objectives define heart failure define sepsis discuss medical management of heart failure and sepsis...
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Objectives Define Heart Failure
Define Sepsis
Discuss medical management of heart failure and sepsis
Describe indications for CRRT for these disorders
Case Study
Clinical syndrome that can result Clinical syndrome that can result from any structural or functional from any structural or functional cardiac disorder that impairs the cardiac disorder that impairs the ability of the ventricle to fill with ability of the ventricle to fill with or eject bloodor eject blood
Incidence of Heart Failure
More deaths from heart failure than from all forms of cancer
Nearly 1 millions people are admitted to the hospital with CHF and 30%-60% are readmitted
Contributed to 53,000 deaths in the U.S. each year
About 550,000 new cases per year
Affects men and women equally
Related to the aging population, lower death rate from MI, and improved treatment for heart disease
http://health.usnews.com/health-conditions/heart-health/congestive-heart
Main causes
Ischemic heart disease, Cardiomyopathy, Hypertension, Diabetes
Other causes: Valvular heart disease, Congenital heart
disease, Alcohol and drugs, Hyperdynamic circulation
(anemia, thyrotoxicosis, hemochromatosis, Paget's
disease), Right heart failure (RV infarct, pulmonary
hypertension, pulmonary embolism, cor pulmonale
(COPD)), Arrhythmia and Pericardial disease.
Impaired cardiac contractility as in myocardial infarction and cardiomyopathy
Ventricular outflow obstruction (pressure overload) as in hypertension and aortic stenosis
Impaired ventricular fillings as in mitral stenosis and constrictive pericarditis
Volume overload as in mitral regurgitation
Infections
Arrhythmias
Physical, Dietary, Fluid, Environmental, and Emotional Excesses.
Myocardial infarction
Pulmonary embolism
Anemia
Thyrotoxicosis and pregnancy
Aggravation of hypertension
Rheumatic, Viral, and Other Forms of Myocarditis
Infective endocarditis
Diabetes
1. Hypertrophy & Dilatation
E.D.V
2. Sympathetic activity:
H.R.• V.C
Angiotensin
Aldosterone
TYPES OF HEART FAILURE
Left- sided or left ventricular (LV) heart failure
is commonly caused by ischemic heart disease but can also occur with valvular heart disease and hypertension. 2 types of (LV) heart failure
diastolic failure is a syndrome consisting of symptoms and signs of heart failure with preserved left ventricular ejection fraction above 45–50% and abnormal left ventricular relaxation assessed by echocardiography
systolic failure is when the left ventricle loses it’s ability to contract normally, can pump enough blood into the systemic circulation
Right-sided or right ventricular (RV)heart failure
may be secondary to chronic( LV ) heart failure but can occur with primary and secondary pulmonary hypertension, right ventricular infarction.
TYPES of HEART FAILURE Congestive Heart Failure-
Blood flow out of the heart slows, blood returning to the heart through the veins backs up and congestion in the body’s tissues
Will see edema, SOB, can affect kidney function
Symptoms & Signs OF Heart Failure
Left heart failure
Symptoms are predominantly fatigue,
exertional dyspnea, orthopnea and PND
Physical signs: Cardiomegaly, gallop
functional mitral regurgitation and crackles a the lung bases.
Right Heart Failure
Symptoms (fatigue, breathlessness, anorexia and nausea) relate to distension and fluid accumulation in areas drained by the systemic veins.
Physical signs are usually more prominent than the symptoms, with:
jugular venous distension
tender smooth hepatic enlargement
dependent pitting edema
development of free abdominal fluid (ascites)
Pleural effusion (commonly right-sided).
Dilatation of the right ventricle produces cardiomegaly and may give rise to functional tricuspid regurgitation. Tachycardia and a right ventricular third heart sound are usual.
Classification of Heart Failure
Functional Capacity Class I – patients with cardiac disease and no
limitation of physical activity
Class II- patients with cardiac disease slight limitation of physical activity results in fatigue, palpitation, dyspnea or angina
Class III-patients with cardiac disease marked limitation of physical activity comfortable at rest
Class IV-patients with cardiac disease inability to carry on any physical activity, symptoms of heart failure at rest
http://www.heartorg/HEARTORG/Conditions/Heart
1. Hypertrophy & Dilatation
E.D.V
2. Sympathetic activity: H.R.• V.C
Angiotensin
Aldosterone
If Resistant to Diuretics
MAY NEED
Ultrafiltration
UNLOAD STUDY The UNLOAD study was a randomized, multicenter
study of 200 patients involving 28 hospitals and medical centers across the United States. UNLOAD compared the short and long-term safety and efficacy of an advanced form of ultrafiltration therapy(Aquapheresis) to the use of conventional diuretic drug therapy in fluid overloaded heart failure patients.
