CRRT교육자료

Report
CRRT
(Continuous Renal Replacement Therapy)
“Any extracorporeal blood purification therapy
intended to substitute for impaired renal
function over an extended period of time and
applied for or aimed at being applied for
24hours/day.”
IHD와 CRRT비교
Contents
IHD
CRRT
Membrane
characteristics
Anticoagulation
Blood flow rate
Dialysate rate
Duration
Clearance(단위시간)
Variable
permeability
Short duration
> 200ml/min
> 500ml/min
3-4hrs
high
High permeability
Prolonged
< 200ml/min
7-34ml/min
Days
low
Classical & alternative indication for CRRT
• Renal indications
– ARF with cardiovascular failure
– ARF with cerebral edema
– ARF with hypercatabolism
• Non-renal indication
–
–
–
–
–
–
Sepsis & other inflammatory disease
ARDS ( acute respiratory disorder syndrome )
Cardiopulmonary Bypass
Crush Syndrome
Lactic Acidosis
Congestive heart failure
Indications for CRRT
Nonobstructive oliguria (u/o<200ml/12h) or anuria.
Severe Acidemia (pH<7.1) d/t metabolic acidosis.
Azotemia (urea>30mmol/l).
Clinically significant organ edema (especially lung).
Hyperkalemia (K>6.5 mmol/l).
Progressive severe Dysnatremia (Na>180 or<115mmol/l)
ARDS or Pulmonary edema.
Hyperthermia (core temp. >39.5c)
Drug overdose
CRRT complication
• 출혈경향
• 저혈압
• 저체온:노폐물과 과잉수분제거 위해 빠른
속도로 신체의 수분이 배출되고 몸 밖에서
다량의 보충액 투입이 반복됨.
• 혈관통로 부위의 합병증: 출혈과 감염
• 전해질, 산 염기 불균형
• 공기색전증
Mechanism of treatment
Ultrafiltration
Diffusion
Convection
Adsorption
물질이동의 원리
1)확산(diffusion)
• 고농도  저농도로
반투막을 통한 용질의
수동적 이동
• 확산의 속도 증가:
– 두용액 사이의 용질의
농도경사 
– 용질의 분자량
– 반투막의 두께 
– 막의 표면적 
– 세공의 크기 
– 세공의 수 
Solutes : Convection
• 용질과 물 사이의 마찰
력에 의해 발생
– 큰 분자량을 가진 물질
제거에 가장 효과적
• 용매끌기(solvent drag)
– 수분 이동 시 수분에 용
해되어있던 분자량이 작
은 용질이 수분과 함께
이동되는 현상
• 대류속도 증가
– 초여과량이 많을수록,
세공의 크기가 클수록
Solutes : Adsorption
molecular adherence to the surface or interior of the membrane.
Amount of adsorption is dependent upon membrane and water flow.
Fluid : Ultrafiltration
Pressure
Membrane
Uf
Uf
ULTRAFILTRATION: The movement of fluid through
a membrane caused by a pressure gradient.
Transport mechanisms
HD
HF
HDF
(Hemodialysis)
(Hemofiltration)
(Hemodiafiltration)
Diffusion
Convection
Convection + diffusion
Molecular Weights
100,000
50,000
10,000
5,000
molecular
weight,
daltons
1,000
500
100
50
10
5
0
•
Albumin (55,000 - 60,000)
}
•
Beta 2 Microglobulin (11,800)
•
Inulin (5,200)
•
•
Vitamin B12 (1,355)
Aluminium/Desferoxamine Complex (700)
•
•
•
•
Glucose (180)
Uric Acid (168)
Creatinine (113)
Phosphate (80)
•
Urea (60)
•
•
•
Potassium (35)
Phosphorus (31)
Sodium (23)
}
“large”
}
“small”
“middle”
CRRT 의 종류
• SCUF
• CVVH
• CVVHD
• CVVHDF
(1) SCUF
(Slow Continuous Ultrafiltration)
Access
Return
• Ultrafiltration
• Dialysate(-), RF(-)
• Only fluid remove
PR I S MA
M100
– RF:
Replacement fluid
Effluent
(2) CVVH
(Continuous Veno-Venous
Hemofiltration)
Access
Return
•Ultrafiltration+
convection
•RF(+)
•High clearance+
Regulation UFR
PR I S MA
M100
Replacement
(pre or post dilution)
Effluent
Replacement Fluids
Access
Return
• Pre-dilution:
• Decreased risk of
clotting
• Higher UF
Replacement
PR I S MA
M100
Effluent
Replacement Fluids
Access
Return
• Post-dilution:
• Slower replacement
solution rates
• Increased anticoagulant needs
Replacement
PR I S MA
M100
Effluent
(3)CVVHD
Continuous Veno-Venous
Hemodialysis
Access
Dialysate
Return
•Ultrafiltration+diffusion
•Dialysate(+)
•Urea clearance는 CVVH
보다 높다.
