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ARF.ppt
 

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    ARF.ppt ARF.ppt Presentation Transcript

    • ARF Curr Opin Crti Care 10:499-504 2004 Crti Care Clin 19: 563-575 2003 Ri B88401075
    • ARF
      • Definition
        • Abrupt decline in GFR
        • Inability of kidneys to regulate fluid, electrolytes and acid-base homeostasis
        • In pediatrics:
          • Serum creatinine increase more than 50%
          • Increase of nitrogenous waste products
          • Decreased urine output (< 0.5~1.0 ml/kg/hr)
    • ARF
      • Etiology
        • Prerenal
        • Renal
        • Postrenal
      • Common cause
        • Sepsis
        • Multiorgan failure
        • Hemolytic uremic syndrome
        • Dehydration
        • Toxin
        • Congenital renal disease
    • ARF
      • Principle of management
        • Maintain fluid and electrolytes homeostasis
        • Avoid life-threatening complication
        • Provide adequate nutrition
    • ARF
      • Methods
        • Non-dialysis
          • Dopamine
          • Diuretics
          • Others
        • Dialysis
          • Peritoneal dialysis
          • Hemodialysis
          • Hemofiltration
    • ARF
      • Non-dialysis
        • Renal dose Dopamine(1~3 mcg/kg/min)
          • No benefit
          • Should not be used for this indication
            • From Surviving Sepsis Campaign Management Guidelines Committee
        • Diuretics
          • Improved U/O, but not reflect increased GFR
          • May avoid intratubular obstruction
          • May lower oxygen consumption
          • Ototoxicity or hyperosmolarity
    • ARF
      • Peritoneal dialysis
      • Intermittent hemodialysis
      • Continous renal replacement therapy
        • Hemodialysis
        • Hemofiltration
    • Dialysis
      • Peritoneal dialysis
        • Advantage
          • Ease of application
          • Minimal equipment
          • Low cost
          • Long history of experience
        • Not enough clearance in:
          • Tumor lysis syndrome
          • Inborn errors of metabolism
    • Dialysis
      • Intermittent hemodialysis
        • Use in:
          • Less critical (more stable) patient
          • Acute intoxication of rapidly clear toxin
        • Disadvantage:
          • Solute rebound
          • Continous nature of toxin production
    • Dialysis
      • Post-op cardiac patients:
        • better recovery if maintaining fluid status better
      • Critical illness with sepsis or MORF:
        • Appropriate fluid and clearance improves morbidity and mortality
      • Hemofiltration > Hemodialysis in:
        • Improved solute and cytokine clearance
    • Dialysis
      • Solution selection
        • Lactate based
          • Previously used
          • Caused higher serum lactate level
        • Bicarbonate based
          • Newly proved by FDA
          • No Calcium
          • Allow citrate to be used as anti-coagulants
    • Dialysis
      • Anticoagulants
        • To avoid blood clot in circuit
        • Heparin
          • More familiar
          • Easily controlled (target INR: 2.0)
          • May induced bleeding or hemorrhage
          • Dose:
            • 30 IU/kg bolus
            • 30 IU/kg/hr maintenance
    • Dialysis
      • Anticoagulants
        • Citrate
          • Pre-circuit infusion
          • Bind to serum calcium
          • Target calcium level: 0.25~0.4 mmole/L
          • Calcium can be supplied by infusion
          • May cause metabolic alkalosis
    • Suggested size for vascular access a: Cook Critical Care b: Medcomp c: Arrow International Reading d: Kendall Heath Care Products Dual lumen 12F c,d >30kg Dual lumen 10.0F c,d >30 kg Dual lumen 9.0F b >15 kg Dual lumen 8.0F c,d 6~30 kg Dual lumen 7.0F a,b Triple lumen 7.0F b,c 3~6 kg Single lumen 5F a Dual lumen 7.0F a,b Neonate Catheter size Patient weight
    • ARF
      • Outcome
        • Varied extremely owing to multi-factorial nature of ARF
          • Metabolic disorders: 60~70% survival
          • Multi-organ dysfunction syndrome: 10~15%
          • BW < 3kg: lower survival rate than BW > 3kg
        • Chronic renal insufficiency
          • Decreased nephron number
          • Hyperfiltration of the rest nephrons