The UNLOAD study was published in the February 13, 2007 issue of Journal of American College of Cardiology. (Costanzo MR et al. JACC 2007; 49(6):675-683).
UNLOAD StudyResults
28% with greater fluid loss with UF
43% reduction in patients being re-hospitalization for HF
63% fewer hospital days for HF
What is SIRS?
The systemic inflammatory response syndrome is systemic level of acute inflammation, that may or may not be due to infection, and is generally manifested as a combination of vital sign abnormalities including fever or hypothermia, tachycardia, and tachypnea.
Definitions Severe SIRS – SIRS in which at least 1 major organ
system has failed.
Sepsis – SIRS which is secondary to infection.
Severe Sepsis – Severe SIRS which is secondary to infection.
Septic Shock – Severe sepsis resulting in hypotensive cardiovascular failure.
Systemic Inflammatory Reponse(SIRS)
Can be triggered by infectious and non-infectious events
Infectious causes bacteria or fungi
Non infectious causes are prancreatitis,burns, trauma
SIRS is the term used for noninfectious causes
Criteria for SIRSRequires 2 of the following 4 features to be present:
Temp >38.3° or <36.0° C
Tachypnea (RR>20 or MV>10L)
Tachycardia (HR>90, in the absence of intrinsic heart disease)
WBC > 10,000/mm3 or <4,000/mm3 or
>10% band forms on differential
Criteria for Severe SIRSMust meet criteria for SIRS, plus 1 of the following: Altered mental status SBP<90mmHg or fall of >40mmHg from baseline Impaired gas exchange Metabolic acidosis (pH<7.30 & lactate > 1.5 x
upper limit of normal) Oliguria (<0.5mL/kg/hr) or renal failure Hyperbilirubinemia Coagulopathy (platelets < 80,000-100,000/mm3,
INR >2.0, PTT >1.5 x control, or elevated fibrin degredation products)
Pathophysiology of Sepsis
Overwhelming inflammatory response
Increased production of proimflamatory cytokines and decreased production of cytokines( which inhibit inflammation)
Clotting cascade activated
Peripheral Vasodilatation systemic vascular resistance
Pathophysiology of Sepsis
continued C/O decreases
Intravascular fluid loss
Decreased pre load-hypotension
ATN-renal hypoperfusion and ischemic injury
MODS
MOF
Relationship Between SIRS and Sepsis
Adapted from: Marini JJ, et al. Critical Care Medicine, 2nd ed. 1997.
Risk Factors for SIRS/Sepsis
Age
Indwelling lines/catheters
Immunocompromised states
Malnutrition
Alcoholism
Malignancy
Diabetes
Cirrhosis
Male sex
Genetic predisposition?
PrognosisOverall mortality from SIRS/sepsis in the U.S. is approximately 20%. Mortality is roughly linearly related to the number of organ failures, with each additional organ failure raising the mortality rate by 15%.
Hypothermia is one of the worst prognostic signs. Patients presenting with SIRS and hypothermia have an overall mortality of ~80%.
Treatment Fluid Resuscitation
Vasopressors
Antibiotics
Eradication of infection
Ventilatory support, activated protein C, steroids, glycemic control, nutrition
CRRT
CONTINUOUS
RENAL REPLACMENT
THERAPY
CRRT Definition
CRRT = Continuous Renal Replacement Therapy
Defined as “Any extracorporeal blood purification
therapy intended to substitute for impaired renal function over an extended period of time and applied for or aimed at being applied for 24 hours /day.” *
* Bellomo R., Ronco C., Mehta R,Nomenclature for Continuous Renal Replacement Therapies,AJKD, Vol 28, No. 5, Suppl 3, November 1996
Introduction to CRRT
Why continuous therapies?
