【持续性肾脏替代治疗crrt英文精品课件】acute renal replacement therapy for the infant

Acute Renal Replacement Therapy for the Infant,Dr.Fahad Gadi, MD Pediatrics Demonstrator King Abdulaziz University Rabigh Medical School,Objectives,Indications and goals for acute renal replacement therapy Modalities for renal replacement therapy Peritoneal dialysis Intermittent hemodialysis Continuous renal replacement therapy (CRRT) Special issues related to the infant,Indications for Renal Replacement,Volume overload Metabolic imbalance Toxins (endogenous or exogenous) Inability to provide needed daily fluids due to insufficient urinary excretion,Goals of Renal Replacement,Restore fluid, electrolyte and metabolic balance Remove endogenous or exogenous toxins as rapidly as possible Permit needed therapy and nutrition Limit complications,Renal Replacement for the Infant: A Set of Special Challenges,Small size of the patient Equipment designed for larger people Small blood volume will magnify effects of any errors Achieving access may be difficult Staff may have infrequent experience,Modalities for Renal Replacement,Peritoneal dialysis Intermittent hemodialysis Continuous renal replacement therapy (CRRT),Modalities for Renal Replacement,Peritoneal dialysis Intermittent hemodialysis Continuous renal replacement therapy (CRRT),PD: Considerations for Infants,ADVANTAGES Experience in the chronic setting No vascular access No extracorporeal perfusion Simplicity ? Preferred modality for cardiac patients?,DISADVANTAGES Infectious risk Leak ? Respiratory compromise? Sodium sieving Dead space in tubing,Modalities for Renal Replacement,Peritoneal dialysis Intermittent hemodialysis Continuous renal replacement therapy (CRRT),IHD: Considerations for Infants,ADVANTAGES Rapid particle and fluid removal; most efficient modality Does not require anticoagulation 24h/d,DISADVANTAGES Vascular access Complicated Large extracorporeal volume Adapted equipment ? Poorly tolerated,Modalities for Renal Replacement,Peritoneal dialysis Intermittent hemodialysis Continuous renal replacement therapy (CRRT),CRRT for Infants: A Series of Challenges,Small patient with small blood volume Equipment designed for bigger people No specific protocols Complications may be magnified No clear guidelines Limited outcome data,Potential Complications of Infant CRRT,Volume related problems Biochemical and nutritional problems Hemorrhage, infection Thermic loss Technical problems Logistical problems,CRRT in Infants 10Kg: Outcome,Patients 10kg,Patients 3-10kg,Patients 3kg,38% Survival,41% Survival,25% Survival,Am J Kid Dis, 18:833-837, 2003,ppCRRT Data of Infants 10Kg: Demographic Information,ppCRRT Data of Infants 10Kg: Primary Diagnoses,ppCRRT Data of Infants 10Kg: Indications for CRRT,N=84,ppCRRT Data of Infants 10Kg: Clinical Data,ppCRRT Data of Infants 10Kg: Technical Characteristics of CRRT,N=84,ppCRRT Data of Infants 10Kg: CRRT Treatment Data,N=84,ppCRRT Data of Infants 10Kg: Survival by Weight,44%,42%,43%,64%,p=0.001,p=1.0,ppCRRT Data of Infants 10Kg: Factors Effecting Survival,PRISMA,Dedicated CRRT device Highly automated Designed for ease of use at the bedside,Bradykinin Release Syndrome,Mucosal congestion, bronchospasm, hypotension at start of CRRT Resolves with discontinuation of CRRT Thought to be related to bradykinin release when patients blood contacts hemofilter Exquisitely pH sensitive,Bypass System to Prevent Bradykinin Release Syndrome,Recirculation System to Prevent Bradykinin Release Syndrome,Recirculation Plan: Qb 200ml/min Qd 40ml/min Time 7.5 min,Acute Initiation Checklist: Example,Infant ICU Nurse Time Zero: Move pt to room with dialysis water Get orders from resident for IV fluids to keep access open 20 40 min: Meet MD; discuss RRT plan 60 120 min: Meet ICU team,Dialysis Nurse 10 60 min: Arrive and begin setup 20 40 min: Meet MD; discuss RRT plan 60 120 min: Complete prime; ready for access Begin RRT Meet ICU team,Acute Initiation Checklist: Example,Nephrology MD Time Zero: Contact dialysis nurse to start RRT urgently 10 20 min: Bring catheters to ICU Enter orders for RRT 20 40 min: Meet ICU MDs & RNs, discuss plan 60 120 min: Present in ICU for initiation Meet ICU team,IV Access MD 10 30 min: Arrive and begin insertion of dialysis access 60 min (or when circuit is ready for Rx) Complete insertion of access Connect ports to heparin IV solutions,Infant RRT: Summary,All modalities of RRT po