【持续性肾脏替代治疗crrt英文精品课件】evolution of renal replacement therapy(57p)

Evolution of Renal Replacement Therapy,Abel, 1913 First dialysis of animal,Kolff, 1945 First dialysis in human,Teschan, 1950s Daily dialysis in Korean war,Since 1960s Chronic, intermittent hemodialysis (IHD) ( 24hrs q.w. 10-16hrs b.i.w. - 4-6hrs t.i.w. ),Daily dialysis?,Kramer, 1977 First CRRT (CAVH),1994 Automated CRRT,CRRT or SLEDD?,Basic Principle of Renal Replacement Therapy,NEJM 336:1303-1309,Diffusion,Ultra-filtration,Convection,Adsorption,Molecular weights,Molecules sizes,Molecules Size,Low-Flux Membrane,High Flux Membrane,20000,IL-1, IL-8, TNF-a,IL-6,Molecular weights cut-offs ,IL-6, TNF-,IL-1, IL-8,Clearance = QF x SC QF= filtration amount SC=sieving coefficients,Hemodialysis,NEJM 336:1303-1309,Hemofiltration,NEJM 336:1303-1309,Component of renal replacement therapy,Membrane Vascular access Anti-coagulant Dialysate Renal replacement fluid,Choice of membrane,Substituted cellulose dialyzers : hydroxyl group Cellulose acetate, diacetate, triacetate Synthetic dialyzers : Polysulfone (PS) Polyamide (PA) Polyacrylonitrile (PAN) Polymethylmethacrylate (PMMA),American Journal of Kidney Disease, Vol 35, NO 5(May), 2000:pp980-991,Choice of membrane,Biocompatible membrane (activate less complement and greater higher 2-microglobulin clearance, greater hydraulic permeability.low and high-flux synthetic membranes) Hypotension and prolongation of ARF in biocompatible membranes Adsorptive vs. nonadsorptive membrane in CRRT,American Journal of Kidney Disease, Vol 35, NO 5(May), 2000:pp980-991,Vascular access,Grade C : avoided subclavian in adults Grade D : avoided femoral vein in neonates and young (femoral vein thrombosis is a significant problem) Grade C : Internal jugular vein Level II and III studies : Ultrasound guidance Re-circulation is likely to be significant for blood flow in excess of 200 c.c/min, but depending on catheter design and location,The first international consensus conference on CRRT, 2002,Double lumen : Re-circulation rate,under 250cc/min blood flow Subclavian , internal jugular vein 3% Catheter length Femoral vein 24cm : 10%, 15cm : 18% Blood flow 400 cc/min : 38% in the femoral vein,American Journal of Kidney disease , 1996,Anticoagulation,Standard protocol Initial bolus 10-30 unit/kg of heparin Infusion 10-30 unit/kg to target ACT :170-220 seconds or PTT: 2 X N.J.Maxvold, T.E. Bunchman/Crit Care Clin 2003 19(2),563-575,Ideal replacement fluid/dialysate,Principle: remove waste, supply lost Nearly plasma water Supply inadequate component Individualized Different disease,Dialysate (透析液),Units: mEq/L,Replacement Fluid (補充液),Hybrid therapies in ICU,CRRT (Continuous Renal Replacement Therapy ) EDD ( Extended daily dialysis ) SLEDD ( Slow Low-efficient Daily Dialysis ) SLEDD-f (Sustained Low-efficiency Daily Diafiltration ) IHD ( Intermittent Hemo-dialysis ),CRRT,iHD,CRRT,iHD,Hybrid or Prolonged Intermittent Renal Replacement Therapies,EDD: Extended Daily Dialysis,Fresenius 2008H delivery system Double lumen Toray 2.0 m2 dialyzer Duration : 6 8 hrs Blood flow : 200 ml/min Dialysate flow rate : 300 (500) ml/min Dialysate potassium concentration 4 meq/L Dialysate bicarbonate concentration : 30 35meq/L,American Journal of Kidney Disease, Vol 36, No 2 (August), 2000: pp 294-300,SLEDD ( Slow Low-efficiency Daily Dialysis ),Fresenius 2008H delivery system Double lumen Duration : 6 12 hrs Blood flow : 