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Kiểm soát cân bằng dịch trong lọc máu liên tục (CRRT)

TS.BS. Bùi Thị Hạnh Duyên

Trưởng khoa HSTC.BVĐHYD.TPHCM

Phó chủ tịch Hội Hen-Miễn dịch-Dị Ứng Lâm sàng TP.HCM

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Nội dung

Ảnh hưởng của quá tải dịch trên kết cục của BN hồi sức

Vận chuyển dịch lòng mạch- mô kẽ

Tốc độ net UF, cân bằng dịch tích lũy và tử vong

Cân bằng dịch mục tiêu và thực tế

Sai lầm trong kiểm soát dịch

Tóm tắt

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Tổng quan

Kiểm soát cân bằng dịch là 1 trong những chỉ định chính của CRRT
Tình trạng quá tải dịch ảnh hưởng xấu lên các cơ quan, kéo dài thời gian nằm viện và tăng nguy cơ tử vong.
Quản lý dịch trong CRRT rất quan trọng đặc biệt là BN bị quá tải dịch hoặc suy thận cấp hay bệnh thận mạn.
BN không đạt được mục tiêu kiểm soát dịch mặc dù có thể có lượng nước tiểu khá/lợi tiểu là có chỉ định thay thế thận (IHD/CRRT)

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�Ảnh hưởng của cân bằng dịch lên kết cục BN�

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Ảnh hưởng của cân bằng dịch dương lên nguy cơ tử vong

Crit Care Med. 2016 Oct;44(10):1891-900

FO: Quá tải dịch

CFB: cân bằng dịch tích lũy

Neyra JA, Li X, Canepa-Escaro F, Adams-Huet B, Toto RD, Yee J, Hedayati SS; Acute Kidney Injury in Critical Illness Study Group. Cumulative Fluid Balance and Mortality in Septic Patients With or Without Acute Kidney Injury and Chronic Kidney Disease. Crit Care Med. 2016 Oct;44(10):1891-900. doi: 10.1097/CCM.0000000000001835. PMID: 27352125; PMCID: PMC5505731.

Higher CFB at 72 hours of ICU admission was independently associated with hospital mortality in adult patients with severe sepsis or septic shock, regardless of AKI or CKD presence. The combination of CFB at 72 hours and admission SOFA score improved the predictive value of SOFA score for hospital mortality.

Stratification of patients by the occurrence of AKI and preexisting CKD identified different CFB cut-offs associated with hospital mortality, with the lowest CFB cut-off in those without incident AKI or prevalent CKD.

The characterization of different CFB cut-offs underpins the heterogeneity of fluid regulation in

critical illness, sepsis, and kidney disease. These differences should be further investigated in future prospective studies in which measurements of interstitial volume and microcirculatory dynamics, in addition to intravascular volume, can be used for guiding fluid therapy in critically ill patients with or without kidney disease.

Objective: Incident acute kidney injury and prevalent chronic kidney disease are commonly encountered in septic patients. We examined the differential effect of acute kidney injury and chronic kidney disease on the association between cumulative fluid balance and hospital mortality in critically ill septic patients.

Design: Retrospective cohort study.

Setting: Urban academic medical center ICU. Patients: ICU adult patients with severe sepsis or septic shock and serum creatinine measured within 3 months prior to and 72 hours of ICU admission. Patients with estimated glomerular filtration rate less than 15 mL/min/1.73 m2 or receiving chronic

dialysis were excluded.

Interventions: None.

Measurements and Main Results: A total of 2,632 patients, 1,211 with chronic kidney disease, were followed up until hospital death or discharge. Acute kidney injury occurred in 1,525 patients (57.9%), of whom 679 (44.5%) had chronic kidney disease. Hospital mortality occurred in 603 patients (22.9%). Every 1-L increase in cumulative fluid balance at 72 hours of ICU admission was independently associated with hospital mortality in all patients (adjusted odds ratio, 1.06 [95% CI] 1.04–1.08; p < 0.001), and in each acute kidney injury/chronic kidney disease subgroup (adjusted odds ratio, 1.06 [1.03–1.09] for acute kidney injury+/chronic kidney disease+; 1.09 [1.05–1.13] for acute kidney injury–/chronic kidney disease+; 1.05 [1.03–1.08] for acute kidney injury+/chronic kidney disease–; and 1.07 [1.02–1.11] for acute kidney injury–/chronic kidney disease–).

There was a significant interaction between acute kidney injury and chronic kidney disease on cumulative fluid balance (p =0.005) such that different cumulative fluid balance cut-offs with the best prognostic accuracy for hospital mortality were identified: 5.9 L for acute kidney injury+/chronic kidney disease+; 3.8 L for acute kidney injury–/chronic kidney disease+; 4.3 L for acute kidney injury+/chronic kidney disease–; and 1.5 L for acute kidney injury–/ chronic kidney disease–. The addition of cumulative fluid balance to the admission Sequential Organ Failure Assessment score had increased prognostic utility for hospital mortality when compared with Sequential Organ Failure Assessment alone, particularly in patients with acute kidney injury.

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Ảnh hưởng của cân bằng dịch dương lên nguy cơ tử vong

Cân bằng dịch tích lũy (CFB) 72 giờ sau nhập ICU là yếu tố độc lập kết hợp với tử vong ở BN NHK/SNK bất kể AKI/CKD.
Kết hợp CFB 72 giờ và SOFA nhập viện cải thiện giá trị tiên đoán tử vong nội viện của SOFA

Crit Care Med. 2016 Oct;44(10):1891-900

Neyra JA, Li X, Canepa-Escaro F, Adams-Huet B, Toto RD, Yee J, Hedayati SS; Acute Kidney Injury in Critical Illness Study Group. Cumulative Fluid Balance and Mortality in Septic Patients With or Without Acute Kidney Injury and Chronic Kidney Disease. Crit Care Med. 2016 Oct;44(10):1891-900. doi: 10.1097/CCM.0000000000001835. PMID: 27352125; PMCID: PMC5505731.

Higher CFB at 72 hours of ICU admission was independently associated with hospital mortality in adult patients with severe sepsis or septic shock, regardless of AKI or CKD presence. The combination of CFB at 72 hours and admission SOFA score improved the predictive value of SOFA score for hospital mortality. Stratification of patients by the occurrence of AKI and preexisting CKD identified different CFB cut-offs associated with hospital mortality, with the lowest CFB cut-off in those without incident AKI or prevalent CKD. The characterization of different CFB cut-offs underpins the heterogeneity of fluid regulation in critical illness, sepsis, and kidney disease. These differences should be further investigated in future prospective studies in which measurements of interstitial volume and microcirculatory dynamics, in addition to intravascular volume, can be used for guiding fluid therapy in critically ill patients with or without kidney disease.