Continuous therapies closely mimic the native kidney in treating ARF and fluid overload Slow & gentle Remove fluid and waste products over time Tolerated well by the hemodynamically unstable patient
2
Intra-Intra-cellular cellular SpaceSpace
Extra-Extra-cellular cellular SpaceSpace
Intra-Intra-Vascular Vascular SpaceSpace
Circulating Circulating Blood VolumeBlood Volume
Toxins
Fluid
Toxins
Fluid
Toxins
Fluid
Dialyzer
23 L 17 L 23 L 17 L 40 Liters40 Liters
5 Liters5 Liters
Three Compartment Model
Indications for Therapy
Acute kidney injury- preferred in the critically ill patient
Fluid overload- can removed large amounts of fluid slowly
Hemodynamically unstable- continuous therapy allow for slow hourly fluid removal which allows the intravascular spaces to refill
Indications continued
Highly catabolic patients who need increased clearance rates
Patients needing large molecular weight substances removed
Sepsis
Molecular Weight SMALL MOLECULES- 0-500 daltons (urea, creatinine)
MIDDLE MOLECULES- 500-5000 daltons ( vitamin B12)
LARGE MOLECULES- 5000-50,000 daltons ( heparin, Beta 2 drugs)
CRRT Modalities
SCUF OR ULTRAFILTRATION - Slow Continuous UltraFiltration
CVVHD - Continuous Veno-Venous HemoDialysis
CVVH - Continuous Veno-Venous Hemofiltration
CVVHDF – Continuous Veno-Venous Hemodiafiltration
SCUF/Ultrafiltration
Primary therapeutic goal: Safe management of fluid removal
Patient UF rate ranges up to 2 L/Hr
No dialysate;No replacement fluids No molecule removal
Large fluid removal via ultrafiltration
Blood Flow rates = 100-200 ml/min
SCUF/ULTRAFILTRATION
Slow Continuous UltraFiltration
AccessAccess
ReturnReturn
EffluentEffluent
45
Ultrafiltration
Particles move through a semi-permeable membrane by use of HYDROSTATIC pressure.
The separation of particles from a suspension by passage through a filter. The separation is accomplished by convective transport.
Convection – Step 1 Filter Action
U
Na
Na
Na
K
U
U
U
U
U
U
U
U
U
U
U
H2O
K
K
K
K
K
K
K
K
K
H2O
H2O
H2O
H2O
H2O
H2O
H2O
H2OH2O
H2O
H2O
Na
Na
Na
Na
Na
Na
Na Na
Na
Na
K
Na
Na
Na
Na
Na
Na
Na
H2O
H2O
H2O
Red Cell
Red Cell
Red Cell
Red Cell
Red Cell
Convection: The movement of solutes with a water-flow,“solvent drag”, e.g... the movement of membrane-permeablesolutes with water across the semipermeable membrane
Solute Removal by Convection
CVVH
Continuous Veno-Venous Hemofiltration
ReplacementReplacement(pre or post dilution(pre or post dilution))
AccessAccess
ReturnReturn
EffluentEffluent
Molecular Transport Mechanisms
Convection - The movement of solutes with a water-flow, “solvent drag”, the movement of membrane-permeable solutes with water across the semipermeable membrane
Convection – Step 1 Filter Action
U
Na
Na
Na
K
U
U
U
U
U
U
U
U
U
U
U
H2O
K
K
K
K
K
K
K
K
K
H2O
H2O
H2O
H2O
H2O
H2O
H2O
H2OH2O
H2O
H2O
Na
Na
Na
Na
Na
Na
Na Na
Na
Na
K
Na
Na
Na
Na
Na
Na
Na
H2O
H2O
H2O
Red Cell
Red Cell
Red Cell
Red Cell
Red Cell
Convection: The movement of solutes with a water-flow,“solvent drag”, e.g... the movement of membrane-permeablesolutes with water across the semipermeable membrane
Solute Removal by Convection
CVVHD - Continuous VV Hemodialysis
Primary therapeutic goal: Solute removal by diffusion Safe fluid volume management by ultrafiltration
Requires Dialysate solution
Patient UF rate ranges 2-7 L/24 hours (~300 ml/hr)
Dialysate Flow rate = 15-45 ml/min (~2 L/hr)
Blood Flow rate = 100-200 ml/min
No replacement solution
Solute removal determined by Dialysate Flow rate.
