Plasma CO2 Removal Due to CRRT and Its Influence on Indirect Calorimetry
NCT ID: NCT03314363
Last Updated: 2022-05-18
Study Results
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Basic Information
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COMPLETED
NA
10 participants
INTERVENTIONAL
2017-04-26
2019-03-15
Brief Summary
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Detailed Description
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Another complication during their stay is the inability to feed themselves. Nutrition is a cornerstone in the care for the critical ill and should be started within 3 days of admission to the intensive care unit. To optimize a nutritional prescription, protein and energy targets need to be defined. Predicting formulae based on anthropometric measures and other parameters can be used to calculate the caloric need but indirect calorimetry (IC) remains the gold standard. Caloric need can be derived from Energy expenditure which is calculated with the Weir's equation using carbon dioxide (CO2) production (VCO2) and oxygen (O2) consumption (VO2). Therefore, it is underestimated if CO2 is lost through other means than the normal respiratory route. Hence one of the contra-indications of IC is CRRT.
The totalCO2 (tCO2) travels through the vascular structures within the red blood cells or inside plasma. There, most of the content has 3 different forms: as physically dissolved CO2, bicarbonate, and carbamino compounds. These compounds are in equilibrium with each other. During RRT, a potential loss of CO2 and its different forms may occur due to ultrafiltration in the dialysate. No large trials were conducted trying to quantify this loss nor identifying the determining factors which can be used to predict this loss. Indeed, one author even found a gain in tCO2 of the blood during dialysis with acetate. Trisodiumcitrate is used as an anticoagulant during CRRT. It is a weak base and due to pH change may alter the equilibrium of the Henderson-Hasselbalch equation and thus influence the balance between CO2 and HCO3- and its extraction through CRRT.
Although indirect calorimetry in the intensive care unit has been evaluated during CRRT, the loss of tCO2was not considered. The investigators explored the possibility to predict and easily calculate this CO2 exchange so IC can be used during CRRT.
Conditions
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Study Design
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NA
SINGLE_GROUP
DIAGNOSTIC
NONE
Study Groups
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all patients
Classic CRRT with citrate predilution
blood gas analysis under citrate predilution
blood gas analysis of blood on different sample points and dialysis fluid
filter replacement
Using local protocol: stop and disconnect CRRT, replace filter and reconnect and restart CRRT.
IC
monitor patients during the whole study period with indirect calorimetry
NaCl predilution
Replace citrate predilution with NaCl
blood gas analysis under NaCl predilution
repeat blood gas analysis of blood on different sample points and dialysis fluid
double ultrafiltration
double the ultrafiltration fluid by augmenting post dilution fluid and keeping ultrafiltration at the same rate.
blood gas analysis under citrate predilution and double ultrafiltration rate
repeat blood gas analysis of blood on different sample points and dialysis fluid
pause and restart nutritional therapy
pause parenteral and enteral nutrition before indirect calorimetry is performed. and restart after first blood analysis for vitamine status
evolution of vitamin and trace elements
blood analysis for vitamin and trace elements. Perform this blood analysis after restart of CRRT but before restart of nutritional therapy, 30 minutes after restart of nutritional therapy and 24h after restart of nutritional therapy.
Interventions
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blood gas analysis under citrate predilution
blood gas analysis of blood on different sample points and dialysis fluid
filter replacement
Using local protocol: stop and disconnect CRRT, replace filter and reconnect and restart CRRT.
IC
monitor patients during the whole study period with indirect calorimetry
NaCl predilution
Replace citrate predilution with NaCl
blood gas analysis under NaCl predilution
repeat blood gas analysis of blood on different sample points and dialysis fluid
double ultrafiltration
double the ultrafiltration fluid by augmenting post dilution fluid and keeping ultrafiltration at the same rate.
blood gas analysis under citrate predilution and double ultrafiltration rate
repeat blood gas analysis of blood on different sample points and dialysis fluid
pause and restart nutritional therapy
pause parenteral and enteral nutrition before indirect calorimetry is performed. and restart after first blood analysis for vitamine status
evolution of vitamin and trace elements
blood analysis for vitamin and trace elements. Perform this blood analysis after restart of CRRT but before restart of nutritional therapy, 30 minutes after restart of nutritional therapy and 24h after restart of nutritional therapy.
Eligibility Criteria
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Inclusion Criteria
* Patient on CRRT who's filter you want to change
* Expected stable patient during the test ( +- 2h) evaluated at discretion of physician :
* No alteration in medication
* Stable respiratory settings where no change in conditions is expected. If possible, controlled mode ventilation is preferred.
* Expected stable pH and lactate
* no intervention will be made on patient (transport/washing/physiotherapy/…)
* no alterations on settings of CRRT is expected to be made.
