Thread by @galindozip

Today I woke up and realized I had homework assigned by @ArgaizR

He asked me to complement his thread about the recent NEJM case, regarding the CRRT approach. Why me? 🤷🏻‍♂️ who knows

but I always turn in my homework, so here it is ——-thread 🧵 #CRRT #COVID19 #AKI

https://twitter.com/argaizr/status/1260832791010381824

So the case is very representative of what we are all seeing in #COVID19 patients:

1️⃣A lot of AKI
2️⃣Intrinsic etiology (host or direct)
3️⃣Many need KRT (RRT)
4️⃣KRT resources are not enough
5️⃣A lot of circuit clotting
6️⃣Nephrologists with headaches

👇

The problem:

Many patients need KRT at the same time, fancy CRRT prescriptions (low efficiency, continuous, kidney like) are not practical, enough or feasible do to clotting

Just like a normal non pandemic day in Mexico 🇲🇽

It seems that physicians at MG didn’t have a different experience:

-Had a patient with intrinsic AKI, that require KRT
-Decided CRRT do to pressors
-Never achieved metabolic control do to clotting
-Changed to IHD (problem solved)

They do not give much information about the actual prescription.

It seems they try CVVH or CVVHDF they mention heparin but not TTP goal and even mention citrate but they only say it didn’t work (No lo se rick), no circuit calcium goals 🤔

So lets imagine we are at the MG and we have available a CRRT machine that is exclusively for our patient.

-patient is in pressors , has a high catabolic rate with difficulty metabolic control and volume overload

Our prescription should be focused on ?

Middle molecule clearance: has been proven to be good in chronic dialysis patients, in long term periods

But no evidence of improving outcomes in AKI. Why?

- not enough (I am a beliver)
- not selective removal (removes good things)
- doesn’t improve anything (maybe)

Citokine removal: is a very attractive goal for KRT

Instead of only support it can actually help with the disease

I really have hopes on this, but the reality is we need more evidence

Intermittent clearance:

Trying to achieve metabolic control with a high efficiency therapy with less circuit time, high flows and theoretically less clotting

Definitely a good option, probably the best option in pandemic times and the option that saved the MG case

Keep the circuit going: my favorite description of a

“GOOD prescription”

CRRT is inefficient just like PD, so therapy time becomes the main prescription priority

Time compensates for efficiency (Intensity)

#keepthecircuitgoing

Why circuits clot, COVID or not COViD?

Rember the Virchow’s triad ?
- Endothelial damage
- Stasis
- Hyper coagulability

Virchow triad Inside a circuit:

-Taking out blood and expose it to non biological materials this will be equivalent to ENDOTHELIAL DAMAGE

-Every time pumps stop (access disfunction, alarms) blood stays in STASIS

-Sepsis, COVID19, or just anything HYPERCOAGULABILITY

Nothing to do about exposing blood to non biological materials, maybe in prismaflex mantain the air chamber in order to avoid air contact with blood (not actual evidence just an equipment recommendation

-Vascular access becomes the most fragile and important variable

Remember high blood flows can be tricky in CRRT. although filtration fraction lowers with higher Qb this leads to extra load of the pump

Use the Qb for a FF <20% but slow enough for the pump to continue

- How many times have you seen something clot when citrate is use to store it (RBC, blood samples for coagulation)
NEVER no mater how much non biological material is in contact or how many time the blood stays in STASIS

Citrate just blocks all coagulation

how i keep the circuit going?
In order of relevance

1. Vascular access/ Low Qb
2. Block Anticoagulation in the circuit (citrate with i ca goals)
4. Use diffusion (the goal is metabolic control, K, P, BUN, Na, Ca are small molecules) diffusion works well

Ok so great case, real problems, real questions

@ArgaizR sorry for the length and please prescribe to

#Keepthecircuitgoing