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  • Talking about solute management in CRRT can get confusing, but it really quite simple We have solutes in the blood that we want to remove and some that we don’t want to remove. Since all solutes do not have the same characteristics, they cannot all be removed the same way. Diffusion and convection are efficient at removing small molecules Convective clearance is better for larger molecules. Ultrafiltration facilitates the convective process and some substances are adsorbed by the membrane. Resulting in more or less what we want “solute management” Let’s take a look at each principle.
  • To illustrate the principle of diffusion, picture a cup of water as seen here on the slide. In the cup on the left, a quantity of salt is poured. The salt gradually diffuses through the water from the high salt concentration area to the low salt concentration area until it is evenly distributed. A uniformly salty solution is created as seen in the cup on the right.
  • To illustrate convection, we go back to the use of the cups. The cup now has a concentrated solution on one side of the semipermeable membrane. As fluid moves (by ultrafiltration), solutes small enough to pass through the pores of the membrane move along with the fluid. Change in blood concentration of a specific solute is dependent on the fluid volume removed.
  • This slide illustrates the process of ultrafiltration. We now have two cups of fluid. Each cup contains two compartments separated by a semipermeable membrane. The cup on the left illustrates how the exertion of a positive pressure on the left compartment will PUSH fluid from that compartment to the one on the right. Similarly, looking at the cup on the right side of the slide, a negative pressure applied to the right compartment will PULL fluid from the compartment on the left into that on the right. How does this work in continuous therapies?
  • This schematic represents a hemofilter (hemodialyzer). Note that there is a semipermeable membrane separating the blood and fluid compartments. Blood exerts a positive pressure on the membrane as it passes from the patient, through the filter, and returns back to the patient. On the fluid side of the filter, a low pressure exists. It is the combination of these positive and negative pressures that together make up the transmembrane pressure (TMP). By adjusting the TMP we can regulate the amount of ultrafiltrate removed. The higher the pressure gradient, the more fluid removed.
  • As you can see with our cups, a semipermeable membrane separates a concentrated solution from a solution with no solute. In this diagram, very little solute actually passes through the membrane, instead, it adheres to the membrane. Movement of fluid is required for adsorption to occur. Not all membranes possess this adsorptive quality and it is necessary to identify specific properties of the membrane and target molecules in order to predict whether adsorption will play a role in the clearance of a specific substance.
  • Note that this schematic indicates the addition of a REPLACEMENT FLUID. The replacement fluid-usually composed of approximate normal plasma values- enters the blood flow path as it circulates through the hemofilter. This not only has a dilutional effect on the blood but enables us to remove large volumes of water into the waste without dehydrating the patient or causing other hemodynamic shifts. Using the principles we discussed, pressures in the system can be adjusted to regulate ultrafiltrate volume. How much clearance of small/midsize molecules will be influenced both by the composition of the replacement fluid, and the amount of fluid we “replace” or force to cross the membrane into the waste collection. Note that replacement fluids may be administered pre or post filter. We will discuss these choices in a few moments.
  • In the schematic we can see how solutes travel from the high concentration of the blood side into the low concentration of the dialysate side. Dialysate prescription is adjusted to preserve necessary components and remove unwanted metabolites. Note that dialysate flow is established counter-current to the blood flow. This serves to increase effectiveness and maximize clearance.
  • Describe flow paths on slide. Note: Point out again that … Replacement fluids may be administered either pre or post filter. We will discuss these options later in the program.
