【持续性肾脏替代治疗crrt英文精品课件】crrt protocol-continuous renal replacement therapy (44p)

CRRTProtocolContinuousRenalReplacementTherapy 台大外科部護理師蔡壁如 Outline HistoryIndicationCRRTMethodUltrafiltrationratesChoiceofreplacementfluidSet upprotocol 1861ThomasGraham etc useasemi permeablemembranetodiffuseurea1924GeorgeHaasdialyseapatientduring15minutes1927Heparin ananticoagulant isavailable1937Productionofcellophaneforfilters1943WillemKolffmakesarotatingdrumdialyser1970Firstartificialmembrane1975 1985Developmentofnewtechniques i e adsorption plasmaexchange filtration History ExtracorporealdepurationinICU 1977 PeterKramerperformsfirstarterio venoushemofiltration CAVH 1982 FDAapprovestheCAVH1984 Bloodpumpcirculatedremovefluid1994 Clinicalimportancetocontrolfluidbalance1994Thefirst automatic machineisavailable2000 higherflowsmachinesbecomesavailable CAVH ExtracorporealdepurationinICU 1977 PeterKramerperformsfirstarterio venoushemofiltration CAVH 1982 FDAapprovestheCAVH1984 Bloodpumpcirculatedremovefluid1994 Clinicalimportancetocontrolfluidbalance1994Thefirst automatic machineisavailable2000 higherflowsmachinesbecomesavailable CVVH ExtracorporealdepurationinICU 1977 PeterKramerperformsfirstarterio venoushemofiltration CAVH 1982 FDAapprovestheCAVH1984 Bloodpumpcirculatedremovefluid1994 Clinicalimportancetocontrolfluidbalance1994Thefirst automatic machineisavailable2000 higherflowsmachinesbecomesavailable CRRT ExtracorporealdepurationinICU 1977 PeterKramerperformsfirstarterio venoushemofiltration CAVH 1982 FDAapprovestheCAVH1984 Bloodpumpcirculatedremovefluid1994 Clinicalimportancetocontrolfluidbalance1994Thefirst automatic machineisavailable2000 higherflowsmachinesbecomesavailable AutomaticCRRT ObjectivesofextracorporealdepurationintheIntensiveCareUnits ICU Withacuterenalfailure ARF functiontocontrolpatientfluid acid basebalancestocorrectelectrolyticdisorderstoremoveureaandcreatininetomaintainsufficientnutritiontopreservethepotentialtorecoverrenalWithoutacuterenalfailuretoreducethefluidoverloadtoimprovecardiacandbrainstatustoremovelactateofmajorlacticacidosis extracorporealdepurationinNTUHSICU C R R T 適應症 1 急性腎衰竭2 急性肺水腫3 在心臟手術進行期間 避免過量鉀及水份 利用體外血液循環系統 4 嚴重性水腫如 心臟衰竭 Congestivecardiacfailure 腎病綜合症 Nephroticsyndrome 5 急性呼吸道病症 ARDS 6 藥物中毒7 嚴重乳酸鹽中毒8 敗血病休克 Septicshock 清除Cytokines和Endotoxin9 體溫過高 發熱 Hyperthermia 10 橫紋肌溶解 Rhabdomyolisis 11 急性溶血 急性腎衰竭治療的終極目標 清除血液中的廢物回復身體的酸鹼平衡改正體內電解質不正常情況 特別是血鉀過高免除體液過量 較高的體液清除能力 不能對心血管有太大的壓抑確保營養支持 Hemodialysis anticoagulant Arterialflow Venousflow Freshdialysate Bloodflow 200 250ml minDialysateflow 500ml minDuration 4hWeightloss 2 4L Hemofiltration Hemofiltration filtrationthroughastrainer blood ultrafiltrate substitution Filterincludingasemi permeablemembrane Whatisrenalreplacementmethodoffirstchoiceforintensivecarepatients IHD Intermittenthemodialysis CRRT Continuousrenalreplacementtherapy SLEDD SlowLow efficientDailyDialysis JournaloftheAmericanSocietyofNephrology 2001 IntermittentH D IHDcomparedwithCRRT JournaloftheAmericanSocietyofNephrology 2001 