Objective: Incident acute kidney injury and prevalent chronic

Kidney disease are commonly encountered in septic patients. We examined the differential effect of acute kidney injury and chronic kidney disease on the association between cumulative fluid

Balance and hospital mortality in critically ill septic patients.

Design: Retrospective cohort study.

Setting: Urban academic medical center ICU.

Patients: ICU adult patients with severe sepsis or septic shock and serum creatinine measured within 3 months prior to and 72 hours of ICU admission. Patients with estimated glomerular

filtration rate less than 15 mL/min/1.73 m2 or receiving chronic dialysis were excluded.

Interventions: None.

Measurements and Main Results: A total of 2,632 patients, 1,211with chronic kidney disease, were followed up until hospital death or discharge. Acute kidney injury occurred in 1,525 patients (57.9%),

of whom 679 (44.5%) had chronic kidney disease. Hospital mortality occurred in 603 patients (22.9%). Every 1-L increase in cumulative fluid balance at 72 hours of ICU admission was independently

associated with hospital mortality in all patients (adjusted odds ratio, 1.06 [95% CI] 1.04–1.08; p < 0.001), and in each acute kidney injury/chronic kidney disease subgroup (adjusted odds ratio, 1.06 [1.03–1.09] for acute kidney injury+/chronic kidney disease+; 1.09 [1.05–1.13] for acute kidney injury–/chronic kidney disease+; 1.05 [1.03–1.08] for acute kidney injury+/chronic kidney disease–;

and 1.07 [1.02–1.11] for acute kidney injury–/chronic kidney disease–). There was a significant interaction between acute kidney injury and chronic kidney disease on cumulative fluid balance (p =0.005) such that different cumulative fluid balance cut-offs with the best prognostic accuracy for hospital mortality were identified: 5.9 L for acute kidney injury+/chronic kidney disease+; 3.8 L for acute kidney injury–/chronic kidney disease+; 4.3 L for acute kidney injury+/chronic kidney disease–; and 1.5 L for acute kidney injury–/ chronic kidney disease–. The addition of cumulative fluid balance to the admission Sequential Organ Failure Assessment score had increased prognostic utility for hospital mortality when compared with Sequential Organ Failure Assessment alone, particularly in patients with acute kidney injury.

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Cân bằng dịch tích lũy và nguy cơ tử vong ở BN CRRT

NC hồi cứu 820 BN ICU được CRRT cho AKI ít nhất 24 giờ
Nhóm sống có có cân bằng dịch tích lũy lúc khởi đầu CRRT thấp hơn so với nhóm tử (1495 vs 2184 ml; p < 0.001)
Sau 7 ngày CRRT, nhóm sống giảm cân bằng dịch tích lũy đáng kể, còn nhóm tử thì không thay đổi đáng kể

Hall A, et al. Crit Care. 2020 Jun 1;24(1):279. doi: 10.1186/s13054-020-02986-4.

Hall A, Crichton S, Dixon A, Skorniakov I, Kellum JA, Ostermann M. Fluid removal associates with better outcomes in critically ill patients receiving continuous renal replacement therapy: a cohort study. Crit Care. 2020 Jun 1;24(1):279. doi: 10.1186/s13054-020-02986-4. PMID: 32487189; PMCID: PMC7268712.

Hall A, et al. Crit Care. 2020 Jun 1;24(1):279. doi: 10.1186/s13054-020-02986-4.

Abstract

Background: Fluid overload is associated with morbidity and mortality in patients receiving renal replacement therapy (RRT). We aimed to explore whether fluid overload at initiation of RRT was independently associated with mortality and whether changes in cumulative fluid balance during RRT were associated with outcome.

Methods: We retrospectively analysed the data of patients who were admitted to the multidisciplinary adult intensive care unit (ICU) in a tertiary care centre in the UK between 2012 and 2015 and received continuous RRT (CRRT) for acute kidney injury for at least 24 h. We collected baseline demographics, body mass index (BMI), comorbidities, severity of illness, laboratory parameters at CRRT initiation, daily cumulative fluid balance (FB), daily prescribed FB target, fluid bolus and diuretic administration and outcomes. The day of the lowest cumulative FB during CRRT was identified as nadir FB.

Results: Eight hundred twenty patients were analysed (median age 65 years; 49% female). At CRRT initiation, the median cumulative FB was + 1772 ml; 89 patients (10.9%) had a cumulative FB > 10% body weight (BW). Hospital survivors had a significantly lower cumulative FB at CRRT initiation compared to patients who died (1495 versus 2184 ml; p < 0.001). In the 7 days after CRRT initiation, hospital survivors had a significant decline in cumulative FB (mean decrease 473 ml per day, p < 0.001) whilst there was no significant change in cumulative FB in non-survivors (mean decrease 112 ml per day, p = 0.188). Higher severity of illness at CRRT initiation, shorter duration of CRRT, the number of days without a prescribed FB target and need for higher doses of noradrenaline were independent risk factors for not reaching a FB nadir during CRRT. Multivariable analysis showed that older age, lower BMI, higher severity of illness, need for higher doses of noradrenaline and smaller reductions in cumulative FB during CRRT were independent risk factors for ICU and hospital mortality. Cumulative FB at CRRT initiation was not independently associated with mortality.

Conclusion: In adult patients receiving CRRT, a decrease in cumulative FB was independently associated with lower mortality. Fluid overload and need for vasopressor support at CRRT initiation were not independently associated with mortality after correction for severity of illness.

Keywords: Acute kidney injury; Fluid balance; Fluid management; Fluid removal; Renal replacement therapy; Ultrafiltration.

�

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Mối tương quan giữa tốc độ siêu lọc, cân bằng dịch tích lũy và tử vong�

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Dịch rút bỏ khỏi CRRT (net UF)

Net UF= Total UF rate - Replacement Rate
Net UF không phản ánh cân bằng dịch (FB) của BN
Net UF chỉ là một trong những loại dịch xuất của BN
Cân bằng dịch của BN (FB) phụ thuộc:

Dịch nhập (dịch truyền, ăn uống)
Dịch xuất (nước tiểu, dẫn lưu, phân, nước mất không nhận biết)
Net UF

John Prowle and Ravindra Mehta, Seminars in Dialysis. 2021;00:1–9, wileyonlinelibrary.com/journal/s, DOI: 10.1111/sdi.12964

However, in all these techniques and hybrid therapies such as diafiltration, extracorporeal fluid removal will be determined by the difference between the total UF and any replacement rate, termed the net ultrafiltration volume

However, in both instances the NetUF represents the fluid removed per unit time across the machine, ie the machine fluid balance. It is important to recognize that NetUF generally represents the net fluid removal within the extracorporeal circuit irrespective of modality, but does not reflect the overall patient fluid balance as patients will have intakes (oral and IV) and outputs (urine, drains etc) that are not captured by the machine.

