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CRRT Continue Renal Replacement Therapy,CVVH CVVHD CVVHDF,Indications,In critically ill patients with renal failure and hemodynaemic instability For patients in whom continuous removal of volume or toxic substance is desirable ( as in septic shock , AMI , severe GI bleeding ,ARDS or condition with or at risk for cerebral edema .),Procedure共同處,Driving force : external pump Circuit : Venovenous Dialysis solutions :一般使用1.5% PD solution Replacement fluid : several types of replacement fluid can be used , depending on patient requirements ,一般使用 pre-dilution 方式.,Anti-coagulation 的方式,STANDARD HEPARIN TYPICAL REGIMEN IN CRRT : Priming of the circuit ( 5000 IU / L ) Initial Heparin Bolus : 5 - 8 IU / kg Infuse Heparin at : 5 to 12 IU / kg / hr ACT on post filter : Adjust heparin rate to keep ACT between 1.5 & 2.0 times,STANDARD HEPARIN,ADVANTAGES Easy to perform Useful method Inexpensive,DISADVANTAGES Occasional Thrombocytopenia Hemorrhagic Risk with Bleeding patient,LOW MOLECULAR WEIGHT (LMW) HEPARIN,TYPICAL REGIMEN IN CRRT : Priming of the circuit : 20 mg in 1 L Maintenance dose : 10 to 40 mg q6 hrs Monitor anti- factor Xa (aXa) units . Adjust between 0.1 and 0.4 /ml Different Dosages for LMW heparin,LOW MOLECULAR WEIGHT (LMW) HEPARIN,ADVANTAGES Decreased Risk of Bleeding,DISADVANTAGES Expensive Special and difficult monitoring With low doses frequent filter clotting,Regional Citrate Anticoagulation,TYPICAL REGIMEN : Citrate anticoagulation is always regional Citrate infusion (4%) at 170 ml/hr initially Special Dialysate at 1 liter/hr ( Na+ 117 , K+ 4 , Mg+ 1.5 , Cl- 121.5 , dextrose 0.5- 2.5% , no Ca+ , no base ) CaCL2 (0.75%) by central I.V at 40-60 ml/hr, Maintain ionized Ca+ at 0.96- 1.20 mmol/L,Citrate,ADVANTAGES : No Bleeding No Thrombocytopenia Improved Filter Life and Efficacy,DISADVANTAGES : Complex for the set up Ca+ monitoring needed Occasional Alkalosis,Heparin- free methos,Normal saline flush Used in patients with 1. Severe liver disease 2. Acitve or recent bleeding 3. Heparine-induced thrombocytopenia 4. Post-op patients,Dialysis modalities in the ICU,CVVH配置簡圖,CVVH Continuous Veno-Venous Hemofiltration,CVVH 模式下, 置換液流速 最高可達4500ml/hr,CVVH order,l Prepare Heparin 2cc + N/S 3cc, then inject 1.6cc into each femoral cath. l For AK priming: (GAMBRO, Polyarylethersulfone, 6S) *1st N/S 1000cc. *2nd Heparin 2,500U. *3rd N/S 500cc. l *Prepare Heparin 25,000U + N/S 500cc IVD 10cc/hr with pump to keep aPPT 1.5-2 and adjust as followed: aPPT bolus hold dose(cc/hr) 2.5 - 60min -4,CVVH order,If non-heparin , N/S 200cc q hr to rinse the AK Predilution run 500cc/hr alternately as followed via artery end 1st bottle N/S 500cc + Sinca 1amp 2nd bottle N/S 500cc + 10% MgSO4 4cc 3rd bottle N/S 500cc 4th bottle D5W 500cc + NaHCO3 5amp Warm dialysate to 37C Record I/O and BP q1hr UF target I-O ( ) cc/hr Check BUN,Crea,Na,K,Cl,aPPT q6hr for 1 day & then q8hr. Check Ca,P,Mg qd.,CVVHD配置簡圖,CVVHD Continuous Veno-Venous Hemodialysis,CVVHD order,l Prepare Heparin 2cc + N/S 3cc, then inject 1.6cc into each femoral cath. l For AK priming: (GAMBRO, Polyarylethersulfone, 6S) *1st N/S 1000cc. *2nd Heparin 2,500U. *3rd N/S 500cc. l *Prepare Heparin 25,000U + N/S 500cc IVD 10cc/hr with pump to keep aPPT 1.5-2 and adjust as followed: aPPT bolus hold dose(cc/hr) 2.5 - 60min -4,CVVHD order,If non-heparin , N/S 200cc q hr to rinse the AK 1.5% PD solution 500cc/hr run as dailysate Warm dialysate to 37C Record I/O and BP q1hr UF target I-O ( ) cc/hr Check BUN,Crea,Na,K,Cl,aPPT q6hr for 1 day & then q8hr. Check Ca,P,Mg qd.,CVVHDF配置簡圖,CVVHDF Continuous Veno-Venous Hemodiafiltration,CVVHDF order,l Prepare Heparin 2cc + N/S 3cc, then inject 1.6cc into each femoral cath. l For AK priming: (GAMBRO, Polyarylethersulfone, 6S) *1st N/S 1000cc. *2nd Heparin 2,500U. *3rd N/S 500cc. l *Prepare Heparin 25,000U + N/S 500cc IVD 10cc/hr with pump to keep aPPT 1.5-2 and adjust as followed: aPPT bolus hold dose(cc/hr) 2.5 - 60min -4,CVVHDF order,If non-heparin , N/S 200cc q hr to rinse the AK Predilution run 500cc/hr alternately as followed via artery end 1st bottle N/S 500cc + Sinca 1amp 2nd bottle N/S 500cc + 10% MgSO4 4cc 3rd bottle N/S 500cc 4th bottle D5W 50
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