Transcript CRRT교육자료
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.