  • CRRT

    1. 1. Continuos RenalReplacement Terapi Tandang Susanto
    2. 2. • Gangguan fungsi renal komplikasi pd pasien kritis. Insiden AKI di ICU 3% - 16% (Groenovold,maulan:1991)• AKI di ICU ± 75% disebabkan pembedahan dan sepsis. Operasi jantung terbuka dan menggunakan CPB → AKI adalah komplikasi mayor.(Conlan,Stafford;1999)• Di RS Jantung Harapan Kita Th 2007, (85 pasien ) 55 / 28/ 2 .... : AKI → CRRT . Th 2008, ( 107 pasien ) 72 / 32/ 3 ...AKI → CRRT• Peran perawat ICU dlm merawat pasien dengan alat bantu CRRT sangat penting (mendampingi pasien 24 jam penuh) perawat perlu pengetahuan luas tentang CRRT
    3. 3. Mesin yang ada di RSJHK GAMBRO MEDIKA 1993 1995
    4. 4. Mesin yang ada di RSJHKAQUARIUS PRISMA DIAPAC 2001 2002 2004
    5. 5. 1.Pengertian CRRT2.Tujuan3.Indikasi,4.Komplikasi5.Prinsip dasar6.Jenis CRRT7. Program Pemberian terapi 8.Indikasi penghentian
    6. 6. Kelompok I - IV• Kelompok I • Kelompok IIPengertian CRRT IndikasiTujuan CRRT Komplikasi• Kelompok III • Kelompok IVPrinsip Dasar Program pemberian TerapiJenis CRRT Indikasi penghentian CRRT
    7. 7. CONTINOUSRENAL Merupakan terapiREPLACEMENT scr terus menerusTHERAPY THERAPI 24 jam untuk PENGGANTI mengeluarkan cairan GINJAL dan solute, KONTINYU mengunakan extra corporal, yang mana darah disaring melalui filter Dilakukan pd pasien hemodynamik tak stabil & stabil.
    8. 8. 1. Mengeluarkan zat-zat yang tidak terpakai.2. Mengatur keseimbangan asam basa3. Memperbaiki kadar elektrolit4. Mengatur stabilitas hemodinamik5. Mengatur keseimbangan cairan6. Membantu dalam pemberian nutrisi7. Mengeluarkan mediator-mediator sepsis. ( Bellomo, 1996 )
    9. 9. 1. Oliguri ( urine out put < 200 ml/12 jam )2. Anuria ( urine out put 50 ml/12 jam3. Urea > 35 mmol/L4. Creatinin > 400 u mol /L5. K > 6.5 mmol/L atau meningkat dg cepat.6. Pulmonary oedem yg tidak respon dg obat.7. Asidosis metabolik ( Ph < 7.1 )8. Na < 110 dan > 160 mmol/L9. Temperatur > 40˚ C.10. Uremic complication (enchelopathy/myopathy/neuropathy).11. Overdosis zat-zat yang mengandung toksin. 1 kriteria dipertimbangkan untuk CRRT 2 kriteria sangat direkomendasikan untuk CRRT ( Bellomo, 2003 )
    10. 10. Indikasi lain1. Hemodinamik yang tidak stabil2. Kelebihan cairan yang tidak respon dg pengobatan diuretik.3. Keadaan hiperkatabolik / trauma / rhandomyolisis.4. Membutuhkan cairan ( Nutrisi, komponen-komponen darah). ( Schetz, 1998 )
    11. 11. 1. Perdarahan2. Infeksi3. Ketidakseimbangan cairan dan elektrolit4. Ketidakseimbangan asam basa5. Hipotermia6. Air emboli7. Filter clotting8. Arrythmia9. Fluid balance error10. Akses problem11. Disconection
    12. 12. DiffusionConvectionUltrafiltrationAdsorption CRRT mengeluarkan molekul yang kecil sampai besar dan juga mengeluarkan mediator sepsis sampai dengan berat molekulnya 50.000 Dalton
    13. 13. Mediator SIRS / Septicemia Mediator Molecul Weight ( Dalton ) Thromboxane A2 352 PAF 524 Leukotriens 600Complement 3a 10.000Complement 5a 11.200Interleukin 1,2 15.000 TNF 17.000 Interleukin 6 25.000 Endotoxin 100.000 Hladik, 2000.
    14. 14. Diffusi: Pergerakan pasif zat / partikelmelaluiMembran semi permeabel dari areakonsentrasi tinggi ke area konsentrasirendah .
    15. 15. Cont…Diffusi
    16. 16. Konveksi: Pergerakan solven & zat terlarut melalui membran dngadanya perbedaan tekanan “solvent drag”. Transport konveksi terjadi karena kekuatan bergesek antara solute & air, efektifmengeluarkan molekul yang besar.
    17. 17. Cont… Konveksi
    18. 18. positive pressure negative pressureUltrafiltrasi: Pergerakan cairan melalui membran karena pressuregradient.
    19. 19. Cont… ultrafiltrasi
    20. 20. Ultrafiltrasi Blood In (from patient) Fluid Volume Reduction Blood Outto waste (to patient) LOW PRESS HIGH PRESS
    21. 21. Adsorpsi: Pergerakan molekul atau solute melewati membran dan menempeldalam filter.
