more suitable for use in

patients with renal failure

Citrate

excellent anticoagulant ability and potential to prolong circuit life

bull Calcium is an essential component of the clotting cascade

bull Citrate binds to the calcium in the patientrsquos blood within the CRRT system and prevents clotting

Citrate is infused prefilter into the CRRT system and calcium is typically infused via another intravenous line outside the circuit

Ionized calcium levels are routinely monitored

1048708Heparin

bull 250500 Uhr

1048708HIT Argatroban

bull 1048708051 mghr

1048708Bleeding risk

bull 1048708Citrate

bull 1048708No anticoagulation

Dialysate

Conculsions

Critically ill patients AKI occurs in up to 30 of all ICU admissions

CRRT is almost exclusively applied to patients in (ICU)

Restrict monitoring and follow up of the patients during CRRT is mandatory

Well trained nurse is the corner stone of adequate CRRT

541 We suggest initiating RRT in patients with AKI via an uncuffed non tunneled dialysis catheter rather than a tunneled catheter (2D)

542 When choosing a vein for insertion of a dialysis catheter in patients with AKI consider these preferences (Not Graded)

bull First choice right jugular vein

bull Second choice femoral vein

bull Third choice left jugular vein

bull Last choice subclavian vein with preference for the dominant side

Anticoagulation

CRRT can be performed with or without anticoagulation

The choice of anticoagulant depends on

bull The physicianrsquos preference

bull The patientrsquos condition

bull The familiarity of the nursing staff with anticoagulation regimens

The bedside nurse is responsiblefor monitoring any adverse effectsof anticoagulation includinghemorrhage formation ofhematomas thrombocytopeniaand allergic reactions

Heparin

bull The least expensive anticoagulant

bull Either systemically or regionally

When heparin is used

bull The hemofilter may be flushed with a dilute heparin solution continuously or intermittently

Systemic heparinization includes

bull Infusing heparin into a separate intravenous access or into the arterial side of the CRRT circuit

bull Mixing of the heparin with the blood from the patient before the blood reaches the filter

bull Anticoagulation of the circuit as well as for the patient

Argatroban and lepirudin

bullDirect thrombin inhibitors

bullHIT

Lepirudin is cleared by the kidneys and therefore may not be the drug of choice

for patients in ARF

Argatroban is eliminated by the liver and is therefore more suitable for use in

patients with renal failure

Citrate

excellent anticoagulant ability and potential to prolong circuit life

bull Calcium is an essential component of the clotting cascade

bull Citrate binds to the calcium in the patientrsquos blood within the CRRT system and prevents clotting

Citrate is infused prefilter into the CRRT system and calcium is typically infused via another intravenous line outside the circuit

Ionized calcium levels are routinely monitored

1048708Heparin

bull 250500 Uhr

1048708HIT Argatroban

bull 1048708051 mghr

1048708Bleeding risk

bull 1048708Citrate

bull 1048708No anticoagulation

Dialysate

Conculsions

Critically ill patients AKI occurs in up to 30 of all ICU admissions

CRRT is almost exclusively applied to patients in (ICU)

Restrict monitoring and follow up of the patients during CRRT is mandatory

Well trained nurse is the corner stone of adequate CRRT

Anticoagulation

CRRT can be performed with or without anticoagulation

The choice of anticoagulant depends on

bull The physicianrsquos preference

bull The patientrsquos condition

bull The familiarity of the nursing staff with anticoagulation regimens

The bedside nurse is responsiblefor monitoring any adverse effectsof anticoagulation includinghemorrhage formation ofhematomas thrombocytopeniaand allergic reactions

Heparin

bull The least expensive anticoagulant

bull Either systemically or regionally

When heparin is used

bull The hemofilter may be flushed with a dilute heparin solution continuously or intermittently

