Pediatric CRRT The Prescription课件.ppt

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 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 Retrospective review of all patients who received CVVH(D) in the Texas Children’s Hospital PICU from February 1996 through September 1998 (32 months) Pre-CVVH initiation data: Age Primary disease leading to need for CVVH Co-morbid diseases Reason for CVVH Fluid intake (Fluid In) from PICU admission to CVVH initiation Fluid output (Fluid Out) from PICU admission to CVVH initiation GFR (Schwartz formula) at CVVH initiation Percent Fluid Overload Calculation 22 pt (12 male/10 female) received 23 courses (3028 hrs) of CVVH (n=10) or CVVHD (n=12) over study period. Overall su