1. The document discusses appropriate prescription of CRRT mode CVVHDF for a patient.
2. It recommends setting the target CRRT dose to 40 mL/hr/kg by determining replacement solution and dialysate volume, and choosing a blood flow rate that achieves a filtration fraction below 20% to minimize clotting while maximizing convective removal.
3. An example is given of setting the parameters for a 67kg male patient to achieve the target dose and volume removal goals.
This document defines massive transfusion as replacing one blood volume or more within 24 hours, which corresponds to approximately 10 units of blood for a 70 kg adult. Massive transfusion can cause numerous complications including dilution coagulopathies, hypothermia, acidosis, and tissue hypoxia. The overall mortality for patients requiring massive transfusion is around 40% but increases to over 75% for those who develop hemostatic disorders. Proper use of massive transfusion protocols which rapidly provide blood products can help minimize complications and reduce mortality rates.
- IV fluids can be either beneficial or harmful depending on how they are administered. The optimal volume and type of fluid needs to be determined based on the individual patient's condition, fluid losses, and volume status. While crystalloids are generally preferred over colloids, aggressive fluid resuscitation is important for conditions like burns, trauma, and sepsis. Close monitoring of fluid administration and outcomes is essential to avoid under- or over-hydration.
This document summarizes the surgical technique and complications of central venous catheters for hemodialysis. It discusses the basic concepts, pre-operative evaluation including imaging of central veins, catheter insertion technique, and perioperative and long-term care and complications. The best site for catheter placement is the right internal jugular vein to minimize risks of kinking and central vein stenosis. Ultrasound and fluoroscopy guidance are recommended for accurate placement and tunneling of cuffed catheters. Major perioperative risks include pneumothorax, hemothorax, and nerve injury, while long-term complications consist of infection, thrombosis, stenosis, and catheter malfunction.
Central venous access devices such as nontunneled central venous catheters and peripherally inserted central catheters can be placed under imaging guidance more safely than with external landmarks alone. Nontunneled catheters are commonly placed at the bedside using local anesthesia for temporary access when patients are too ill to transport. They provide advantages over tunneled catheters in that they do not require strict coagulation parameter adherence and can be easily removed. Proper placement of catheter tips is important to avoid complications and the superior vena cava-right atrial junction is the ideal target location.
1. Most common cardiac conduction abnormalities during CVC insertion are right bundle branch blocks and new left anterior and posterior fascicular blocks which result from overzealous advancement of the guide wire.
2. The most common site of catheter-related deep vein thrombosis is the internal jugular vein. Risk factors include history of DVT, subclavian insertion site, and improper catheter tip positioning.
3. Symptoms of venous air embolism during CVC insertion include chest pain, dyspnea, headache, EKG changes, and decreased cardiac output. Treatment involves stopping air entry, placing the patient in Trendelenburg and left lateral position, and
1. The document discusses appropriate prescription of CRRT mode CVVHDF for a patient.
2. It recommends setting the target CRRT dose to 40 mL/hr/kg by determining replacement solution and dialysate volume, and choosing a blood flow rate that achieves a filtration fraction below 20% to minimize clotting while maximizing convective removal.
3. An example is given of setting the parameters for a 67kg male patient to achieve the target dose and volume removal goals.
This document defines massive transfusion as replacing one blood volume or more within 24 hours, which corresponds to approximately 10 units of blood for a 70 kg adult. Massive transfusion can cause numerous complications including dilution coagulopathies, hypothermia, acidosis, and tissue hypoxia. The overall mortality for patients requiring massive transfusion is around 40% but increases to over 75% for those who develop hemostatic disorders. Proper use of massive transfusion protocols which rapidly provide blood products can help minimize complications and reduce mortality rates.
- IV fluids can be either beneficial or harmful depending on how they are administered. The optimal volume and type of fluid needs to be determined based on the individual patient's condition, fluid losses, and volume status. While crystalloids are generally preferred over colloids, aggressive fluid resuscitation is important for conditions like burns, trauma, and sepsis. Close monitoring of fluid administration and outcomes is essential to avoid under- or over-hydration.