Systemic heparinization includes

bull Infusing heparin into a separate intravenous access or into the arterial side of the CRRT circuit

bull Mixing of the heparin with the blood from the patient before the blood reaches the filter

bull Anticoagulation of the circuit as well as for the patient

Argatroban and lepirudin

bullDirect thrombin inhibitors

bullHIT

Lepirudin is cleared by the kidneys and therefore may not be the drug of choice

for patients in ARF

Argatroban is eliminated by the liver and is therefore more suitable for use in

patients with renal failure

Citrate

excellent anticoagulant ability and potential to prolong circuit life

bull Calcium is an essential component of the clotting cascade

bull Citrate binds to the calcium in the patientrsquos blood within the CRRT system and prevents clotting

Citrate is infused prefilter into the CRRT system and calcium is typically infused via another intravenous line outside the circuit

Ionized calcium levels are routinely monitored

1048708Heparin

bull 250500 Uhr

1048708HIT Argatroban

bull 1048708051 mghr

1048708Bleeding risk

bull 1048708Citrate

bull 1048708No anticoagulation

Dialysate

Conculsions

Critically ill patients AKI occurs in up to 30 of all ICU admissions

CRRT is almost exclusively applied to patients in (ICU)

Restrict monitoring and follow up of the patients during CRRT is mandatory

Well trained nurse is the corner stone of adequate CRRT

The bedside nurse is responsiblefor monitoring any adverse effectsof anticoagulation includinghemorrhage formation ofhematomas thrombocytopeniaand allergic reactions

Heparin

bull The least expensive anticoagulant

bull Either systemically or regionally

When heparin is used

bull The hemofilter may be flushed with a dilute heparin solution continuously or intermittently

Systemic heparinization includes

bull Infusing heparin into a separate intravenous access or into the arterial side of the CRRT circuit

bull Mixing of the heparin with the blood from the patient before the blood reaches the filter

bull Anticoagulation of the circuit as well as for the patient

Argatroban and lepirudin

bullDirect thrombin inhibitors

bullHIT

Lepirudin is cleared by the kidneys and therefore may not be the drug of choice

for patients in ARF

Argatroban is eliminated by the liver and is therefore more suitable for use in

patients with renal failure

Citrate

excellent anticoagulant ability and potential to prolong circuit life

bull Calcium is an essential component of the clotting cascade

bull Citrate binds to the calcium in the patientrsquos blood within the CRRT system and prevents clotting

Citrate is infused prefilter into the CRRT system and calcium is typically infused via another intravenous line outside the circuit

Ionized calcium levels are routinely monitored

1048708Heparin

bull 250500 Uhr

1048708HIT Argatroban

bull 1048708051 mghr

1048708Bleeding risk

bull 1048708Citrate

bull 1048708No anticoagulation

Dialysate

Conculsions

Critically ill patients AKI occurs in up to 30 of all ICU admissions

CRRT is almost exclusively applied to patients in (ICU)

Restrict monitoring and follow up of the patients during CRRT is mandatory

Well trained nurse is the corner stone of adequate CRRT

Heparin

bull The least expensive anticoagulant

bull Either systemically or regionally

When heparin is used

bull The hemofilter may be flushed with a dilute heparin solution continuously or intermittently

Systemic heparinization includes

bull Infusing heparin into a separate intravenous access or into the arterial side of the CRRT circuit

bull Mixing of the heparin with the blood from the patient before the blood reaches the filter

bull Anticoagulation of the circuit as well as for the patient

Argatroban and lepirudin

bullDirect thrombin inhibitors

bullHIT

Lepirudin is cleared by the kidneys and therefore may not be the drug of choice

for patients in ARF

Argatroban is eliminated by the liver and is therefore more suitable for use in

patients with renal failure

Citrate

excellent anticoagulant ability and potential to prolong circuit life

bull Calcium is an essential component of the clotting cascade

bull Citrate binds to the calcium in the patientrsquos blood within the CRRT system and prevents clotting

Citrate is infused prefilter into the CRRT system and calcium is typically infused via another intravenous line outside the circuit

Ionized calcium levels are routinely monitored

1048708Heparin

bull 250500 Uhr

1048708HIT Argatroban

bull 1048708051 mghr

1048708Bleeding risk

bull 1048708Citrate

bull 1048708No anticoagulation

Dialysate

Conculsions

Critically ill patients AKI occurs in up to 30 of all ICU admissions

CRRT is almost exclusively applied to patients in (ICU)