* Maximal respiratory settings: max FiO2: 60% / max inspiratory plateau pressure 30 mmHg/max tidal volumes 8ml/kg
* pH between 7,30-7,50, lactate levels \<2,0
* starting settings CRRT with citrate:
* Blood pump flow: 150 ml/min
* Predilution ( citrate): 1500-2300ml/h
* Dialysate dose: 25-40 ml/kg/h
* ultrafiltration: 0-300 ml /h
* Substitution: NaCl 300-800 ml/h or B22: 400-2000 ml/h
Exclusion Criteria
* Contra-indications for the use of indirect calorimetry as stated by the AARC (FiO2\>60%, chest tubes)
* Severe hemodynamic or ventilator instability.
* CRRT modalities unusual to daily clinical ICU practice
18 Years
ALL
No
Sponsors
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Universitair Ziekenhuis Brussel
OTHER
Responsible Party
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Elisabeth De Waele
Principal Investigator, clinical professor
Principal Investigators
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Elisabeth De Waele, Phd
Role: PRINCIPAL_INVESTIGATOR
Universitair Ziekenhuis Brussel
Locations
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universitair ziekenhuis Brussel
Brussels, , Belgium
Countries
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References
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Case J, Khan S, Khalid R, Khan A. Epidemiology of acute kidney injury in the intensive care unit. Crit Care Res Pract. 2013;2013:479730. doi: 10.1155/2013/479730. Epub 2013 Mar 21.
Metnitz PG, Krenn CG, Steltzer H, Lang T, Ploder J, Lenz K, Le Gall JR, Druml W. Effect of acute renal failure requiring renal replacement therapy on outcome in critically ill patients. Crit Care Med. 2002 Sep;30(9):2051-8. doi: 10.1097/00003246-200209000-00016.
Rabindranath K, Adams J, Macleod AM, Muirhead N. Intermittent versus continuous renal replacement therapy for acute renal failure in adults. Cochrane Database Syst Rev. 2007 Jul 18;(3):CD003773. doi: 10.1002/14651858.CD003773.pub3.
Singer P, Berger MM, Van den Berghe G, Biolo G, Calder P, Forbes A, Griffiths R, Kreyman G, Leverve X, Pichard C, ESPEN. ESPEN Guidelines on Parenteral Nutrition: intensive care. Clin Nutr. 2009 Aug;28(4):387-400. doi: 10.1016/j.clnu.2009.04.024. Epub 2009 Jun 7.
Wichansawakun S, Meddings L, Alberda C, Robbins S, Gramlich L. Energy requirements and the use of predictive equations versus indirect calorimetry in critically ill patients. Appl Physiol Nutr Metab. 2015 Feb;40(2):207-10. doi: 10.1139/apnm-2014-0276. Epub 2014 Oct 27.
Oshima T, Berger MM, De Waele E, Guttormsen AB, Heidegger CP, Hiesmayr M, Singer P, Wernerman J, Pichard C. Indirect calorimetry in nutritional therapy. A position paper by the ICALIC study group. Clin Nutr. 2017 Jun;36(3):651-662. doi: 10.1016/j.clnu.2016.06.010. Epub 2016 Jun 22.
Honore PM, De Waele E, Jacobs R, Mattens S, Rose T, Joannes-Boyau O, De Regt J, Verfaillie L, Van Gorp V, Boer W, Collin V, Spapen HD. Nutritional and metabolic alterations during continuous renal replacement therapy. Blood Purif. 2013;35(4):279-84. doi: 10.1159/000350610. Epub 2013 May 8.
AARC clinical practice guideline. Metabolic measurement using indirect calorimetry during mechanical ventilation. American Association for Respiratory Care. Respir Care. 1994 Dec;39(12):1170-5. No abstract available.
Bosch JP, Glabman S, Moutoussis G, Belledonne M, von Albertini B, Kahn T. Carbon dioxide removal in acetate hemodialysis: effects on acid base balance. Kidney Int. 1984 May;25(5):830-7. doi: 10.1038/ki.1984.97.
Scheinkestel CD, Kar L, Marshall K, Bailey M, Davies A, Nyulasi I, Tuxen DV. Prospective randomized trial to assess caloric and protein needs of critically Ill, anuric, ventilated patients requiring continuous renal replacement therapy. Nutrition. 2003 Nov-Dec;19(11-12):909-16. doi: 10.1016/s0899-9007(03)00175-8.
Wu C, Wang X, Yu W, Li P, Liu S, Li J, Li N. Short-term consequences of continuous renal replacement therapy on body composition and metabolic status in sepsis. Asia Pac J Clin Nutr. 2016;25(2):300-7. doi: 10.6133/apjcn.2016.25.2.29.
Jonckheer J, Spapen H, Debain A, Demol J, Diltoer M, Costa O, Lanckmans K, Oshima T, Honore PM, Malbrain M, De Waele E. CO2 and O2 removal during continuous veno-venous hemofiltration: a pilot study. BMC Nephrol. 2019 Jun 17;20(1):222. doi: 10.1186/s12882-019-1378-y.
Other Identifiers
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B.U.N. 143201731636
Identifier Type: -
Identifier Source: org_study_id
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