(精选)Pediatric CRRT The Prescription教学课件.pptVIP

Clearance: Convection vs. Diffusion Solute Molecular Weight and Clearance Solute (MW) Sieving Coefficient Diffusion Coefficient Urea (60) 1.01 ± 0.05 1.01 ± 0.07 Creatinine (113) 1.00 ± 0.09 1.01 ± 0.06 Uric Acid (168) 1.01 ± 0.04 0.97 ± 0.04* Vancomycin (1448) 0.84 ± 0.10 0.74 ± 0.04** *P0.05 vs sieving coefficient**P0.01 vs sieving coefficient Flores FX et al: CRRT 2006 abstract Flores FX et al: CRRT 2006 abstract ppCRRT Pediatric Sepsis Outcome Data 57/102 (56%) pts survived. Ventilated pts had similar survival rate as non-ventilated pts (53% vs. 68%, p=0.1). There was no significant difference in the survival rate among CRRT modalities. Tendency toward better survival with convective therapies Flores FX et al: CRRT 2006 abstract Survival Based on CRRT Modality? Confounded Center Timing of initiation Sepsis definition not standardized Suggestive If all else equal, why not convect? Flores FX et al: CRRT 2006 abstract * Pediatric CRRT: The Prescription Stuart L. Goldstein, MD Associate Professor of Pediatrics Baylor College of Medicine What’s in a CRRT Prescription? Indication (Why? Who? When?) Technical Aspects (What?) Fluids (Symons) Anticoagulation (Brophy) Access (Hackbarth) CRRT Delivery (How?) Blood pump flow rates Modality Priming Dose Why CRRT in AKI? Critically ill patient Advantages Slower blood flows Slower UF rates UF rates can be prescriptive (versus PD) Adjust UF rates with hourly patient intake Increased cytokine (bad humors) removal? Disadvantages Increased cytokine (good humors) removal? Non-dialysis personnel with many other bedside responsibilities required to monitor circuit When Should CRRT Be Started? Standard AKI criteria not responsive to medical therapy OR only preventable with limiting adequate nutrition Uremia Hyperkalemia Acidosis Fluid Overload Prevention of worsening fluid overload? Timing of Pediatric RRT No adequate definition for “timing of initiation” Absence of a generally accepted, validated and applied AKI d