Importantly, in recent years, our understanding of the vascular biology of edema formation has progressed from the classic Starling model, to a revised model incorporating knowledge of the structure and function of the endothelial glycocalyx

Net ultrafiltration (UF_NET), được định nghĩa là lượng dịch được rút bỏ trong quá trình điều trị thay thế thận RRT

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Rút dịch trong CRRT

Net-UF

Chỉ rút dịch trực tiếp từ lòng mạch
Không loại bỏ trực tiếp dịch từ mô kẽ
Mà thay đổi dịch mô kẽ phụ thuộc vào quá trình tái phân bố dịch giữa các khoang.

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Tái phân bố dịch

Tái phân bố dịch:

Sau khi rút dịch từ huyết tương qua RRT, dịch từ khoang kẽ và nội bào sẽ dần tái phân bố vào lòng mạch.
Đây là một quá trình chậm, và cần được theo dõi cẩn thận để tránh gây thiếu dịch trong lòng mạch nghiêm trọng.

Quản lý cân bằng dịch:

Điều chỉnh tốc độ rút dịch cần tính đến khả năng tái hấp thu dịch vào lòng mạch từ các khoang dịch trong cơ thể
Tránh mất cân bằng dịch nghiêm trọng, gây sốc hoặc thiếu máu cơ quan

Prowle J, Mehta R. Fluid balance management during continuous renal replacement therapy. Semin Dial. 2021 Nov;34(6):440-448. doi: 10.1111/sdi.12964. Epub 2021 Mar 23. PMID: 33755249.

A key aspect of both normal renal function and forms of RRT in controlling fluid balance is that fluid removal occurs only from the plasma volume, whereas the majority of fluid within the body lies within the intracellular space and the interstitial space (Figure 1).

Thus, when fluid is removed from the

plasma water in order to achieve a total body fluid balance goal,

there is the inevitable risk of intravascular hypovolemia if rates of

fluid removal exceed the rates of intravascular refilling from the

interstitial space. Thus, when considering the prescription of UF in

RRT one must always consider the whole organism's response to

the prescribed fluid removal physiological limits of vascular refilling.

According to the glycocalyx model, the majority of vascular

refilling occurs via lymphatic return of interstitial fluid and this

lymphatic inflow will be relatively fixed during acute application

of UF. Total thoracic duct lymph flow in man is around 4–5

L/day

(around 200–250

ml/h), but can escalate several-fold

in exercise

and a similar volume of fluid may return directly to the circulation

in lymph nodes.25 However, as indicated above, lymphatic drainage

is likely to be impaired and in fluid overload arising in the context

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Vận chuyển dịch Lòng mạch -mô kẽ

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Thành phần của nước trong cơ thể

Rational Use of Intravenous Fluids in Critically Ill Patients. https://doi.org/10.1007/978-3-031-42205-8

Tổng lượng nước trong cơ thể (TBW) =60% Cân nặng
Nước trong nội bào (ICW) (66%)	Nước ngoại bào (ECW) (33%)
	Nước trong lòng mạch 20%	Nước mô kẽ 75%	Nước xuyên tế bào (transcellular water) 2.5%	Hệ bạch huyết 2.5%

Body water composition for an adult 80 kg male. ECW extracellular water, ICW intracellular water, ISF interstitial fluid, IVF intravascular fluid, TBW total body water, TCF transcellular fluid. These fluids are contained within epithelial lined spaces. Examples of this fluid are cerebrospinal fluid, pleural fluid, pericardial fluid, peritoneal fluid, bladder urine, eye fluid, joint fluid, etc.

4 compartments: This can be dealt with in different ways, classically you have fat–water–protein–and minerals while water on its own is also distributed into four compartments: intracellular water (ICW), interstitial water, intravascular water and transcellular, with extracellular water (ECW) calculated as the sum of interstitial + intravascular + transcellular water content.

4 D’s: Fluids are medications in which one should take into account the 4D’s in analogy to antimicrobial stewardship: Drug–Dose–Duration–De-escalation.

4 hits: The four hits are:

first hit = initial insult,

second hit = ischemia reperfusion,

third hit = global increased permeability syndrome (GIPS).

fourth hit = potential risk of hypoperfusion during de-resuscitation.

4 indications: Fluids can be given for four reasons: resuscitation, maintenance, replacement and nutrition.

4 fluid losses: Traditionally four ways can be taken into account with regard to fluid losses: insensible loss, urine output, gastrointestinal losses and third space. Additional losses can occur in trauma with overt bleeding or in severely burned patients.

4 phases: The four dynamic fluid phases are: resuscitation, optimization, stabilization and evacuation.

4 questions: The four main questions surrounding fluid therapy that need to be solved are:

when to start IV fluids?

when to stop IV fluids?

when to start fluid removal?

when to stop fluid removal?

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Prowle J et al., Dial. 2021 Nov;34(6):440-448. doi: 10.1111/sdi.12964

Prowle J, Mehta R. Fluid balance management during continuous renal replacement therapy. Semin Dial. 2021 Nov;34(6):440-448. doi: 10.1111/sdi.12964. Epub 2021 Mar 23. PMID: 33755249.

F I G U R E 1 Systemic inflammation results in disruption of endothelial glycocalyx and changes in the extra-cellular matrix (ECM) and lymphatic drainage that promote loss of plasma fluid to the extra-cellular

space and its retention in the interstitial compartment. These processes have implications for the magnitude and duration of response to fluid therapy and ability to resolve fluid overload once it has arisen. Reproduced from ref. 8

F I G U R E 3 Rate of mechanical fluid removal. Examples of patients with fluid overload as a result of disease or fluid resuscitation requiring

mechanical fluid management to illustrate how different rates of fluid removal are appropriate to different clinical settings. Rapid early fluid

removal may be indicated in cardio-renal

syndrome (A), but a slower removal than required for hemodynamic tolerability after resolution of

pulmonary edema. Patients with single organ renal failure (B) may tolerate more rapid fluid removal than patients with acute kidney injury

complicating severe sepsis (C) or septic shock (D). In septic shock mechanical fluid removal may at first be targeted to limit the accumulation

of further fluid until clinical stabilization allows slow resolution of accumulated fluid excess. Modified with permission from Acute Dialysis

Quality Initiative 12 www.adqi.org

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Tốc độ net UF và nguy cơ tử vong

Nghiên cứu hồi cứu từ RCT RENAL trial
1,434 BN ICU tại Úc và New Zealand
Net UF rate (mL/kg/h): Là lượng dịch được loại bỏ mỗi giờ, điều chỉnh theo cân nặng của BN ,
Phân nhóm Net UF rate:

