pediatric crrt the prescription课件

PediatricCRRT ThePrescription StuartL Goldstein MDAssociateProfessorofPediatricsBaylorCollegeofMedicine What sinaCRRTPrescription Indication Why Who When TechnicalAspects What Fluids Symons Anticoagulation Brophy Access Hackbarth CRRTDelivery How BloodpumpflowratesModalityPrimingDose WhyCRRTinAKI CriticallyillpatientAdvantagesSlowerbloodflowsSlowerUFratesUFratescanbeprescriptive versusPD AdjustUFrateswithhourlypatientintakeIncreasedcytokine badhumors removal DisadvantagesIncreasedcytokine goodhumors removal Non dialysispersonnelwithmanyotherbedsideresponsibilitiesrequiredtomonitorcircuit WhenShouldCRRTBeStarted StandardAKIcriterianotresponsivetomedicaltherapyORonlypreventablewithlimitingadequatenutritionUremiaHyperkalemiaAcidosisFluidOverloadPreventionofworseningfluidoverload TimingofPediatricRRT Noadequatedefinitionfor timingofinitiation Absenceofagenerallyaccepted validatedandappliedAKIdefinitionhasimpededtheadequateinvestigationofthisquestionThedecisiontoinitiateRRTaffectedbyStronglyheldphysicianbeliefsPatientcharacteristicsOrganizationalcharacteristics Retrospectiveevaluationof226childrenwhoreceivedRRTforAKIfrom1992 1998PressorusesurrogatemarkerforpatientseverityofillnessSurvivaldefinedatPICUdischarge RetrospectivereviewofallpatientswhoreceivedCVVH D intheTexasChildren sHospitalPICUfromFebruary1996throughSeptember1998 32months Pre CVVHinitiationdata AgePrimarydiseaseleadingtoneedforCVVHCo morbiddiseasesReasonforCVVHFluidintake FluidIn fromPICUadmissiontoCVVHinitiationFluidoutput FluidOut fromPICUadmissiontoCVVHinitiationGFR Schwartzformula atCVVHinitiation PercentFluidOverloadCalculation FOatCVVHinitiation FluidIn FluidOutICUAdmitWeight 100 FluidIn TotalInputfromICUadmittoCRRTinitiationFluidOut TotalOutputfromICUadmittoCRRTinitiation 22pt 12male 10female received23courses 3028hrs ofCVVH n 10 orCVVHD n 12 overstudyperiod Overallsurvivalwas41 9 22 Survivalinsepticpatientswas45 5 11 PRISMscoresatICUadmissionandCVVHinitiationwere13 5 5 7and15 7 9 0 respectively p NS ConditionsleadingtoCVVH D Sepsis 11 Cardiogenicshock 4 HypovolemicATN 2 EndStageHeartDisease 2 Hepaticnecrosis viralpneumonia bowelobstructionandEnd StageLungDisease 1each Survivalcurvedemonstratesthatnearly75 ofdeathsoccurredlessthan25daysintotheICUcourse Lesser FOatCVVH D initiationwasassociatedwithimprovedoutcome p 0 03 Lesser FOatCVVH D initiationwasalsoassociatedwithimprovedoutcomewhensamplewasadjustedforseverityofillness p 0 03 multipleregressionanalysis N 113 p 0 02 p 0 01 N 77 Kaplan Meiersurvivalestimates bypercentagefluidoverloadcategory TheEvolutionofIdeatoPracticeParadigm Singlecenterstudy Registry RandomizedTrial ProspectivePediatricCRRT ppCRRT Registry Phase1Design Collectprospectivedatafrom10pediatriccenterstreating15to20patientsannually 376patientsover5years EachcenterfollowsowninstitutionalpracticePatientselectionInitiationandterminationAnti coagulationprotocolsConvectionversusdiffusionversushemodiafiltrationFluidcomposition SevencenterstudyfromtheppCRRTRegistry116patientswithMODSPRISM2scoreusedtoassesspatientseverityofillnessSurvivaldefinedatPICUdischarge 77 ofnon survivorsdiewithin3weeksofICUadmissionSurvivalratessimilarbyCRRTmodality H57 DF53 HD50 Survivalratessimilarforpatientson 0 1 53 2 54 or3 39 pressorsSurvivalratesbetterforpatientswith 20 FO 40 atCRRTinitiation p 0 001 ThePCRRTPrescription How BloodpumpflowratesMembranesPrimingModalityDoseUFrates BloodflowratesvarybypatientsizeMean5ml min kgCRRTclearancenotlimitedbyQb50 ofppCRRTpatientsreceivedsomeconvection PediatricCRRTCircuitPriming Heparinized 5000units L formostpatientsSmallerpatientsrequirebloodprimingtopreventhypotension hemodilutionCircuitvolume 10 15 patientbloodvolumePackedRBCsCitrated lowionizedcalciumAcidloadPotassiumload BradykininReleaseSyndrome Mucosalcongestion bronchospasm hypotensionatstartofCRRTResolveswithdiscontinuationofCRRTThoughttoberelatedtobradykininreleasewhenpatient sbloodcontactshemofilterMostcommonwithAN 69membranesExquisitelypHsensitive TechniqueModificationstoPreventBradykininReleaseSyndrome BufferedsystemTHAM CaCl NaBicarbtoPRBCsBypasssystemprimecircuitwithsaline runPRBCsintopatientonvenousreturnlineRecirculationsystemrecirculatebloodprimeagainstdialysate RecirculationPlan Qb200ml minQd 40ml minTime7 5min DoesModalityMakeADifference EqualclearanceofsmallermoleculesMiddleandlargemoleculeclearanceenhancedbyconvection MembraneSelectivity CourtesyofJ Symons Clearance Convectionvs Diffusion SoluteMolecularWeightandClearance Solute MW SievingCoefficientDiffusionCoefficientUrea 60 1 01 0 051 01 0 07Creatinine 113 1 00 0 091 01 0 06UricAcid 168 1 01 0 040 97 0 04 Vancomycin 1448 0 84 0 100 74 0 04 P 0 05vssievingcoefficient P 0 01vssievingcoefficient FloresFXetal CRRT2006abstract FloresFXetal CRRT2006abstract ppCRRTPediatricSepsisOutcomeData 57 102 56 ptssurvived Ventilatedptshadsimilarsurvivalrateasnon ventilatedpts 53 vs 68 p 0 1 TherewasnosignificantdifferenceinthesurvivalrateamongCRRTmodalities Tendencytowardbettersurvivalwithconvectivetherapies FloresFXetal CRRT2006abstract SurvivalBasedonCRRTModality ConfoundedCenterTimingofinitiationSepsisdefinitionnotstandardizedSuggestiveIfallelseequal whynotconvect FloresFXetal CRRT2006abstract Dialysate UltrafiltrationRates TheUFrate plasmaflowrate BFRx 1 HCT ratioshould 0 35 0 4inordertoavoidfilterclotting GolperAJKD6 373 386 1985 Dialysateflowratesrangingfrom20 30ml min m2 2000ml 1 72m2 hr areusuallyadequate experientialbutconsistentwithadultdata MediansurvivalGroup1 19days Group2 33days Group3 46days Groups2and3withlongersurvivalthanGroup1 MinimumUFrat