    22. 22. Cont… Adsorpsi
    23. 23. Hemofiltrationto waste Blood In (from patient) Repl. Solution Blood Out (to patient)LOW PRESS HIGH PRESS
    24. 24. Hemodialysisto waste Dialysate Out Blood In (from patient) Dialysate In Blood Out (to patient) LOW CONC HIGH CONC
    25. 25. Hemodiafiltration to waste Blood In (from patient)DialysateSolution Repl. Solution Blood Out (to patient) LOW PRESS HIGH PRESS LOW CONC HIGH CONC
    27. 27. SCUF• Slow Continuous Ultra Filtration: Proses pengeluaran cairan secara kontinyu melalui membran semi permiable dengan filtrasi lambat, tanpa cairan pengganti.• Indikasi Kelebihan cairan
    28. 28. • Slow ContinuousUltra-Filtration• Arterio-venous or veno-venous• Slow filtration• Filtrate flow < 5 ml/min (< 3 l/d)• No replacement fluid & dyalisat• Treatment time less than one day Measuring device Filtrate
    29. 29. CVVH : Continuous Veno-Venous Hemofiltration Prinsip : Konveksi,ultrafiltrasi dan adsorpsi Access Return H V F ReplacementCairan keluar melalui cairan Ultra Filtrate.Pemberian cairan Pengganti dapat diberikan predan post filter EffluentMax. Fluid Removal Rate 1000 ml/hr Mengeluarkan molekul kecil dan besar.
    30. 30. CVVHD : Continuous Veno- Venous Hemodialysis• prinsip : Diffusi, ultrafiltrasi dan adsorpsi Access Dialysate Return H F 1 2Pergerakan cairan dengan Diffusi danpengeluaran cairan pasien di bantu Dialysat yg Sdipompakan /mengalir berlawanan dengan alirandarah Max Fluid Removal Rate 1000 ml/jam. Mengeluarkan molekul kecil -sedang Effluent Indikasi : AKI, Lactit acidosis
    31. 31. CVVHDF:Continuous Veno-Venous Hemodiafiltration• Prinsip : Konveksi + Diffusi ultrafiltrasi dan adsorpsi Access Dialysate Return H F 1 2 Replacement S Pergerakan cairan dng Diffusi dan konveksi bersamaan. Pengeluaran Effluent cairan pasien dan pemberian cairan pengganti juga dapat dilakukan. Max Fluid Removal Rate 1000 ml/jam
    32. 32. CVVHDF mengeluarkan molekul kecil - sedangIndikasi CVVHDF : •Fluid over load •CHF •AKI •Sepsis •Crush syndrom
    33. 33. TPE (Therapeutic Plasma Exchange)• Pertukaran plasma melalui membrane filtrasi. Plasma yang mengandung mediators dikeluarkan dari darah pasien melewati membran filter. Cairan pengganti diberikan untuk mengganti cairan plasma yang keluar.
    34. 34. Replac e-ment fluidTherapeutic Plasma Exchange Plasma Separator Measuring device Filtrate
    35. 35. 7. Program pemberian terapi 1. Blood flow ( aliran darah ) : 0 – 200 ml/mt 2. Fluid loss ( pengeluaran cairan ) : 0 – 200 cc/jam 3. Fluid Replacement ( cairan pengganti ) : • Ringer laktat dengan bicnat 10 meq/liter • Hemosol Cairan Dyalisat : Ringer laktat Hemosol Perisol 4. Antikoagulan Bolus 1000 unit,dilanjutkan dengan drip 5 – 15 unit/kg,dan selanjutnya tergantung nilai ACT ( 150 – 180 )
    36. 36. Physician Order Blood flow : 120 mls/minPatient fluid removal: 50 mls/hr Replacement solution: 0 mls/hr Dialysate solution: 0 mls/hr SCUF
    37. 37. Physician Order Blood flow : 120 mls/min Patient fluid removal: 100 mls/hrReplacement solution: 2000 mls/hr Dialysate solution: 0 mls/hr CVVH
    38. 38. Physician Order Blood flow : 120 mls/minPatient fluid removal: 200 mls/hr Replacement solution: 0 mls/hr Dialysate solution: 2000 mls/hr CVVHD
    39. 39. Physician Order Blood flow : 120 mls/min Patient fluid removal: 200 mls/hrReplacement solution: 2000 mls/hr Dialysate solution: 1000 mls/hr CVVHDF
    40. 40. Selain mengeset program terapi,secara rutin juga kita memberikan dan memeriksa :• CaCl : 6 x 1 gram•MgSo4 : 2 gram/hari• Memeriksa ACT setiap 6 – 8 jam•Memeriksa kadar elektrolit minimal setiap8 jam• Memeriksa analisa gas darah 1 – 2x/ harisesuai dg kondisi pasien.