Cao > 1.75 mL/kg/h
Trung bình 1.01–1.75 mL/kg/h
Thấp < 1.01 mL/kg/h

Murugan R, et al. JAMA Netw Open. 2019 Jun 5;2(6):e195418. doi: 10.1001/jamanetworkopen.2019.5418

Murugan R, Kerti SJ, Chang CH, Gallagher M, Clermont G, Palevsky PM, Kellum JA, Bellomo R. Association of Net Ultrafiltration Rate With Mortality Among Critically Ill Adults With Acute Kidney Injury Receiving Continuous Venovenous Hemodiafiltration: A Secondary Analysis of the Randomized Evaluation of Normal vs Augmented Level (RENAL) of Renal Replacement Therapy Trial. JAMA Netw Open. 2019 Jun 5;2(6):e195418. doi: 10.1001/jamanetworkopen.2019.5418. PMID: 31173127; PMCID: PMC6563576.

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�Murugan R, et al. JAMA Netw Open. 2019 Jun 5;2(6):e195418. doi: 10.1001/jamanetworkopen.2019.5418. �

Abstract

Importance: Net ultrafiltration (NUF) is frequently used to treat fluid overload among critically ill patients, but whether the rate of NUF affects outcomes is unclear.

Objective: To examine the association of NUF with survival among critically ill patients with acute kidney injury being treated with continuous venovenous hemodiafiltration.

Design, setting, and participants: The Randomized Evaluation of Normal vs Augmented Level (RENAL) of Renal Replacement Therapy trial was conducted between December 30, 2005, and November 28, 2008, at 35 intensive care units in Australia and New Zealand among critically ill adults with acute kidney injury who were being treated with continuous venovenous hemodiafiltration. This secondary analysis began in May 2018 and concluded in January 2019.

Exposures: Net ultrafiltration rate, defined as the volume of fluid removed per hour adjusted for patient body weight.

Main outcomes and measures: Risk-adjusted 90-day survival.

Results: Of 1434 patients, the median (interquartile range) age was 67.3 (56.9-76.3) years; 924 participants (64.4%) were male; median (interquartile range) Acute Physiology and Chronic Health Evaluation III score was 100 (84-118); and 634 patients (44.2%) died. Using tertiles, 3 groups were defined: high, NUF rate greater than 1.75 mL/kg/h; middle, NUF rate from 1.01 to 1.75 mL/kg/h; and low, NUF rate less than 1.01 mL/kg/h. The high-tertile group compared with the low-tertile group was not associated with death from day 0 to 6. However, death occurred in 51 patients (14.7%) in the high-tertile group vs 30 patients (8.6%) in the low-tertile group from day 7 to 12 (adjusted hazard ratio [aHR], 1.51; 95% CI, 1.13-2.02); 45 patients (15.3%) in the high-tertile group vs 25 patients (7.9%) in the low-tertile group from day 13 to 26 (aHR, 1.52; 95% CI, 1.11-2.07); and 48 patients (19.2%) in the high-tertile group vs 29 patients (9.9%) in the low-tertile group from day 27 to 90 (aHR, 1.66; 95% CI, 1.16-2.39). Every 0.5-mL/kg/h increase in NUF rate was associated with increased mortality (3-6 days: aHR, 1.05; 95% CI, 1.00-1.11; 7-12 days: aHR, 1.08; 95% CI, 1.02-1.15; 13-26 days: aHR, 1.11; 95% CI, 1.04-1.18; 27-90 days: aHR, 1.13; 95% CI, 1.05-1.22). Using longitudinal analyses, increase in NUF rate was associated with lower survival (β = .056; P < .001). Hypophosphatemia was more frequent among patients in the high-tertile group compared with patients in the middle-tertile group and patients in the low-tertile group (high: 308 of 477 patients at risk [64.6%]; middle: 293 of 472 patients at risk [62.1%]; low: 247 of 466 patients at risk [53.0%]; P < .001). Cardiac arrhythmias requiring treatment occurred among all groups: high, 176 patients (36.8%); middle: 175 patients (36.5%); and low: 147 patients (30.8%) (P = .08).

Conclusions and relevance: Among critically ill patients, NUF rates greater than 1.75 mL/kg/h compared with NUF rates less than 1.01 mL/kg/h were associated with lower survival. Residual confounding may be present from unmeasured risk factors, and randomized clinical trials are required to confirm these findings.

Trial registration: ClinicalTrials.gov identifier: NCT00221013.

PubMed Disclaimer

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Tốc độ net UF và nguy cơ tử vong

Từ ngày 7 trở đi, nhóm có Net UF cao liên quan đến tỷ lệ tử vong cao hơn đáng kể so với nhóm Net UF thấp.
Mỗi 0.5 mL/kg/h tăng thêm trong Net UF liên quan đến nguy cơ tử vong tăng dần ở mọi giai đoạn (3–6, 7–12, 13–26, và 27–90 ngày).
Hạ phosphat máu và loạn nhịp tim xảy ra nhiều hơn ở nhóm Net UF cao.

Murugan R, et al. JAMA Netw Open. 2019 Jun 5;2(6):e195418. doi: 10.1001/jamanetworkopen.2019.5418

Murugan R, Kerti SJ, Chang CH, Gallagher M, Clermont G, Palevsky PM, Kellum JA, Bellomo R. Association of Net Ultrafiltration Rate With Mortality Among Critically Ill Adults With Acute Kidney Injury Receiving Continuous Venovenous Hemodiafiltration: A Secondary Analysis of the Randomized Evaluation of Normal vs Augmented Level (RENAL) of Renal Replacement Therapy Trial. JAMA Netw Open. 2019 Jun 5;2(6):e195418. doi: 10.1001/jamanetworkopen.2019.5418. PMID: 31173127; PMCID: PMC6563576.

CopyDownload .nbib

�Murugan R, et al. JAMA Netw Open. 2019 Jun 5;2(6):e195418. doi: 10.1001/jamanetworkopen.2019.5418. �

Abstract

Importance: Net ultrafiltration (NUF) is frequently used to treat fluid overload among critically ill patients, but whether the rate of NUF affects outcomes is unclear.

Objective: To examine the association of NUF with survival among critically ill patients with acute kidney injury being treated with continuous venovenous hemodiafiltration.

Design, setting, and participants: The Randomized Evaluation of Normal vs Augmented Level (RENAL) of Renal Replacement Therapy trial was conducted between December 30, 2005, and November 28, 2008, at 35 intensive care units in Australia and New Zealand among critically ill adults with acute kidney injury who were being treated with continuous venovenous hemodiafiltration. This secondary analysis began in May 2018 and concluded in January 2019.

