【持续性肾脏替代治疗crrt英文精品课件】the clinical application of crrt—current status (76p)

R3郭韋宏/F1李岳庭/VS陳德全 July 29,2009,高雄長庚腎臟科Journal reading,The clinical application of CRRT current status,Critically ill patient,Wein: Campbell-Walsh Urology, 9th ed,Acute kidney injury: RIFLE criteria,retrospective cohort study 5,383 adults admitted to intensive care unit and not on chronic dialysis,critical care 2006,10,R73,Acute kidney injury: RIFLE criteria,critical care 2006,10,R73,IHD & CRRT,JAMA 2008 Feb 20;299(7):793,What is an optimal application for CRRT ?,CVVH & CVVHDF,CVVH ：25cc/kg/hr CVVHDF: 42 cc/kg/hr (UF:25 cc/kg/hr + dialysate 15cc/kg/hr),Kidney Int 2006 Oct;70(7):1312,What is an optimal application for CRRT ?,Relationship between effluent flow rate and solute clearance,Nephrol Dial Transplant. 2003 May;18(5):961-6,What is the optimal dose？,NEJM 2002, 346,305-310 Am J Kidney Dis 1996, 28, S-81,High dose & standard dose,200 critically ill patients Method: CVVHDF with prefilter replacement fluid high dose : 35 ml/kg/hr standard dose: 20ml/kg/hr Primary outcome： survival rate at 30 days,High dose： 56% Standard dose: 49% ( p=0.32 ),J Am Soc Nephrol. 2008 Jun;19(6):1233-8,Acute Renal Failure Trial Network (ATN) study,NEJM 2008, 359,7-20,NEJM 2008, 359,7-20,Acute Renal Failure Trial Network (ATN) study,NEJM 2008, 359,7-20,The Randomized Evaluation of Normal versus Augmented Level of RRT (RENAL) study,Another large multicenter randomized control trial 1500 patients In Australia and New Zealand CVVHDF effluent rate 25 VS 40 cc/kg/hr Primary outcome: 90-day all cause mortality,Kidney Int 2006; 70:1202-4,What is the optimal dose？,NEJM 2002, 346,305-310 Am J Kidney Dis 1996, 28, S-81,Effluent flow rate： 20 or 2535 cc/kg/hr,Study population Actually delivered,What is an optimal application for CRRT ?,Early & Late initiation,Early ( 7hrs) & Late (42hrs) High-volume (72-96 L/day) & Low-volume (24-36 L/day),Critical Care Med 2002, 30, 2205-2211,Early & Late initiation,28-day survival EHV： 74% ELV： 69% LLV : 75% P value: 0. 80,Neither use of high ultrafiltrate volumes nor early initiation of hemofiltration improved survival in oliguric acute renal failure,Critical Care Med 2002, 30, 2205-2211,Prospective observational study（23 countries, 54 ICU ) 1006 patients All patients except one were treated with venovenous circuits, most commonly as venovenous hemofiltration (52.8%). The median dose of CRRT was 20.4 ml/kg/h. Hospital mortality was 63.8%. Multivariable analysis showed that no CRRT-related variables (mode, filter material, drug for anticoagulation, and prescribed dose) predicted hospital mortality,Intensive Care Med. 2007 Sep;33(9):1503-5.,What is an optimal application for CRRT ?,Avoid complication, more survival rate,Complication,Complications of CRRT (1),Complications of CRRT (2),How to select RRT?,CRRT in renal application,CRRT in non-renal application,How to prescribe ultrafiltration,Target： fluid balance Not static, dynamic pathophysiology of underlying disease process of care,3 levels for prescribe ultrafiltration (UF) 以預期intake + 期待 fluid loss 調整: Ex: intake : 4L , desired fluid loss: 2L during 24hrs UF= 4+ 2 L/ 24hr = 250 cc/hr 2) 以 postdilution 調整 3) 以hemodynamic parameters調整 Ex: CVP level 8-12mmhg net fluid balance is 0 CVP level 12mmhg net fluid balance is -50100cc/hr,Protocol for Early Goal-Directed Therapy of severe sepsis and septic shock,N Engl J Med. 2001 Nov 8;345(19):1368-77,Early goal-directed therapy,N Engl J Med. 2001 Nov 8;345(19):1368-77,Acute neurologic injury, Minimizes fluctuations in hemodynamic (CPP = MAP ICP) Avoid anticoagulation High Na (140mM) ; Low bicarbonate (30mM) Cooling of solutions (32-33。C),Cause fewer changes in brain edema compared to IHD,Sepsis and multiple organ failure,C-HF can remove septic mediators from circulation, High adsorptive hemofiltration (AN69) High volume hemofiltration (HVH) wait for IVORIE study: (septic shock +AKI) CVVH: 35cc/kg/hr VS70 cc/kg/hr Int J Artif Organs. 