    41. 41. 8. Indikasi penghentian CRRT
    42. 42.  Gangguan keseimbangan cairan & elektrolit Kurang cairan karena perdarahaan Perubahan nutrisi kurang dari kebutuhan tubuh Cedera karena akses vaskuler, komplikasi pe nusukan & pemeliharaan akses Vaskuler Gangguan mobilisasi fisik Kurang pengetahuan tentang kondisi, prognosis & pengobatan Resiko terjadi emboli udara  Risiko terjadi infeksi  Resiko terjadi Hipotermia
    43. 43. ASUHAN KEPERAWATAN PASIEN YANG TERPASANG CRRT• Proses keperawatan yang dilakukan pada pasien dengan CRRT sama dengan proses keperawatan lain; mulai dari penyusunan Diagnosa keperawatan, menetapkan tujuan, merencanakan tindakan keperawatan dan evaluasi.
    44. 44. 1. Pengkajian• Status Respirasi• Status Kardiovaskuler• Status Neurologi• Status Renal• Status Gastrointestinal• Status Imunologi• Keseimbangan cairan dan elektrolit
    45. 45. 2.Diagnosa Keperawatan• Kelebihan /kekurangan volume cairan yang berhubungan dengan perubahan mekanisme pengaturan ( gagal ginjal ) retensi cairan dan sodium• Kekurangan / kelebihan volume cairan dan elektrolit berhubungan dengan efek ultrafiltrasi selama dialisis.
    46. 46. Kekurangan volume cairan dan elektrolit b/d efek ultrafiltrasi selama dialisis.• Tujuan : Mencegah kekurangan volume cairan• Kriteria : Pasien tetap stabil selama haemofiltrasi dan setelah dialisis
    47. 47. Intervensi Keperawatan:• Kaji tanda vital• Auskultasi bunyi pernafasan, bunyi jantung• Pantau respon terhadap ultrafiltrasi (TD tiap ½ jam atau lebih sering, frekuensi nadi, dan CVP• Atur derajat kecepatan ultrafiltrasi sesuai dengan respon pasien Ukur intake out put
    48. 48. Lanjutan• Berikan cairan pengganti sesuai indikasi ( kolaborasi)• Kolaborasi dengan dokter untuk pemberian vasoaktif bila ada indikasi• Periksa kadar ion K, Na, Ca, Mg, dan CO2 pra dan selama dialisa.• Observasi pasien terhadap tanda tanda hipokalemia ( perubahan EKG dan kelemahan otot) Dokumentasikan tindakan yang dilakukan
    49. 49.   • Evaluasi dilakukan pada masing-masing masalah keperawatan baik proses maupun hasil
    50. 50.  Penjelasan Pasien dan Keluarga Tanggal dan waktu Terapi  Balance Cairan Tiap Jam Dimulai  Respon Pasien Terhadap Kondisi Patency Kateter, Terapi, dan Kemajuan Pasien Kualitas Blood Flow, Masalah  Hasil Yang Tidak Diharapkan saat Kanulasi  Intervensi Keperawatan Tanggal dan Waktu Dressing  BB Tiap Hari Kondisi Luka Tusukan, Apa  Hasil Laboratorium (ACT, Ada Tanda2 & Gejala Infeksi Elektrolit, Ureum, Creatinin, AGDA, Hb, leukosit )
    51. 51. • Dasar pengetahuan CRRT seharusnya dimengerti oleh staf perawat• Pemilihan program tergantung klinis pasien, kemampuan dokter, staf perawat, juga fasilitas Rumah sakit askep dilakukan dengan benar• Perawatan pasien dengan CRRT memerlukan integritas tinggi dari perawat  mampu mendokumentasikan tindakan yang dilakukan
    52. 52. • Dasar pengetahuan CRRT seharusnya dimengerti oleh staf perawat• Pemilihan program tergantung klinis pasien, kemampuan dokter, staf perawat, juga fasilitas Rumah sakit