Exposures: Net ultrafiltration rate, defined as the volume of fluid removed per hour adjusted for patient body weight.

Main outcomes and measures: Risk-adjusted 90-day survival.

Results: Of 1434 patients, the median (interquartile range) age was 67.3 (56.9-76.3) years; 924 participants (64.4%) were male; median (interquartile range) Acute Physiology and Chronic Health Evaluation III score was 100 (84-118); and 634 patients (44.2%) died. Using tertiles, 3 groups were defined: high, NUF rate greater than 1.75 mL/kg/h; middle, NUF rate from 1.01 to 1.75 mL/kg/h; and low, NUF rate less than 1.01 mL/kg/h. The high-tertile group compared with the low-tertile group was not associated with death from day 0 to 6. However, death occurred in 51 patients (14.7%) in the high-tertile group vs 30 patients (8.6%) in the low-tertile group from day 7 to 12 (adjusted hazard ratio [aHR], 1.51; 95% CI, 1.13-2.02); 45 patients (15.3%) in the high-tertile group vs 25 patients (7.9%) in the low-tertile group from day 13 to 26 (aHR, 1.52; 95% CI, 1.11-2.07); and 48 patients (19.2%) in the high-tertile group vs 29 patients (9.9%) in the low-tertile group from day 27 to 90 (aHR, 1.66; 95% CI, 1.16-2.39). Every 0.5-mL/kg/h increase in NUF rate was associated with increased mortality (3-6 days: aHR, 1.05; 95% CI, 1.00-1.11; 7-12 days: aHR, 1.08; 95% CI, 1.02-1.15; 13-26 days: aHR, 1.11; 95% CI, 1.04-1.18; 27-90 days: aHR, 1.13; 95% CI, 1.05-1.22). Using longitudinal analyses, increase in NUF rate was associated with lower survival (β = .056; P < .001). Hypophosphatemia was more frequent among patients in the high-tertile group compared with patients in the middle-tertile group and patients in the low-tertile group (high: 308 of 477 patients at risk [64.6%]; middle: 293 of 472 patients at risk [62.1%]; low: 247 of 466 patients at risk [53.0%]; P < .001). Cardiac arrhythmias requiring treatment occurred among all groups: high, 176 patients (36.8%); middle: 175 patients (36.5%); and low: 147 patients (30.8%) (P = .08).

Conclusions and relevance: Among critically ill patients, NUF rates greater than 1.75 mL/kg/h compared with NUF rates less than 1.01 mL/kg/h were associated with lower survival. Residual confounding may be present from unmeasured risk factors, and randomized clinical trials are required to confirm these findings.

Trial registration: ClinicalTrials.gov identifier: NCT00221013.

PubMed Disclaimer

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Blood Purif. 2022;51(5):397-409. doi: 10.1159/000517281

Tốc độ rút dịch và phục hồi chức năng thận

BN bệnh nặng đang CRRT, net UF > 1,75 mL/kg/giờ vs net UF <1,01 và 1,01–1,75 mL/kg/giờ có liên quan đến thời gian phụ thuộc vào RRT lâu hơn

Murugan R, Kerti SJ, Chang CH, Gallagher M, Neto AS, Clermont G, Ronco C, Palevsky PM, Kellum JA, Bellomo R. Association between Net Ultrafiltration Rate and Renal Recovery among Critically Ill Adults with Acute Kidney Injury Receiving Continuous Renal Replacement Therapy: An Observational Cohort Study. Blood Purif. 2022;51(5):397-409. doi: 10.1159/000517281. Epub 2021 Jul 21. PMID: 34289471.

Tốc độ rút dịch và phục hồi chức năng thận

Abstract

Introduction: Higher net ultrafiltration (UFNET) rates are associated with mortality among critically ill patients with acute kidney injury (AKI) and treated with continuous renal replacement therapy (CRRT).

Objective: The aim of the study was to discover whether UFNET rates are associated with renal recovery and independence from renal replacement therapy (RRT).

Methods: Retrospective cohort study using data from the Randomized Evaluation of Normal versus Augmented Level of Renal Replacement Therapy trial that enrolled 1,433 critically ill patients with AKI and treated with CRRT between December 2005 and November 2008 across 35 intensive care units in Australia and New Zealand. We examined the association between UFNET rate and time to independence from RRT by day 90 using competing risk regression after accounting for mortality. The UFNET rate was defined as the volume of fluid removed per hour adjusted for patient body weight.

Results and conclusions: Median age was 67.3 (interquartile range [IQR], 57-76.3) years, 64.4% were male, median Acute Physiology and Chronic Health Evaluation-III score was 100 (IQR, 84-118), and 634 (44.2%) died by day 90. Kidney recovery occurred in 755 patients (52.7%). Using tertiles of UFNET rates, 3 groups were defined: high, >1.75; middle, 1.01-1.75; and low, <1.01 mL/kg/h. Proportion of patients alive and independent of RRT among the groups were 47.8 versus 57.2 versus 53.0%; p = 0.01. Using competing risk regression, higher UFNET rate tertile compared with middle (cause-specific hazard ratio [csHR], 0.79, 95% CI, 0.66-0.95; subdistribution hazard ratio [sHR], 0.80, 95% CI, 0.67-0.97) and lower (csHR, 0.69, 95% CI, 0.56-0.85; sHR, 0.78, 95% CI 0.64-0.95) tertiles were associated with a longer time to independence from RRT. Every 1.0 mL/kg/h increase in rate was associated with a lower probability of kidney recovery (csHR, 0.81, 95% CI, 0.74-0.89; and sHR, 0.87, 95% CI, 0.80-0.95). Using the joint model, longitudinal increases in UFNET rates were also associated with a lower renal recovery (β = -0.29, p < 0.001). UFNET rates >1.75 mL/kg/h compared with rates 1.01-1.75 and <1.01 mL/kg/h were associated with a longer duration of dependence on RRT. Randomized clinical trials are required to confirm this UFNET rate-outcome relationship.

Conclusion

Among critically ill patients receiving CRRT, UF_NET rates beyond 1.75 mL/kg/h compared with UF_NET rates <1.01 and 1.01–1.75 mL/kg/h were associated with a longer duration of dependence on RRT after accounting for competing risk of death. Although this study design does not exclude the possibility of residual confounding due to unmeasured risk factors, it provides the rationale for the design of randomized controlled trials comparing conservative with liberal UF_NET rates in critically ill patients and examining its association with renal outcomes.