Restrict monitoring and follow up of the patients during CRRT is mandatory

Well trained nurse is the corner stone of adequate CRRT

Argatroban and lepirudin

bullDirect thrombin inhibitors

bullHIT

Lepirudin is cleared by the kidneys and therefore may not be the drug of choice

for patients in ARF

Argatroban is eliminated by the liver and is therefore more suitable for use in

patients with renal failure

Citrate

excellent anticoagulant ability and potential to prolong circuit life

bull Calcium is an essential component of the clotting cascade

bull Citrate binds to the calcium in the patientrsquos blood within the CRRT system and prevents clotting

Citrate is infused prefilter into the CRRT system and calcium is typically infused via another intravenous line outside the circuit

Ionized calcium levels are routinely monitored

1048708Heparin

bull 250500 Uhr

1048708HIT Argatroban

bull 1048708051 mghr

1048708Bleeding risk

bull 1048708Citrate

bull 1048708No anticoagulation

Dialysate

Conculsions

Critically ill patients AKI occurs in up to 30 of all ICU admissions

CRRT is almost exclusively applied to patients in (ICU)

Restrict monitoring and follow up of the patients during CRRT is mandatory

Well trained nurse is the corner stone of adequate CRRT

Lepirudin is cleared by the kidneys and therefore may not be the drug of choice

for patients in ARF

Argatroban is eliminated by the liver and is therefore more suitable for use in

patients with renal failure

Citrate

excellent anticoagulant ability and potential to prolong circuit life

bull Calcium is an essential component of the clotting cascade

bull Citrate binds to the calcium in the patientrsquos blood within the CRRT system and prevents clotting

Citrate is infused prefilter into the CRRT system and calcium is typically infused via another intravenous line outside the circuit

Ionized calcium levels are routinely monitored

1048708Heparin

bull 250500 Uhr

1048708HIT Argatroban

bull 1048708051 mghr

1048708Bleeding risk

bull 1048708Citrate

bull 1048708No anticoagulation

Dialysate

Conculsions

Critically ill patients AKI occurs in up to 30 of all ICU admissions

CRRT is almost exclusively applied to patients in (ICU)

Restrict monitoring and follow up of the patients during CRRT is mandatory

Well trained nurse is the corner stone of adequate CRRT

Citrate

excellent anticoagulant ability and potential to prolong circuit life

bull Calcium is an essential component of the clotting cascade

bull Citrate binds to the calcium in the patientrsquos blood within the CRRT system and prevents clotting

Citrate is infused prefilter into the CRRT system and calcium is typically infused via another intravenous line outside the circuit

Ionized calcium levels are routinely monitored

1048708Heparin

bull 250500 Uhr

1048708HIT Argatroban

bull 1048708051 mghr

1048708Bleeding risk

bull 1048708Citrate

bull 1048708No anticoagulation

Dialysate

Conculsions

Critically ill patients AKI occurs in up to 30 of all ICU admissions

CRRT is almost exclusively applied to patients in (ICU)

Restrict monitoring and follow up of the patients during CRRT is mandatory

Well trained nurse is the corner stone of adequate CRRT

1048708Heparin

bull 250500 Uhr

1048708HIT Argatroban

bull 1048708051 mghr

1048708Bleeding risk

bull 1048708Citrate

bull 1048708No anticoagulation

Dialysate

Conculsions

Critically ill patients AKI occurs in up to 30 of all ICU admissions

CRRT is almost exclusively applied to patients in (ICU)

Restrict monitoring and follow up of the patients during CRRT is mandatory

Well trained nurse is the corner stone of adequate CRRT

Dialysate

Conculsions

Critically ill patients AKI occurs in up to 30 of all ICU admissions

CRRT is almost exclusively applied to patients in (ICU)

Restrict monitoring and follow up of the patients during CRRT is mandatory

Well trained nurse is the corner stone of adequate CRRT

Conculsions

Critically ill patients AKI occurs in up to 30 of all ICU admissions

CRRT is almost exclusively applied to patients in (ICU)

Restrict monitoring and follow up of the patients during CRRT is mandatory

Well trained nurse is the corner stone of adequate CRRT