This document summarizes the surgical technique and complications of central venous catheters for hemodialysis. It discusses the basic concepts, pre-operative evaluation including imaging of central veins, catheter insertion technique, and perioperative and long-term care and complications. The best site for catheter placement is the right internal jugular vein to minimize risks of kinking and central vein stenosis. Ultrasound and fluoroscopy guidance are recommended for accurate placement and tunneling of cuffed catheters. Major perioperative risks include pneumothorax, hemothorax, and nerve injury, while long-term complications consist of infection, thrombosis, stenosis, and catheter malfunction.
Central venous access devices such as nontunneled central venous catheters and peripherally inserted central catheters can be placed under imaging guidance more safely than with external landmarks alone. Nontunneled catheters are commonly placed at the bedside using local anesthesia for temporary access when patients are too ill to transport. They provide advantages over tunneled catheters in that they do not require strict coagulation parameter adherence and can be easily removed. Proper placement of catheter tips is important to avoid complications and the superior vena cava-right atrial junction is the ideal target location.
1. Most common cardiac conduction abnormalities during CVC insertion are right bundle branch blocks and new left anterior and posterior fascicular blocks which result from overzealous advancement of the guide wire.
2. The most common site of catheter-related deep vein thrombosis is the internal jugular vein. Risk factors include history of DVT, subclavian insertion site, and improper catheter tip positioning.
3. Symptoms of venous air embolism during CVC insertion include chest pain, dyspnea, headache, EKG changes, and decreased cardiac output. Treatment involves stopping air entry, placing the patient in Trendelenburg and left lateral position, and
Spinal anesthesia involves injecting local anesthetic into the subarachnoid space to temporarily numb sensation and motor function in the lower body. The anesthesiologist inserts the needle below L2 to access the spinal fluid and avoid the spinal cord. Spinal anesthesia provides excellent surgical conditions for various abdominal, pelvic, and lower extremity procedures. It has been used since the late 1800s and involves carefully positioning the patient and needle to safely access the spinal fluid and distribute the anesthetic in the spinal canal.
This document discusses perioperative fluid therapy. It begins by defining fluid compartments and compositions. It then discusses fluid balance and exchange between compartments via diffusion, osmosis, and hydrostatic/oncotic pressures. Specific conditions like hyponatremia and hypernatremia are examined along with calculating fluid deficits and replacements. Intravenous fluid types and their properties are outlined as well as estimating fluid requirements. Surgical fluid losses and allowable blood loss calculations are provided. Patient positioning and essential anesthesia monitors are also mentioned.
This document provides information on spinal anesthesia techniques. It discusses the history, indications, contraindications, and proper procedures for spinal anesthesia. Key points include that spinal anesthesia involves injecting local anesthetic into the subarachnoid space to block nerve signals from the injection site down. The document outlines best practices for patient positioning, identifying anatomical landmarks, needle selection, introduction techniques, and managing complications that may arise. Proper administration of spinal blocks is outlined to achieve sufficient anesthesia height and duration.
This document discusses anticoagulation for continuous renal replacement therapy (CRRT). It begins by outlining factors that can lead to clotting of CRRT filters and circuits. The main anticoagulation modalities discussed are heparin, low molecular weight heparin, citrate, and no anticoagulation. For each option, the mechanisms of action, advantages, disadvantages, dosing protocols, and typical filter life spans are summarized. Regional citrate anticoagulation is highlighted as it avoids systemic anticoagulation effects while effectively preventing clotting. Details are provided on citrate metabolism and calcium replacement to maintain safe ionized calcium levels.
The document outlines the objectives and key concepts of a training course on continuous renal replacement therapy (CRRT). It defines CRRT and discusses the basic principles of CRRT, including solute transport mechanisms, clinical indications, machine setup and safety features, and fluid balance principles. It also summarizes evidenced-based research showing improved patient survival with early CRRT initiation and adequate dose delivery.
