Difference between revisions of "CRRT (Continuous Renal Replacement Therapy)"

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Provides renal support to patients. Usually veno-venous, but arterio-venous exists too (not covered here).
Provides renal support to patients. Usually veno-venous, but arterio-venous exists too (not covered here).


== Mechanisms and types ==
== Mechanisms ==
'''Solute removal mechanisms:'''
'''Solute removal mechanisms:'''


* Diffusion
* Diffusion
** Accomplished by passive movement of solute across a membrane
** Accomplished by passive movement of solute across a membrane (due to a solute concentration gradient, movement from high to low)
** Efficient clearance of low-molecular-weight solutes (< 500-1,500 Daltons)
** Efficient clearance of low-molecular-weight solutes (< 500-1,500 Daltons)
** Clearance decreases with increasing molecular weight of solute
** Clearance decreases with increasing molecular weight of solute
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** Clearance of different size of solute similar until the size of the solute reaches with size of the pores
** Clearance of different size of solute similar until the size of the solute reaches with size of the pores
** Overall CVVH with higher clearance rate than CVVHD for solutes 1,000 to 20,000 Daltons
** Overall CVVH with higher clearance rate than CVVHD for solutes 1,000 to 20,000 Daltons
'''Membrane characteristics:'''
* Geometric: length, mean inner radius, wall thickness, number of pores, number of fibers (determines membrane surface area)
* Membrane ultrafiltration coefficient: water permeability of filter
* Filter ultrafiltration coefficient: membrane ultrafiltration coefficient multiplied by membrane surface area
* Mass transfer area coefficient: overall capacity of membrane to provide diffusive removal of solute
* Membrane sieving coefficient: ratio of specific solute concentration in ultrafiltrate (only removed by convection) divided by mean plasma concentration in filter
* Cutoff: molecular weight of the smallest solute retained by the membrane
== Types of CRRT (see figure 1 for diagrams) ==
[[File:Img 1.png|thumb|Figure 1: Types of CRRT (Recreated based on Tandukar 2019 & Asahi Kasei Medical Co.)]]
[[File:Img 1.png|thumb|Figure 1: Types of CRRT (Recreated based on Tandukar 2019 & Asahi Kasei Medical Co.)]]
'''Main types (see figure 1 for diagrams):'''
'''SCUF (Slow continuous ultrafiltration)'''


* SCUF (Slow continuous ultrafiltration)
* Convection
** Convection
* Mainly fluid removal
** Mainly fluid removal
 
* CVVH (Continuous venovenous hemofiltration)
'''CVVH (Continuous venovenous hemofiltration)'''
** Convection  
* Convection
* CVVHD (Continuous venovenous hemodialysis)
'''CVVHD (Continuous venovenous hemodialysis)'''
** Diffusion
* Diffusion
* CVVHDF (Continuous venovenous hemodiafiltration)
'''CVVHDF (Continuous venovenous hemodiafiltration)'''
** Combination of convection and diffusion
* Combination of convection and diffusion


== Anesthetic implications<!-- Briefly summarize the anesthetic implications of this comorbidity. --> ==
== Anesthetic implications<!-- Briefly summarize the anesthetic implications of this comorbidity. --> ==


=== Preoperative optimization<!-- Describe how this comorbidity may influence preoperative evaluation and optimization of patients. --> ===
=== Indications ===
Renal replacement for patients with cardiovascular/hemodynamic instability, acute brain injury, cerebral edema, or raised intracranial pressure (for slow electrolyte correction).


=== Intraoperative management<!-- Describe how this comorbidity may influence intraoperative management. --> ===
=== Intraoperative management<!-- Describe how this comorbidity may influence intraoperative management. --> ===


=== Postoperative management<!-- Describe how this comorbidity may influence postoperative management. --> ===
== Pathophysiology<!-- Describe the pathophysiology of this comorbidity. Add subsections as needed. -->==
 
== Related surgical procedures<!-- List and briefly describe any procedures which may be performed specifically to treat this comorbidity or its sequelae. If none, this section may be removed. --> ==
 
== Pathophysiology<!-- Describe the pathophysiology of this comorbidity. Add subsections as needed. --> ==


== Signs and symptoms<!-- Describe the signs and symptoms of this comorbidity. --> ==
== Signs and symptoms<!-- Describe the signs and symptoms of this comorbidity. --> ==
== Diagnosis<!-- Describe how this comorbidity is diagnosed. --> ==
== Treatment<!-- Summarize the treatment of this comorbidity. Add subsections as needed. --> ==
=== Medication<!-- Describe medications used to manage this comorbidity. --> ===
=== Surgery<!-- Describe surgical procedures used to treat this comorbidity. --> ===
=== Prognosis<!-- Describe the prognosis of this comorbidity --> ===


