【持续性肾脏替代治疗CRRT英文精品课件】Pediatric CRRT The Prescription.pptVIP

* * * * * * Pediatric CRRT: The Prescription Stuart L. Goldstein, MD Professor of Pediatrics Baylor College of Medicine What’s in a CRRT Prescription? Indication (Why? Who? When?) Technical Aspects (What?) Nutrition (Maxvold) Anticoagulation (Brophy) Access (Bunchman) 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 definition has impeded the adequate investigation of this question The decision to initiate RRT affected by Strongly held physician beliefs Patient characteristics Organizational characteristics Retrospective evaluation of 226 children who received RRT for AKI from 1992-1998 Pressor use surrogate marker for patient severity of illness Survival defined at PICU discharge Percent Fluid Overload Calculation % FO at CVVH initiation = [ Fluid In - Fluid Out ICU Admit Weight ] * 100% Fluid In = Total Input from ICU admit to CRRT initiation Fluid Out = Total Output from ICU admit to CRRT initiation Lesser % FO at CVVH (D) initiation was associated with improved outcome (p=0.03) Lesser % FO at CVVH (D) initiation was also associated with improved outcome when sample was adjusted for severity of illness (p=0.03; multiple regression analysis) Fluid Overload Thresholds at CRRT Initiation and Mortality Author FO Threshold Outcome Goldstein Flu