2006 Jul;29(7):649-59 High Cut-off hemofiltration (40-100kD) Hybrid Techniques (CRRT + plasmapheresis) Renal artificial device (RAD),Lancet 2000,Critical caree 2002,KI 2006,JASN 2008,Acute decompensated heart failure,Ultrafiltration for acute decompensated heart failure, May consider SCUF (slow continuous ultrafiltration) Less hemodynamic changes Swan-Ganz guided,Cardiorenal syndrome,Iranian Journal of Kidney Diseases,2009, Nov3,61,Classification of Cardiorenal Syndrome Proposed By Ronco and Colleagues,Iranian Journal of Kidney Diseases,2009, Nov3,61,Liver disease,Chronic liver disease (wait for liver transplantation): easy intradialytic hypotension : midrodine hepatorenal syndrome : Na132 meq/l Acute liver disease (fulminant hepatic failure) cerebral edema,臨床演練,67 y/o man (BW: 79kg) , hx of ESRD in uremic stage, s/p AV shunt creation on 6/18 HCC s/p TAE Liver cirrhosis,HD,CVVHDF,Effluent rate : 20cc/kg/hr, (Prismaflex),Dialysate flow rate _ ml/hr Solution A (3000cc/soft bag)+Solution B (250+2760 cc/bag) Total patient weight loss_ ml/hr Blood blow: _ml/min Check Bun/Cr, Na, K, Ca, P, Cl QD Check Mg QW1, QW4 Check ACT Q6H AND Keep ACT 200-250 sec, (Prismaflex),Dialysate flow rate _ ml/hr Solution A (3000cc/soft bag)+Solution B (250+2760 cc/bag) Replacement flow rate: Pre blood pump_ ml/hr, Post blood pump _ ml/hr Solution A (3000cc/soft bag)+Solution B (250+2760 cc/bag) Total patient weight loss_ ml/hr Blood flow: _ml/min Check Bun/Cr, Na, K, Ca, P, Cl QD Check Mg QW1, QW4 Check ACT Q6H AND Keep ACT 200-250 sec,Thanks for your attention！,CVVH 的併發症,出血 透析器凝固 失溫 低血壓 電解質不平衡 通路脫落或阻塞 感染,JAMA 2008 May 28;299(20):2413,What are the indications for CRRT? What is the RIFLE criteria? What is the role of CRRT in the different disease process? What is an adequate CRRT dose? Which complications can we expect during CRRT?,Cascade of SIRS / Sepsis,Cell wall lipopolysaccharide (LPS) “pyrogens”,Complement activation,complement fragments,C3a, C5a,Hypercatabolism,cell (monocyte) activation,cytokines/leukotrienes,TNFa, IL-1,6,8 Prostacyclins, Thromboxane,Anorexia, Fever,Hypotension,Clotting activation,contact phase activation, platelet depletion,Bleeding,54,Septic shock,Infection SIRS Sepsis Septic shock MODS,Accompanying problems: ARDS (acute respiratory distress syndrome) DIC (disseminated intravascular coagulation) Acidosis AKI (acute kidney injury),Bruce A. Molitoris. Critical Care Nephrology 2005. 28-34, 白蛋白 Albumin (55,000 - 60,000), Beta 2 Microglobulin (11,800), Inulin (5,200), Vitamin B12 (1,355), Aluminum/Desferoxamine Complex (700), Glucose (180), Uric Acid (168), Creatinine (113), Phosphate (80), Urea (60), Phosphorus (31), Sodium (23), Potassium (35),100,000,50,000,10,000,5,000,1,000,500,100,50,10,5,0,“小份子”,“中份子”,“大份子”,分子量 (大小) Molecular Weight,擴散作用 Diffusion,對流作用 Convection,57,KEYPOINTS,CRRT prevents further damage to the kidney and improves renal recovery. The RIFLE criteria was established by ADQI committee to categorize patients based on renal function and to create a guideline in prescription of therapy to ARF patients. The main indications for CRRT are: A - acidosis, E - electrolyte balance, I - Intoxications, O - Overload, U uremia. Recommended dose in CRRT based on Ronco study: 35ml/kgBW/hr effluent flow rate. Early initiation of therapy improves patient outcome and survival. Complications of CRRT include hemodynamic instability, electrolyte disorders, malnutrition, infection, thrombosis, bleeding, unnecessary patient fluid removal/gain.,CRRT 特點,CVVH的技術,幫浦：可區分為靠動靜脈壓力差推動或洗腎機幫浦推動。 抗凝劑：包括使用肝素或其他抗凝劑如Citrate於出血傾向的病患。 血管通路: CVVHD較CAVHD安全，不會引起動脈阻塞、出血、及栓塞。但是使用CVVHD則要注意是否有空氣跑入，或管路連接脫落導致大量出血。 透析器：一般使用高透量的短型人工腎臟，當然傳統的人工腎臟透析器也可使用。 補充液及透析液：可以使用一般腹膜透析的含1.5%葡萄糖透析液，或CAVHD專用補充液；或自己泡製。,A filtration rate of more than 25 - 30% greatly increases blood viscosity within the circuit, risking clot and malfunction.,Sluggishness,Sludging problems are reduced, but the efficiency of ultrafiltration is compromised, as the ultrafiltrate now contains a portion of the replacement fluid.,Pre-dilution,63,CRRT 適應症,64,葯