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Tốc độ tái hấp thu dịch từ mô kẽ vào lòng mạch (plasma refilling rate)

Tốc độ tại hấp thu dịch vào nội mach tuỳ thuộc vào giai đoạn bệnh

Giai đoạn cấp: tăng tính thấm thành mạch, dịch thoát ra mô kẽ
Giai đoạn phục hồi: Tăng tái hấp thu nước vào nội mạch 🡪 có thể gây quá tải tuần hoàn

Không biết chính xác được tốc độ này

Bellomo R, Kellum JA, Fluid Management on Continuous Renal

Replacement Therapy, Karger, 2018, vol 194, pp 60–69

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Tốc độ rút dịch theo từng giai đoạn bệnh

Rational Use of Intravenous Fluids in Critically Ill Patients. https://doi.org/10.1007/978-3-031-42205-8

4 giai đoạn của động học dịch truyền (dynamic fluid phases):

Hồi sức dịch (R: resuscitation)
Tối ưu hóa (O: optimization)
Ổn định (S: stabilization)
Rút dịch (E: evacuation)

4 tác động là:

Sự tổn thương ban đầu
Tái tưới máu do thiếu máu cục bộ
Hội chứng tăng tính thấm toàn thể (GIPS).
Nguy cơ giảm tưới máu trong quá trình xuống thang hồi sức.

Giai đoạn R: Không rút dịch--> cân bằng dịch dương

Giai đoạn O: Không rút hay rút dịch ít🡪 cân bằng dịch bằng không hoặc dương nhẹ

Giai đoạn S: rút dịch ít--> cân bằng dịch âm nhẹ

Giai đoạn E: rút dịch nhiều: cân bằng dịch âm nhiều hơn

Giai đoạn hồi phục: rút dịch ít🡪 cân bằng dịch bằng không hay âm nhẹ

$ g

4 compartments: This can be dealt with in different ways, classically you have fat–water–protein–and minerals while water on its own is also distributed into four compartments: intracellular water (ICW), interstitial water, intravascular water and transcellular, with extracellular water (ECW) calculated as the sum of interstitial + intravascular + transcellular water content.

4 D’s: Fluids are medications in which one should take into account the 4D’s in analogy to antimicrobial stewardship: Drug–Dose–Duration–De-escalation.

4 hits: The four hits are:

first hit = initial insult,

second hit = ischemia reperfusion,

third hit = global increased permeability syndrome (GIPS).

fourth hit = potential risk of hypoperfusion during de-resuscitation.

4 indications: Fluids can be given for four reasons: resuscitation, maintenance, replacement and nutrition.

4 fluid losses: Traditionally four ways can be taken into account with regard to fluid losses: insensible loss, urine output, gastrointestinal losses and third space. Additional losses can occur in trauma with overt bleeding or in severely burned patients.

4 phases: The four dynamic fluid phases are: resuscitation, optimization, stabilization and evacuation.

4 questions: The four main questions surrounding fluid therapy that need to be solved are:

when to start IV fluids?

when to stop IV fluids?

when to start fluid removal?

when to stop fluid removal?

Fig. 1.20 Graph showing the four-hit model of shock with evolution of patients’ cumulative fluid volume status over time during the five distinct phases of resuscitation: Resuscitation (R), Optimization (O), Stabilization (S) and Evacuation (E) (ROSE), followed by a possible risk of hypoperfusion in case of too aggressive de-resuscitation. On admission patients are often hypovolemic, followed by normovolemia after fluid resuscitation (escalation or EAFM, early adequate fluid management), and possible fluid overload, again followed by a phase returning to normovolemia with de-escalation via achieving zero fluid balance or late conservative fluid management (LCFM) and followed by late goal directed fluid removal (LGFR) or de-resuscitation. In the case of hypovolemia, O2 cannot get into the tissue because of convective problems, in the case of hypervolemia O2 cannot get into the tissue because of diffusion problems related to interstitial and pulmonary oedema and gut oedema (ileus and abdominal hypertension). Adapted from Malbrain et al. with permission, according to the Open Access CC BY License 4.0 [5]. * Volumetric preload indicators such as GEDVI, LVEDAI or RVEDVI are preferred over barometric ones like CVP or PAOP. ** Vasopressor can be started or increased to maintain MAP/APP above 55/45 during the de-resuscitation phase. # can only be measured via the Swan-Ganz pulmonary artery catheter (PAC) and became obsolete. APP abdominal perfusion pressure (APP = MAP-IAP), BIA bio-electrical impedance analysis, CI cardiac index, CLI capillary leak index (serum CRP divided by serum albumin), COP colloid oncotic pressure, CVP central venous pressure, EAFM early adequate fluid management, ECW/ICW extracellular/intracellular water, EVLWI extravascular lung water index, FAS fluid accumulation syndrome, GEDVI global end-diastolic volume index, GIPS global increased permeability syndrome, IAP intra-abdominal pressure, ICG-PDR indocyanine green plasma disappearance rate, IVCCI inferior vena cava collapsibility index, LCFM late conservative fluid management, LGFR late goal-directed fluid removal, LVEDAI left ventricular end-diastolic area index, MAP mean arterial pressure, PAOP pulmonary artery occlusion pressure, PF PaO2 over FiO2 ratio, PLR passive leg raising, PPV pulse pressure variation, PVPI pulmonary vascular permeability index, RVEDVI right ventricular end-diastolic volume index, ScvO2 central venous oxygen saturation, SSCG surviving sepsis campaign guidelines, SvO2 mixed venous oxygen saturation, SVV stroke volume variation, VE volume excess (from baseline body weight), VExUS venous congestion by ultrasound

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Prowle J et al., Dial. 2021 Nov;34(6):440-448. doi: 10.1111/sdi.12964

Prowle J, Mehta R. Fluid balance management during continuous renal replacement therapy. Semin Dial. 2021 Nov;34(6):440-448. doi: 10.1111/sdi.12964. Epub 2021 Mar 23. PMID: 33755249.

F I G U R E 3 Rate of mechanical fluid removal. Examples of patients with fluid overload as a result of disease or fluid resuscitation requiring

mechanical fluid management to illustrate how different rates of fluid removal are appropriate to different clinical settings. Rapid early fluid

removal may be indicated in cardio-renal syndrome (A), but a slower removal than required for hemodynamic tolerability after resolution of

pulmonary edema. Patients with single organ renal failure (B) may tolerate more rapid fluid removal than patients with acute kidney injury

complicating severe sepsis (C) or septic shock (D). In septic shock mechanical fluid removal may at first be targeted to limit the accumulation

of further fluid until clinical stabilization allows slow resolution of accumulated fluid excess. Modified with permission from Acute Dialysis

Quality Initiative 12 www.adqi.org

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Sự khác biệt giữa cân bằng dịch mục tiêu và thực tế�

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Ảnh hưởng lên cân bằng dịch của máy CRRT của việc override (2005)

NC in vitro, sử dụng nước muối cho tuần hoàn máu và regular dialysate/reinfusate
Tạo ra lỗi cân bằng dịch bởi thay đổi dòng chảy chính xác trong dây lọc máu của 05 thiết bị CRRT khác nhau.
Thời gian xảy ra cảnh báo và giá trị ngưỡng cho lỗi cân bằng chất lỏng được đánh giá.
Cảnh báo được override và lỗi cân bằng dịch mà máy cho phép đã được đánh giá.
Mỗi máy đã được thử nghiệm trong các điều kiện khác nhau tốc độ dòng thẩm tách/lọc và trong các mô phỏng khác nhau các phương thức điều trị.