•Azotemia가 심한 환자
PR I S MA
M100
Effluent
(4)CVVHDF
ContinuousVeno-Venous
Hemodiafiltration
Dialysate
Convection(HF)
+Diffusion(HD)
Dialysate(+)& RF(+)
Access
Return
PR I S MA
M100
Replacement
(pre or post dilution)
CRRT중 가장 효과적인 치료 방법
Effluent
Comparison of different CRRT modalities
Modality
Simplicity
Blood
Pump
SCUF
CAVH
CVVH
CAVHD
CVVHD
CAVHDF
CVVHDF
Yes/No
No
Yes
No
Yes
No
Yes
Dialysate(D)
Urea
Middle
Replacement
Clearance
Molecular
fluid(RF)
(L/d)
Clearance
No
RF
RF
D
D
RF+D
RF+D
1-4
10-15
22-24
24-30
24-30
36-38
36-38
+
++
+++
+++
+++
Goals of Anticoagulation
Bleeding
Clotting
• Maintain patency of
extracorporeal
circuit
• Minimize patient
complications of
anticoagulation
therapy
Factors Favoring Clotting
Low blood flow(BFR≤80ml/min)
High hematocrit
High ultrafiltration rate
Infusion of blood and blood products
into EC
• Infusion of lipids into the EC
• Presence of air in the EC
•
•
•
•
Anticoagulation for CRRT
Methods
Loading dose
Maintenance
dose
Comments (see text)
Least hemorrhagic risk, short filter patency,
most successful with low platelets, and
predilution
Saline flush
Heparin
1000-2000 U
5-10 U/kg/h
Standard technique, easy reversibility with
protamine, risk of thrombocytopenia
Regional
heparinization
1000-2000 U
heparin
5-20 U/kg/h,
Protamine
at 10-20 mg/h
Reduced risk of bleeding, variable
requirement for protamine, frequent
readjustments of heparin/protamine ratio
LMW heparin
40mg
10-40 mg/h
Decreased risk of bleeding, prolonged
half-life, incomplete reversal with
protamine, specialized monitoring
Regional citrate
100-180 ml/h,
4% trisodium citrate
Decreased risk of bleeding, excellent filter
patency, requires diffusive component to
system(CAVHD), extensive monitoring
required
Prostacyclin
4-8 ng/kg/min
heparin
at 2-4 U/Kg
Difficult to monitor, risk of hypotension,
prolonged action, no reversibility,
excellent filter patency, often used with
heparin
Nafomostate
mesilate
0.1 mg/kg/h
Excellent potential, limited experience
Hemosol
Hemosol B0 사용법
bicarbonate
Ionic formula of final solution
obtained after transfer of bicarbonate
into electrolyte solution
IONIC FORMULA
mEq / l
Sodium Na+
140
Calcium Ca++
3.5
Magnesium Mg++
1.0
1) 외포를 열고 백안의 절단막을
부러뜨린다.
2) 작은 백안의 용액을 모두 큰백
안으로 내려보낸다.
3) 큰 백을 눌러서 작은백으로 흘러
들어간 용액이 남은용액을 깨끗이
Chloride Cl-
109.5
씻어 주도록 한다.(2회)
Lactate C3H503-
3
Bicarbonate HCO3-
32
4) 작은백이 완전히 비면 잘 흔들어
Potassium K+
0
섞고 바로 사용하도록 한다.
Theoretical osmolarity
(mOsm/l)
287
* 두 용액이 섞이면서 HCO3-와 Ca++
이 만나 침전을 이룰 수 있으므로
mix시간을 표시한다.
유효기간은 12시간이다.

similar documents