Cvvh in sicu
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CVVH in SICU. 外科加護病房 護理師 蔡壁如. Hemodynamic instability during different forms of dialysis therapy : Do we really know why ?. CRRT Program consideration and evaluation. Which the renal replacement method of first choice in the ICU P ’ t. Simple to manage / low work-load Inexpensive

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CVVH in SICU

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Cvvh in sicu

CVVH in SICU

外科加護病房 護理師

蔡壁如


Hemodynamic instability during different forms of dialysis therapy do we really know why

Hemodynamic instability during different forms of dialysis therapy : Do we really know why ?


Crrt program consideration and evaluation

CRRT Program consideration and evaluation


Which the renal replacement method of first choice in the icu p t

Which the renal replacement method of first choice in the ICU P’t

  • Simple to manage / low work-load

  • Inexpensive

  • Reliable and predictable ( solute and water removal)

  • Optimal survival and complication profile

  • Optimal recovery of renal function


Hybrid therapies in icu

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 Dia-filtration )

  • IHD ( Intermittent Hemo-dialysis )

  • Plasmapheresis


Basic principle of r enal r eplacement t herapy

Basic Principle of Renal Replacement Therapy

NEJM 336:1303-1309


Cvvh in sicu

血液透析的原理


Cvvh in sicu

脫水的原理


Cvvh in sicu

連續性血液過濾術(CVVH)原理


Cvvh in sicu

人工腎臟吸附毒素


Cvvh in sicu

CRRT

Dialysis


Introduction of acute renal failure

Introduction of Acute Renal Failure

  • 17 ~ 25 % of ICU case develop ARF

  • 5 ~ 10% of cases will require CRRT

  • Outcome is dependent upon the original cause of ARF

  • Mortality from underlying disease, and complication like sepsis

  • Clinical care nephrology, 1998. P405-411


Cvvh in sicu

Classification ARF

Acute renal failure

Pre-renal

Intrinsic renal

Post-renal

Absolute decrease in

effective blood volume

Haemorrhage

Volume depletion

Relative decrease in blood Volume

(ineffective arterial

volume)

Congestive heart failure

Decompensated liver cirrhosis

Arterial occlusion or

Stenosis of renal artery

Haemodynamic from

NSAIDs

ACE inhibitors or angiotensin-II receptor

in renal- artery stenosis

or congestive heart failure

Vascular

Vasculitis

Malignant

hypertension

Acute glomerulo-

nephritis

Postinfections

Glomerulonephrit

tis ,disease caused

by antibody to

glomerular basement

membrane

Acute

Interstitial

nephritis

Drug-

associated

Acute

tubular

necrosis

Obstruction of collecting

system or extrarenal drainage

Bladder –outlet obstruction

Bilateral ureteral obstruction

Nephrotoxic

Ischaemic

Exogenous

Antibiotics(gentamicin)

Radio contrast agents

Cisplatin

Endogenous

Intratubular pigments(haemoglobinuria,

myoglobinuria)

Intratubular proteins(myeloma)

Intratublar crystals(uric acid,oxalate)


Rifle criteria

RIFLE Criteria

Crit Care Med 2006, Vol. 34 No 7


Acute kidney injury stage 3

Acute Kidney Injury stage 3

Renal replacement therapy


Cvvh indication

CVVH Indication

  • CAVH in ECMO

  • Cerebral edema:Mannitol ≧ q12hr in use frequency

  • Prevention of post-dialytic “ rebound” intoxication:lithium, tumor lysis, rhabdomyolysis, tissue necrosis


Cvvh in sicu

專有名詞

  • CAVH, CAVHD, CAVHDF

  • CVVH, CVVHD, CVVHDF

  • IHD, EDD, SLEDD, SLEDDF

  • RRT

    Renal Replacement Therapy


Cvvh in sicu

Effects of different doses in continuous veno-venous hemofiltration on outcomes of acute renal failure : a prospective randomized trial

  • CVVH Ultrafiltration rate ?

  • Recommend 2L per hour or more

    • 20 ml/hr/kg : 41% (survival rate)

    • 35ml/hr/kg : 57%

    • 45ml/hr/kg : 58%

  • High treatment doses might be difficult

  • Early start of treatment : improved outcome

Lancet 2000;355:26-30


Cvvh in sicu

脫水量愈多效果愈好 ?

答案是: 病患的indication

增加護理人力

血流速相對要提高

電解質的的監控: K+ loss

The Third International Course on Critical Care Nephrology held in Vicenza, Italy in June 2004


Vascular access

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

Double lumen : Re-circulation rate不是血流速愈高愈好:看導管大小 位置

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


Double lumen re circulation rate1

Double lumen : Re-circulation rate

Blood flow : 298 cc/min

  • Femoral vs Subclavian:16.1±1.8% vs 4.1 ±0.7%

  • Femoral cath 13.5 cm vs 19.5 cm : 22.8 ±3.0% vs12.6 ±1.7%

  • 台大SICU Double lumen準備時要注意

    • 14Fr 20cm (Femoral )

    • 14Fr 16cm (Neck )

American Journal of Kidney disease, 1996


Anticoagulation

Anticoagulation

  • Grade E : priming solution: 2000 U/1000c.c

  • Grade E : avoided systemic heparin in high risk bleeding p’t

  • Grade D : without any anticoagulation, circuit life may be less than 24hr

  • Grade E : anticoagulation monitoring , ACT(activated clotting times) or PTT(partial thromboplastin time)

  • The first international consensus conference on CRRT, 200


Anticoagulation1

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


Cvvh in sicu

Automatic CRRT

優點:

全自動計算

可加熱

缺點:

太敏感

機器不穩定


Fresenius machine

Fresenius machine

優點:

容易操作

缺點:

沒有加熱器 溫度散失厲害

外掛的輸液機不穩定


Cvvh in sicu

Replacement Fluid A, B Solution


Cvvh solution formula

CVVH Solution Formula

1. B solution + 250c.c Rolikan

2. A B溶液單獨進入體內:Ca+HCO3會沉澱

3. 溶液內沒有K離子,注意電解質問題

4. 若要加鉀離子,A液一袋加一支 (20Meq )


Cvvh in sicu

Inner lumen 220 µm

220 µm

Wallthickness

35 µm

35 µm

CVVH 人工腎臟特性

The membrane geometry was adapted to meet the specific needs in CRRT

Increased inner lumen:Decreased wall thickness:


Cvvh in sicu

Inner lumen 200 µm

200 µm

Wallthickness

40 µm

Dialysate side

40 µm

40 

1

Blood side

血液透析之人工腎臟

FreseniusPolysulfone® :

Fibre structure

  • No pores filling agent

  • Not wettable: no swelling

  • Consistency of fibre geometry


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