Ronco C, Ricci Z, Bellomo R, Baldwin I, Kellum J. Management of fluid balance in CRRT: a technical approach. Int J Artif Organs. 2005 Aug;28(8):765-76. doi: 10.1177/039139880502800802

https://doi.org/10.1177/039139880502800802

Ronco C, Ricci Z, Bellomo R, Baldwin I, Kellum J. Management of fluid balance in CRRT: a technical approach. Int J Artif Organs. 2005 Aug;28(8):765-76. doi: 10.1177/039139880502800802. PMID: 16211526.

�ABSTRACT: Background: The possibility of making fluid balance errors during continuous renal replacement therapy has been identified since the beginning of this modality of treatment. The advent of automated machines has partially overcome this problem. Nevertheless, there are conditions and operation modes in which the potential for fluid balance errors is still present.

Objective: To analyse fluid balance management in CRRT therapies across a range of currently marketed machine.�Methods: The tests were conducted in vitro, utilizing saline solution for the blood circuit and regular dialysate/reinfusate for the dialysate/reinfusion circuit. The methodology used was based on the voluntary creation of a fluid balance error by altering the correct flow in the circuit of the different machines. Subsequently, the time for alarm occurrence and the threshold value for fluid balance error was evaluated. The alarm was overridden and the overall fluid error allowed by the machine was evaluated. Each machine was tested in conditions of different dialysate/filtrate flow rates and in different simulated treatment modalities.

Results: Fluid balance errors can be easily avoided not only by a correct and careful adherence to the protocols of use of the current CRRT machines, but also by the compliance to prescriptions and programmed controls during therapy. Most importantly, if an alarm appears on the machine, one can try to override it without major problems; major problems may occur when multiple override commands are operated without identifying the problem and solving it adequately.

Conclusion: Machines seem to be designed with adequate safety features and accurate alarm systems. However, features and alarms can be manipulated by operators creating the opportunity for serious error. Physicians and nurses involved in prescription and delivery of CRRT should have precise protocols and defined procedures in relation to machine alarms to prevent major clinical problems. (Int J Artif Organs 2005; 28: 765-76)

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Ảnh hưởng lên cân bằng dịch của máy CRRT của việc override (2005)

	Prisma machine	Aquarius	Multifiltrate machine	Diapact	Prismaflex
	ml/error
4800ml	20-30 ml	30-70 ml/alarm Không giới hạn số alarm	20-30ml/error Có thể hơn 13 error	Max 190 ml	361 g-400 g/10 lần lỗi
2400ml	10-20ml
1200 ml	10ml
900ml/h (replacement)					Stop sau 10 alarm

Ronco C, Ricci Z, Bellomo R, Baldwin I, Kellum J. Management of fluid balance in CRRT: a technical approach. Int J Artif Organs. 2005 Aug;28(8):765-76. doi: 10.1177/039139880502800802

Prismaflex: When the machine reached the 10th alarm, a specific message was generated equivalent to: “incorrect weight change alarm not cleared”. This alarm permitted no action other than to STOP the treatment and have a look at the causes.

https://doi.org/10.1177/039139880502800802

Ronco C, Ricci Z, Bellomo R, Baldwin I, Kellum J. Management of fluid balance in CRRT: a technical approach. Int J Artif Organs. 2005 Aug;28(8):765-76. doi: 10.1177/039139880502800802. PMID: 16211526.

�ABSTRACT: Background: The possibility of making fluid balance errors during continuous renal replacement therapy has been identified since the beginning of this modality of treatment. The advent of automated machines has partially overcome this problem. Nevertheless, there are conditions and operation modes in which the potential for fluid balance errors is still present.

Objective: To analyse fluid balance management in CRRT therapies across a range of currently marketed machine.�Methods: The tests were conducted in vitro, utilizing saline solution for the blood circuit and regular dialysate/reinfusate for the dialysate/reinfusion circuit. The methodology used was based on the voluntary creation of a fluid balance error by altering the correct flow in the circuit of the different machines. Subsequently, the time for alarm occurrence and the threshold value for fluid balance error was evaluated. The alarm was overridden and the overall fluid error allowed by the machine was evaluated. Each machine was tested in conditions of different dialysate/filtrate flow rates and in different simulated treatment modalities.

Results: Fluid balance errors can be easily avoided not only by a correct and careful adherence to the protocols of use of the current CRRT machines, but also by the compliance to prescriptions and programmed controls during therapy. Most importantly, if an alarm appears on the machine, one can try to override it without major problems; major problems may occur when multiple override commands are operated without identifying the problem and solving it adequately.

Conclusion: Machines seem to be designed with adequate safety features and accurate alarm systems. However, features and alarms can be manipulated by operators creating the opportunity for serious error. Physicians and nurses involved in prescription and delivery of CRRT should have precise protocols and defined procedures in relation to machine alarms to prevent major clinical problems. (Int J Artif Organs 2005; 28: 765-76)

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Net UF mục tiêu vs thực tế

Thời gian CRRT/ngày

Dự tính CRRT 24h
Thời gian CRRT/ngày thực tế ít hơn🡪 không đạt mục tiêu

VD: Nếu thời gian không CRRT 8h

🡪 sẽ không đạt được so với mục tiêu 150ml x 8=1200ml

🡪 cần điều chỉnh UF trong thời gian CRRT tới

Thời gian không CRRT:

Do đông màng🡪 thay bộ lọc khác.
Máy hư
Bn cần làm XN (Ctscan)
Bn cần can thiệp điều tri khác: phẫu thuật. Plasma exchange

🡪 Bs phải dự tính trước hoặc ĐD phải thông báo với bs khi có thời gian không CRRT

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Các sai lầm trong kiểm soát dịch

Thời gian CRRT thực tế

Máy ngưng hoạt động tạm thời:
🡪 Có thể từ 5-10 phút/ cho mỗi giờ CRRT
🡪 120 phút🡪240 phút cho 24h là tgian ko CRRT🡪 ko đạt được mục tiêu cân bằng dịch ban đầu

