Renal Replacement Th..
Transcript of Renal Replacement Th..
Renal Replacement TherapyRenal Replacement Therapy
Trauma ConferenceTrauma Conference
11-27-200611-27-2006
Amanda Wheeler, MDAmanda Wheeler, MD
PrinciplesPrinciples
4 Main Modalities in ICU4 Main Modalities in ICU
HDHD PDPD CVVHCVVH CVVHDCVVHD
Definition of TermsDefinition of Terms
SCUF- Slow Continuous UltrafiltrationSCUF- Slow Continuous Ultrafiltration CAVH- Continuous Arteriovenous CAVH- Continuous Arteriovenous
HemofiltrationHemofiltration CAVH-D- Continuous Arteriovenous CAVH-D- Continuous Arteriovenous
Hemofiltration with DialysisHemofiltration with Dialysis CVVH- Continuous Venovenous CVVH- Continuous Venovenous
HemofiltrationHemofiltration CVVH-D- Continuous Venovenous CVVH-D- Continuous Venovenous
Hemofiltration with DialysisHemofiltration with Dialysis
Indications for Continuous Renal Indications for Continuous Renal Replacement TherapyReplacement Therapy
Volume OverloadVolume Overload Electrolyte ImbalanceElectrolyte Imbalance UremiaUremia Acid-Base DisturbancesAcid-Base Disturbances DrugsDrugs
Hemodialysis vs Hemofiltration Hemodialysis vs Hemofiltration MembraneMembrane
The The hemofiltrationhemofiltration membrane membrane consists of relatively consists of relatively straight channels of ever-straight channels of ever-increasing diameter that increasing diameter that offer little resistance to offer little resistance to fluid flow.fluid flow.
Hemodialysis membranes contain long, tortuous inter-connecting channels that result in high resistance to fluid flow.
Hemodialysis allows the removal of water and solutes by diffusion across a concentration gradient.
HemodialysisHemodialysis
maximum solute maximum solute clearanceclearance
best tx for severe best tx for severe hyper-K+hyper-K+
ready availabilityready availability limited anti-coagulation limited anti-coagulation
timetime bedside vascular bedside vascular
accessaccess
hemodynamic hemodynamic instabilityinstability
hypoxemiahypoxemia rapid fluid + solute rapid fluid + solute
shiftsshifts complex equipmentcomplex equipment specialized specialized
personnelpersonnel
advantages disadvantages
Peritoneal DialysisPeritoneal Dialysis
simple to set up + simple to set up + performperform
easy to useeasy to use hemodynamic stabilityhemodynamic stability no anti-coagulationno anti-coagulation bedside peritoneal bedside peritoneal
accessaccess
unreliable ultrafiltrationunreliable ultrafiltration slow fluid + solute slow fluid + solute
removalremoval drainage failure, drainage failure,
leakageleakage catheter obstructioncatheter obstruction respiratory compromiserespiratory compromise hyperglycemiahyperglycemia peritonitisperitonitis
advantages disadvantages
CVVHD vs CVVHCVVHD vs CVVH
CVVHCVVH
1. near-complete control of the rate of 1. near-complete control of the rate of fluid removal (i.e. the ultrafiltration rate)fluid removal (i.e. the ultrafiltration rate)
2. precision and stability2. precision and stability
3. electrolytes or any formed element 3. electrolytes or any formed element of the circulation, including platelets or of the circulation, including platelets or red or white blood cells, can be red or white blood cells, can be removed or added independent of removed or added independent of changes in the volume of total body changes in the volume of total body waterwater
CVVHCVVH
easy to use in ICUeasy to use in ICU rapid electrolyte correctionrapid electrolyte correction excellent solute clearancesexcellent solute clearances rapid acid/base correction rapid acid/base correction controllable fluid balancecontrollable fluid balance tolerated by unstable tolerated by unstable
patientspatients early use of TPNearly use of TPN bedside vascular access bedside vascular access
routineroutine
systemic systemic anticoagulation *anticoagulation *
citrate anticoagulation citrate anticoagulation newnew
frequent filter clottingfrequent filter clotting hypotensionhypotension
advantages disadvantages