ARF.ppt

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ARF.ppt

  1. 1. ARF Curr Opin Crti Care 10:499-504 2004 Crti Care Clin 19: 563-575 2003 Ri B88401075
  2. 2. ARF <ul><li>Definition </li></ul><ul><ul><li>Abrupt decline in GFR </li></ul></ul><ul><ul><li>Inability of kidneys to regulate fluid, electrolytes and acid-base homeostasis </li></ul></ul><ul><ul><li>In pediatrics: </li></ul></ul><ul><ul><ul><li>Serum creatinine increase more than 50% </li></ul></ul></ul><ul><ul><ul><li>Increase of nitrogenous waste products </li></ul></ul></ul><ul><ul><ul><li>Decreased urine output (< 0.5~1.0 ml/kg/hr) </li></ul></ul></ul>
  3. 3. ARF <ul><li>Etiology </li></ul><ul><ul><li>Prerenal </li></ul></ul><ul><ul><li>Renal </li></ul></ul><ul><ul><li>Postrenal </li></ul></ul><ul><li>Common cause </li></ul><ul><ul><li>Sepsis </li></ul></ul><ul><ul><li>Multiorgan failure </li></ul></ul><ul><ul><li>Hemolytic uremic syndrome </li></ul></ul><ul><ul><li>Dehydration </li></ul></ul><ul><ul><li>Toxin </li></ul></ul><ul><ul><li>Congenital renal disease </li></ul></ul>
  4. 4. ARF <ul><li>Principle of management </li></ul><ul><ul><li>Maintain fluid and electrolytes homeostasis </li></ul></ul><ul><ul><li>Avoid life-threatening complication </li></ul></ul><ul><ul><li>Provide adequate nutrition </li></ul></ul>
  5. 5. ARF <ul><li>Methods </li></ul><ul><ul><li>Non-dialysis </li></ul></ul><ul><ul><ul><li>Dopamine </li></ul></ul></ul><ul><ul><ul><li>Diuretics </li></ul></ul></ul><ul><ul><ul><li>Others </li></ul></ul></ul><ul><ul><li>Dialysis </li></ul></ul><ul><ul><ul><li>Peritoneal dialysis </li></ul></ul></ul><ul><ul><ul><li>Hemodialysis </li></ul></ul></ul><ul><ul><ul><li>Hemofiltration </li></ul></ul></ul>
  6. 6. ARF <ul><li>Non-dialysis </li></ul><ul><ul><li>Renal dose Dopamine(1~3 mcg/kg/min) </li></ul></ul><ul><ul><ul><li>No benefit </li></ul></ul></ul><ul><ul><ul><li>Should not be used for this indication </li></ul></ul></ul><ul><ul><ul><ul><li>From Surviving Sepsis Campaign Management Guidelines Committee </li></ul></ul></ul></ul><ul><ul><li>Diuretics </li></ul></ul><ul><ul><ul><li>Improved U/O, but not reflect increased GFR </li></ul></ul></ul><ul><ul><ul><li>May avoid intratubular obstruction </li></ul></ul></ul><ul><ul><ul><li>May lower oxygen consumption </li></ul></ul></ul><ul><ul><ul><li>Ototoxicity or hyperosmolarity </li></ul></ul></ul>
  7. 7. ARF <ul><li>Peritoneal dialysis </li></ul><ul><li>Intermittent hemodialysis </li></ul><ul><li>Continous renal replacement therapy </li></ul><ul><ul><li>Hemodialysis </li></ul></ul><ul><ul><li>Hemofiltration </li></ul></ul>
  8. 8. Dialysis <ul><li>Peritoneal dialysis </li></ul><ul><ul><li>Advantage </li></ul></ul><ul><ul><ul><li>Ease of application </li></ul></ul></ul><ul><ul><ul><li>Minimal equipment </li></ul></ul></ul><ul><ul><ul><li>Low cost </li></ul></ul></ul><ul><ul><ul><li>Long history of experience </li></ul></ul></ul><ul><ul><li>Not enough clearance in: </li></ul></ul><ul><ul><ul><li>Tumor lysis syndrome </li></ul></ul></ul><ul><ul><ul><li>Inborn errors of metabolism </li></ul></ul></ul>