🡪 kiểm tra thực tế dịch được rút bỏ trên máy (không được ước tính dựa trên tốc độ rút dịch được cài đặt)

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Tốc độ rút dịch trong RRT trong thực tế LS

Murugan R, et al., Crit Care Med. 2020 Feb;48(2):e87-e97

Không ổn định huyết động	80.0 mL/h (49.0–111.0)
BN ổn định huyết động	tối đa 299.0 mL/hr (200.0–365.0)

Chỉ khoảng 1/3 BS (31% (13,7-47,8) là có đánh gía dịch rút mỗi giờ khi CRRT

Murugan R, Ostermann M, Peng Z, Kitamura K, Fujitani S, Romagnoli S, Di Lullo L, Srisawat N, Todi S, Ramakrishnan N, Hoste E, Puttarajappa CM, Bagshaw SM, Weisbord S, Palevsky PM, Kellum JA, Bellomo R, Ronco C. Net Ultrafiltration Prescription and Practice Among Critically Ill Patients Receiving Renal Replacement Therapy: A Multinational Survey of Critical Care Practitioners. Crit Care Med. 2020 Feb;48(2):e87-e97. doi: 10.1097/CCM.0000000000004092. PMID: 31939807.

Design: Multinational internet-assisted survey.

Setting: Critical care practitioners involved with 14 societies in

80 countries.

Subjects: Intensivists, nephrologists, advanced practice providers,

ICU and dialysis nurses.

Intervention: A cross-sectional survey.

Measurement and Main Results: Of 2,567 practitioners who

initiated the survey, 1,569 (61.1%) completed the survey. Most

practitioners were intensivists (72.7%) with a median duration of

13.2 years of practice (interquartile range, 7.2–22.0 yr). Two third

of practitioners (71.0%; regional range, 55.0–95.5%) reported

using continuous renal replacement therapy with a net ultrafiltration

rate prescription of median 80.0 mL/hr (interquartile range,

49.0–111.0 mL/hr) for hemodynamically unstable and a maximal

rate of 299.0 mL/hr (interquartile range, 200.0–365.0 mL/hr) for

hemodynamically stable patients, with regional variation. Only

a third of practitioners (31.5%; range, 13.7–47.8%) assessed

hourly net fluid balance during continuous renal replacement

therapy. Hemodynamic instability was reported in 20% (range,

20–38%) of patients and practitioners decreased the rate of fluid

removal (70.3%); started or increased the dose of a vasopressor

(51.5%); completely stopped fluid removal (35.8%); and administered

a fluid bolus (31.6%), with significant regional variation.

Compared with physicians, nurses were most likely to report patient

intolerance to net ultrafiltration (73.4% vs 81.3%; p = 0.002),

frequent interruptions (40.4% vs 54.5%; p < 0.001), and unavailability

of trained staff (11.9% vs 15.6%; p = 0.04), whereas physicians

reported unavailability of dialysis machines (14.3% vs 6.1%;

p < 0.001) and costs associated with treatment as barriers

(12.1% vs 3.0%; p < 0.001) with significant regional variation.

Conclusions: Our study provides new knowledge about the

presence and extent of international practice variation in net ultrafiltration.

We also identified barriers and specific targets for

quality improvement initiatives. Our data reflect the need for evidence-

based practice guidelines for net ultrafiltration. (Crit Care

Med 2019; XX:00–00)

Key Words: fluid overload; net ultrafiltration; prescription; renal

replacement therapy; survey

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Sự khác biệt giữa cân bằng dịch được tính toán và cân bằng dịch thực tế của BN�

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Sử dung dung cụ đo lường không chính xác

Sủ dung dung cụ đo lường không chính xác
Túi nước tiểu thường: còn 60-70%
Dẫn lưu khác: ít được đo lường
Cân của máy CRRT bị sai

VD: 4000ml: thực tế còn 2400ml-2800ml--> sai từ 1200ml-1600ml🡪 bilan thực tế dương được tính ra âm (bilan âm giả)
Nếu yêu cầu dùng dụng cụ đo lường🡪 người quên, người nhớ
Có ĐD tự ý trừ hao bớt🡪 ko cxác và ko thống nhất
Bs xả nước tiểu từ bộ đo ra: không báo điều dưỡng🡪 sai dịch xuất

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Bỏ sót dịch nhập lúc CRRT

Sai lầm từ bỏ sót dịch nhập trong lúc CRRT

Dịch trong hệ thống dây và lọc lúc priming: lượng dịch khoảng 175-250ml

Nếu bn dư dịch, chỉ nên nối đường trở về khi dịch priming được đuổi ra hết
Nếu bn thiếu dịch, có thể gắn đường trở về từ ban đầu (dịch không có heparin)

Cần ghi nhận vào dịch nhập nếu lượng dịch này vào BN

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Bỏ sót dịch nhập lúc CRRT

Nếu máy báo áp lực hút âm nhiều lần, bù dòng nhiều lần🡪 nguy cơ quá tải dịch hay tính cân bằng dịch không chính xác nếu không nhập đầy đủ dịch bù vào

Cần điều chỉnh catheter lấy máu để đường lấy máu thông suốt

Cần ghi nhận vào dịch nhập

Máy báo áp lực hút âm:

Xử trí tạm thời bù dòng

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Bỏ sót dịch nhập trong lúc CRRT

Bn hay đông màng, cần phải thay màng

🡪 giảm thời gian chạy CRRT
🡪nước trong bộ lọc và dây dẫn

Bn cần rửa màng nhiều lần:

Nguy cơ quá tải dịch mà điều dưỡng rút dịch ra không hết

Nếu không tính dịch trong bộ lọc dây dẫn:

🡪tính cân bằng dịch sai

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Cần nhập đầu đủ các loại dịch vào người BN

Phải ghi nhận vào bilan nhập tất cả các dịch nhập vào cơ thể BN mà không thông qua hệ thống bơm của máy CRRT:

Dịch trong hệ thống dây dẫn bộ lọc primming
Dịch bù dòng
Dịch rửa màng
Dịch trả máu

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Các sai lầm trong kiểm soát dịch

Sai sót trong khâu cộng trừ:

Cộng trừ sai
Ghi sai dương thành âm và ngược lại (thay vì dấu (-) ghi thành dấu (+))
Nhập thiếu dữ liệu

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Khó đo lường chính xác lượng nước mất không nhận biết

Dịch không thể đo lường chính xác được:

lượng phân.
Nước mất qua da, hơi thở

Sử dung cân để ước lượng cân bằng dịch:

Cần thiết bị
Cần cân chỉnh máy
Tốn nhân lực và thời gian để có kết quả tin cậy

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Những rào cản lên việc rút dịch trong CRRT

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Những can thiệp khi huyết động không ổn định khi RRT