Diffusion – Filter Action
U
Na
NaNa
KU
U
U
U
U
U
U
U
U
U
UH2O
KK
KK
K
K
K
Mg
K
H2O
H2O
H2O
H2O
H2O
H2O
H2O
H2O
H2O
H2O
H2O
Na
Na
Na
Na
Na
NaNa Na
Na
Na
K
Na
Na
Na
Na
Na
Na
Na
Mg Mg
Mg
Mg
Vascular Access Depending on the device used lumen size matters
If using AquaDex FlexFlow Fluid Removal System midline catheters can be used
If using CRRT devices hemodialysis type catheters need to be placed.
Catheter Size Adults
12.5 to 14 french Length will vary
16,19,24,cm Femoral placement
least preferred
Children (weight based) 5 french single
catheter 7 fr dual lumen8 fr dual lumen10 fr dual lumen11 fr dual lumen
Length9 cm, 10 cm, 12 cm, 15 cm
Case Study #1
Mr. G is a 60 year old man with CAD s/p MI and PTCA to LAD in 1997, dyslipidemia, and tobacco use who called 911 for severe chest pain on 11/01/10. This pain was similar in nature to his previous MI.
ECG in the ambulance
History In the ambulance en route to the emergency room,
the patient developed two episodes of ventricular fibrillation which both successfully responded to DC cardioversion. After arrival to the cath lab, the patient developed cardiogenic shock and recurrent ventricular fibrillation requiring multiple shocks (he was shocked 11 times in the cath lab prior to intervention) and intubation with mechanical ventilation.
Cath Lab Course Coronary angiography showed:
Totally occluded mid LAD with thrombus Mild diffuse atherosclerosis of left circumflex and right
coronary arteries
Soon after the first injection there was proximal propagation of the LAD thrombus which occluded the left main coronary artery
A wire was passed to the distal LAD and an AngioJet thrombectomy device was used which re-established flow
Cath Lab Course After the Impella device was placed, the patient had
no further episodes of ventricular fibrillation
Immediately Post Cath Patient admitted to the CCU on IV Epinephrine,
Dobutamine, and Dopamine continuous infusions
Echocardiogram the next day showed severe anterior wall hypokinesis with EF 25%
The patient was placed on CVVH then on SCUF to remove excess fluid
Hospital Course
Hospital day 3: Impella device was removed
Hospital Day 6: Repeat echocardiogram, EF 50-55%
Hospital Day 8: Extubated, neurologically intact
Hospital Day 16: Discharged to home
Case Study#2
Alan is a 20 year old admitted to a cardiology unit with CHF and Situs Inversus. He had SOB , anascara, arrythmias. His blood pressure was 110/60 mm Hg. He has a serum creatinine of 1.5 mg/dl. He is in need of a pacemaker but first needs 10 liters of fluid removed before placement of a pacemaker.
He is started on furosemide 80 mg every 8 hours and metolazone 10mg/d for 2 days. On day three he is given mannitol 25 g every eight hours.
He is putting out 3L of urine a day but has only decreased his net fluid loss by 3 L due to lack of adherance to his fluid restriciton
Case StudyContinued
Because of his need for a pacemaker, the decision was made to place the patient on SCUF.
After three days of therapy the patient was at his dry weight and stable and was able to receive his pacemaker
Consideration has to be given related to rate of fluid removal and his overall renal function
Patient was discharged to home with a follow up to a nephrologist
Case Study#3
Mrs. D was admitted to MICU for sepsis. She had been hypotensive that required vasopressors. During the course of her stay in MICU, she developed AKI. To manage her fluid and electrolytes, she was started on CRRT. She seemed to tolerate CRRT well.
On her 5th day of therapy, her Serum Creatinine was down to 1.2 from 6.9 and her electrolytes were stable, her BP was borderline with MAP > 60 mmHg and < 70 mmHg.
CRRT was discontinued and only to be restarted after 2 days when the patient became hypotensive again that regular HD was not possible given her hemodynamic parameters.
Patient was started on phenylephrine at 200 mcg/min and nor-epinephrine at 10 mcg/min. On the 3rd day of the 2nd therapy, the patient had the following data:
Patient Data
Questions What happened in this scenario?
What should have been considered in setting the net fluid removal rate?
How would we assess for the intravascular vs extra-vascular fluid status?
When will be the right time to advocate for discontinuance of CRRT?
Conclusion CRRT therapies can be applied to many clinical
situations
The patient goals/outcomes can be enhanced with early initiation of this therapy