== References ==
== References ==
Tandukar S, Palevsky PM. Continuous Renal Replacement Therapy: Who, When, Why, and How. Chest. 2019 Mar;155(3):626-638. doi: 10.1016/j.chest.2018.09.004. Epub 2018 Sep 25. PMID: 30266628; PMCID: PMC6435902.
Tandukar S, Palevsky PM. Continuous Renal Replacement Therapy: Who, When, Why, and How. Chest. 2019 Mar;155(3):626-638. doi: 10.1016/j.chest.2018.09.004. Epub 2018 Sep 25. PMID: 30266628; PMCID: PMC6435902.
Neri M, Villa G, Garzotto F, Bagshaw S, Bellomo R, Cerda J, Ferrari F, Guggia S, Joannidis M, Kellum J, Kim JC, Mehta RL, Ricci Z, Trevisani A, Marafon S, Clark WR, Vincent JL, Ronco C; Nomenclature Standardization Initiative (NSI) alliance. Nomenclature for renal replacement therapy in acute kidney injury: basic principles. Crit Care. 2016 Oct 10;20(1):318. doi: 10.1186/s13054-016-1489-9. PMID: 27719682; PMCID: PMC5056503.


Continuous Renal Replacement Therapy (CRRT) | Asahi Kasei Medical Co., Ltd. (n.d.). <nowiki>https://www.asahi-kasei.co.jp/medical/en/apheresis/product/crrt/about/cure.html</nowiki>  
Continuous Renal Replacement Therapy (CRRT) | Asahi Kasei Medical Co., Ltd. (n.d.). <nowiki>https://www.asahi-kasei.co.jp/medical/en/apheresis/product/crrt/about/cure.html</nowiki>  

Revision as of 14:06, 4 May 2024

CRRT (Continuous Renal Replacement Therapy)
Anesthetic relevance
Anesthetic management

{{{anesthetic_management}}}

Specialty
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Diagnosis
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Provides renal support to patients. Usually veno-venous, but arterio-venous exists too (not covered here).

Mechanisms

Solute removal mechanisms:

  • Diffusion
    • Accomplished by passive movement of solute across a membrane (due to a solute concentration gradient, movement from high to low)
    • Efficient clearance of low-molecular-weight solutes (< 500-1,500 Daltons)
    • Clearance decreases with increasing molecular weight of solute
  • Convection
    • Accomplished by active movement of solute (due to a pressure gradient) across a membrane
    • Limited primarily by size of pores in membrane
    • Clearance of different size of solute similar until the size of the solute reaches with size of the pores
    • Overall CVVH with higher clearance rate than CVVHD for solutes 1,000 to 20,000 Daltons

Membrane characteristics:

  • Geometric: length, mean inner radius, wall thickness, number of pores, number of fibers (determines membrane surface area)
  • Membrane ultrafiltration coefficient: water permeability of filter
  • Filter ultrafiltration coefficient: membrane ultrafiltration coefficient multiplied by membrane surface area
  • Mass transfer area coefficient: overall capacity of membrane to provide diffusive removal of solute
  • Membrane sieving coefficient: ratio of specific solute concentration in ultrafiltrate (only removed by convection) divided by mean plasma concentration in filter
  • Cutoff: molecular weight of the smallest solute retained by the membrane

Types of CRRT (see figure 1 for diagrams)

Figure 1: Types of CRRT (Recreated based on Tandukar 2019 & Asahi Kasei Medical Co.)

SCUF (Slow continuous ultrafiltration)

  • Convection
  • Mainly fluid removal

CVVH (Continuous venovenous hemofiltration)

  • Convection

CVVHD (Continuous venovenous hemodialysis)

  • Diffusion

CVVHDF (Continuous venovenous hemodiafiltration)

  • Combination of convection and diffusion

Anesthetic implications

Indications

Renal replacement for patients with cardiovascular/hemodynamic instability, acute brain injury, cerebral edema, or raised intracranial pressure (for slow electrolyte correction).

Intraoperative management

Pathophysiology

Signs and symptoms

References

Tandukar S, Palevsky PM. Continuous Renal Replacement Therapy: Who, When, Why, and How. Chest. 2019 Mar;155(3):626-638. doi: 10.1016/j.chest.2018.09.004. Epub 2018 Sep 25. PMID: 30266628; PMCID: PMC6435902.

Neri M, Villa G, Garzotto F, Bagshaw S, Bellomo R, Cerda J, Ferrari F, Guggia S, Joannidis M, Kellum J, Kim JC, Mehta RL, Ricci Z, Trevisani A, Marafon S, Clark WR, Vincent JL, Ronco C; Nomenclature Standardization Initiative (NSI) alliance. Nomenclature for renal replacement therapy in acute kidney injury: basic principles. Crit Care. 2016 Oct 10;20(1):318. doi: 10.1186/s13054-016-1489-9. PMID: 27719682; PMCID: PMC5056503.

Continuous Renal Replacement Therapy (CRRT) | Asahi Kasei Medical Co., Ltd. (n.d.). https://www.asahi-kasei.co.jp/medical/en/apheresis/product/crrt/about/cure.html

Cronin B, O'Brien EO. Intraoperative Renal Replacement Therapy: Practical Information for Anesthesiologists. J Cardiothorac Vasc Anesth. 2022 Aug;36(8 Pt A):2656-2668. doi: 10.1053/j.jvca.2021.10.002. Epub 2021 Oct 8. PMID: 34750060.

Top contributors: Christopher Deeble

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