200 ml/min Dialysate flow rate : 300 ml/min Dialysate bicarbonate concentration : 30 35meq/L,American Journal of Kidney Disease, 2000,SLEDD-f Sustained Low-efficiency Daily Diafiltration,Fresenius 4008S Double lumen Duration : 8 12 hrs Blood flow : 200 ml/min Dialysate flow rate : 200-300 ml/min High Flux Dialyzer Online replacement fluid,Nephrol Dial Transplant 2004 19:877-887,Nomenclature,HD treatment in ICU depend,Treatment behavior Availability of treatment methods Organization of the unit Knowledge and experience of nurses Existence of nephrological unit in the hospital Cost Individual doctor must therefore know the advantages and disadvantage of different treatment options,Kidney Blood Press Res2003;26:123-127,Daily hemodialysis and the outcome of acute renal failure,ARF require CRRT is related high mortality and uremic damage to other organ systems Intensive hemodialysis reduces mortality without increasing hemodynamically induced morbidity. Survival was the primary endpoint of the study Mortality rate : 28% Vs. 46% (daily H/D Vs. Alternate H/D ),N Engl J Med 2002;346:305-10,IHD vs CVVH,Journal of the American Society of Nephrology, 2001,IHD vs CVVH,What is SLEDD-f ?,Sustained Low-Efficient Daily Diafiltration A conceptual and technical hybrid of continuous veno-veno hemofiltration(CVVH : convection) and intermittent hemodialysis (IHD : diffusion ),Advantage of SLEDD-f,Patient mobility Anticoagulation hemodynamic stability or Nursing labor Professional Cost ,American Journal of Kidney Disease, 2000,The predominant potential advantages of continuous renal replacement therapy,Hemodynamics stability correction of hypervolemia and metabolic acidosis Better solute removal Recovery of renal function Biocompatibility Correction of malnutrition Better removal of cytokines Overall outcomes ?,Kidney Blood Press Res2003;26:123-127 Journal of the American Society of Nephrology, 2001,Potential disadvantages of CRRT,Need for continuous anticoagulation More difficult drug dosing Low efficiency interims of unit/ time ( e.g. Severe hyperkalemia) Nonselective solute removal : depletion syndrome with prolonged use of high Qf ?,The Netherlands Journal of Medicine August 2003,Sustained low-efficiency dialysis in the ICU: Cost, anticoagulation, and solute removal,Treatment parameters for current and previous SLED studies,KI (2006) 70, 963-968,Sustained low-efficiency dialysis in the ICU: Cost, anticoagulation, and solute removal,Measures of small solute removal,KI (2006) 70, 963-968,Sustained low-efficiency dialysis in the ICU: Cost, anticoagulation, and solute removal,Daily and weekly cost of SLED and CRRT,KI (2006) 70, 963-968,Dialysis guideline in NTUH SICU,Dominant and responsibility by Intensivist Hybrid Therapies in NTUH SICU Setting up and performing by Technician and NP,Guideline in CVVH,Indication： (1). Cerebral edema：Mannitol q12hr in use frequency (2). Prevention of post-dialytic “ rebound” intoxication Setting: Double lumen: 14Fr，儘量打在right neck vein blood flow: 200mL/min hemofiltration: 35mL/kg/hr dialyzer: PAN 10 HF-400 CVVH：pre-dilution : post-dilution 50%:50% Replacement fluid：信東A(BRolikcan)，若病人K+低，則每袋B液加KCl (20 meq)一支,Guideline in IHD,(1). IHD (4 hr)：病況穩定時使用之 (2). EDD (4 6hr)：stable hemodynamics，但預計脫水超過2L，為了增加脫水量而延長H/D時Initial H/D setting for patients with double lumen Blood Flow：200c.c/min Dialyzer：FK-18C (EVAL 1.8m2) Dialysate：IHD、EDD set 500c.c/min，SLEDD set 300c.c/min