TheoreticalAdvantageofCRRT HemodynamicStabilityRecoveryofrenalfunctionCorrectionofmetabolicacidosisBiocompatibilityCorrectionofmalnutritionBetterremovalofcytokinesSoluteremovalOveralloutcomes JournaloftheAmericanSocietyofNephrology 2001 DisadvantageofCRRT ContinuousanticoagulationPatientimmobilityIntensivenursingrequirementsIncreasedexpense JournaloftheAmericanSocietyofNephrology 2001 SLEDD SlowLow efficientDailyDialysis Fresenius2008HdeliverysystemToraymodel2 0dialyzerDoublelumenDuration 6 8hrsBloodflow 200ml minDialysateflowrate 300ml minDialysatebicarbonateconcentration 30 35meq L AmericanJournalofKidneyDisease 2000 SLEDDasanAlternative LowbloodflowLowdialysateflowratesProlongperiodoftime 6 12hrs ComparedwithIHDHemodynamicstabilityBettercorrectionofhypervolemiaAdequatesoluteremovalCostlowerthanCRRT JournaloftheAmericanSocietyofNephrology 2001 AdvantageofSLEDD LesscumbersometechniquePatientmobilityDecreasedrequirementsforanticoagulationProvidingsimilarhemodynamicstabilityandvolumecontrol AmericanJournalofKidneyDisease 2000 CVVHD P DSolution Dialysatesolution35 45 infuseddextroseabsorbedthroughthehemodiafilterGlucosedelivery5 8g hr P D1 5 rate1L hr Impactnitrogenandcarbohydratebalance IntensiveCareMed 1991 1995 CVVHDContinuousVeno Venoushemodiafiltration V CVVHD GlucosedynamicsduringcontinuoushemodiafiltrationLipogenesisintheliverExcessivecarbondioxideproduction MV minuteventilation HyperglycemiaPreventingglucoseoverloadDextrosefreedialysateGlucoseloadfromdialysateConclusionDextrosefree lossissmallandpredictable IntensiveCareMed 1995 Ultrafiltrationrates Recommend2Lperhourormore20ml hr kg 41 survivalrate 35ml hr kg 57 45ml hr kg 58 HightreatmentdosesmightbedifficultEarlystartoftreatment improvedoutcome Lancet2000 355 26 30 EarlyandIntensiveContinuousHemofiltrationforsevererenalfailureaftercardiacsurgery Early 2 8dayspost opToolateinthepost opLeadingprolongedandpoorlycontrolleduremiaRestrictednutritionVolumeoverloadIntensive 2L hrurtrafiltrationrateLimitedintensityleadingtoinferioruremiccontrolwithitsattendantsequelActualmortality 40 vs66 AnnThoracSurg2001 Hemofiltrationwithpredilutionorpostdilution ultrafiltrate Predilution InjectionbeforethefilterPostdilution Injectionafterthefilter Doublelumen Re circulationrate 250cc minbloodflowSubclavian internaljugularvein 3 CatheterlengthFemoralvein24cm 10 15cm 18 400c c minbloodflow38 inthefemoralvein AmericanJournalofKidneydisease 1996 Doublelumen Re circulationrate 298c c minbloodflowFemoralvsSubclavian 16 1 vs4 1 Femoralcath13 5cmvs19 5cm 22 8 3 0 vs12 6 1 7 AmericanJournalofKidneydisease 1996 Choiceofreplacementfluid Acetate BasedfluidsHyperacetatemia peripheralvasodilator myocardialdepressanteffectAcetatemetabolism oxygenconsumptionBicarbonate Basedfluid SVR CILactate Basedfluid lactate proteincatabolism ADPlevelandimpairoxygendeliveryandventricularfunction myocardialdepression ExcessiveaccumulationofD lactate IICP AmericanJournalofKidneydisease 1996 Effectsofbicarbonateandlactate bufferedreplacementflui