  9. 9. Dialysis <ul><li>Intermittent hemodialysis </li></ul><ul><ul><li>Use in: </li></ul></ul><ul><ul><ul><li>Less critical (more stable) patient </li></ul></ul></ul><ul><ul><ul><li>Acute intoxication of rapidly clear toxin </li></ul></ul></ul><ul><ul><li>Disadvantage: </li></ul></ul><ul><ul><ul><li>Solute rebound </li></ul></ul></ul><ul><ul><ul><li>Continous nature of toxin production </li></ul></ul></ul>
  10. 10. Dialysis <ul><li>Post-op cardiac patients: </li></ul><ul><ul><li>better recovery if maintaining fluid status better </li></ul></ul><ul><li>Critical illness with sepsis or MORF: </li></ul><ul><ul><li>Appropriate fluid and clearance improves morbidity and mortality </li></ul></ul><ul><li>Hemofiltration > Hemodialysis in: </li></ul><ul><ul><li>Improved solute and cytokine clearance </li></ul></ul>
  11. 11. Dialysis <ul><li>Solution selection </li></ul><ul><ul><li>Lactate based </li></ul></ul><ul><ul><ul><li>Previously used </li></ul></ul></ul><ul><ul><ul><li>Caused higher serum lactate level </li></ul></ul></ul><ul><ul><li>Bicarbonate based </li></ul></ul><ul><ul><ul><li>Newly proved by FDA </li></ul></ul></ul><ul><ul><ul><li>No Calcium </li></ul></ul></ul><ul><ul><ul><li>Allow citrate to be used as anti-coagulants </li></ul></ul></ul>
  12. 12. Dialysis <ul><li>Anticoagulants </li></ul><ul><ul><li>To avoid blood clot in circuit </li></ul></ul><ul><ul><li>Heparin </li></ul></ul><ul><ul><ul><li>More familiar </li></ul></ul></ul><ul><ul><ul><li>Easily controlled (target INR: 2.0) </li></ul></ul></ul><ul><ul><ul><li>May induced bleeding or hemorrhage </li></ul></ul></ul><ul><ul><ul><li>Dose: </li></ul></ul></ul><ul><ul><ul><ul><li>30 IU/kg bolus </li></ul></ul></ul></ul><ul><ul><ul><ul><li>30 IU/kg/hr maintenance </li></ul></ul></ul></ul>
  13. 13. Dialysis <ul><li>Anticoagulants </li></ul><ul><ul><li>Citrate </li></ul></ul><ul><ul><ul><li>Pre-circuit infusion </li></ul></ul></ul><ul><ul><ul><li>Bind to serum calcium </li></ul></ul></ul><ul><ul><ul><li>Target calcium level: 0.25~0.4 mmole/L </li></ul></ul></ul><ul><ul><ul><li>Calcium can be supplied by infusion </li></ul></ul></ul><ul><ul><ul><li>May cause metabolic alkalosis </li></ul></ul></ul>
  14. 14. 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
  15. 15. ARF <ul><li>Outcome </li></ul><ul><ul><li>Varied extremely owing to multi-factorial nature of ARF </li></ul></ul><ul><ul><ul><li>Metabolic disorders: 60~70% survival </li></ul></ul></ul><ul><ul><ul><li>Multi-organ dysfunction syndrome: 10~15% </li></ul></ul></ul><ul><ul><ul><li>BW < 3kg: lower survival rate than BW > 3kg </li></ul></ul></ul><ul><ul><li>Chronic renal insufficiency </li></ul></ul><ul><ul><ul><li>Decreased nephron number </li></ul></ul></ul><ul><ul><ul><li>Hyperfiltration of the rest nephrons </li></ul></ul></ul>

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