A woman with a history of anorexia nervosa and a BMI of 12 kg/m2 was admitted for investigation of weight loss. She deteriorated after initiation of enteral feeding and dextrose infusion, presenting with respiratory failure, hypotension, arrhythmia, and metabolic abnormalities. Given her history of malnutrition and rapid change in nutritional status with feeding, she had likely developed refeeding syndrome, a condition caused by shifts in electrolytes and metabolism during the reintroduction of nutrition to a malnourished patient. Proper identification of high-risk patients and gradual, monitored refeeding is key to preventing refeeding syndrome.
A 19-year-old female presented with a rapidly enlarging neck mass. Imaging revealed multiple enlarged cervical and mediastinal lymph nodes compressing the superior vena cava. Due to the risk of airway compromise, the anesthetic plan included difficult airway equipment and careful induction to avoid further compression. The mass was biopsied under general anesthesia without complications. Mediastinal masses can compress vital structures, so thorough preoperative evaluation is needed to identify high-risk patients and plan a safe anesthetic approach.
Regional intravenous anesthesia involves injecting local anesthetic into the venous system of an extremity isolated using a tourniquet. It was introduced in 1908 and became popular in the 1960s. The local anesthetic diffuses into surrounding veins, nerves, and skin to produce anesthesia in a centrifugal pattern. Indications include short surgeries of the upper or lower extremities. Complications can include systemic toxicity from rapid release of local anesthetic or tourniquet-related issues like compartment syndrome. Proper technique such as slow drug injection and tourniquet deflation aims to prevent complications.
This document summarizes a case presentation of a 74-year-old Thai female patient undergoing peritoneal dialysis who presented with increasing fatigue. Her peritoneal dialysis prescription was adjusted and tests revealed a left pleural effusion. Further imaging with nuclear scintigraphy confirmed omental wrapping around the peritoneal catheter. The patient was temporarily switched to hemodialysis and underwent catheter revision surgery. The importance of proper peritoneal catheter placement and design is discussed to reduce complications.
This document provides an overview of the anatomy of the epidural space. It discusses the boundaries, contents, size, and structures that must be penetrated to access the epidural space. Key points include that the epidural space lies between the spinal meninges and vertebral canal, contains connective tissue, fat, blood vessels and spinal nerves. It varies in size from 1-6mm depending on the spinal region. To access it requires penetrating the skin, ligaments and ligamentum flavum in the midline.
Atracurium is a non-depolarizing neuromuscular blocking agent used for intubation and muscle relaxation during surgery. It has a quaternary ammonium structure and acts by competitively binding to nicotinic receptors at the motor end plate. Atracurium has a moderately rapid onset and duration of action. It is metabolized rapidly by Hofmann elimination and ester hydrolysis in the liver and excreted in urine. Common side effects include hypotension, tachycardia, and potential allergic reactions.
Hemodialysis in children has some differences from adults. Dialysis should start when the estimated GFR is below 15 mL/min/1.73m2 with symptoms of uremia, fluid overload, or malnutrition despite medical management, or below 6 mL/min/1.73m2 without symptoms. Clinical factors like growth, development, and nutrition are also important considerations. Hemodialysis facilities for children should be located within 30 minutes of patients' homes and have age-appropriate decorations to create a comfortable environment. Vascular access may include temporary catheters or arteriovenous fistulas created 6-12 months before dialysis. Hemodialysis prescriptions consider factors like dry weight estimation, dial
This document discusses various protocols for anticoagulation during hemodialysis. It begins by noting that patients on hemodialysis are at risk of both bleeding and thrombosis. It then outlines several protocols for anticoagulation including unfractionated heparin (UFH) administered via constant infusion or intermittent bolus, and low molecular weight heparin (LMWH). LMWH has benefits over UFH like longer half-life and more predictable effects, but is also more expensive. The document also discusses heparin-free dialysis, regional citrate anticoagulation, and other alternatives to standard heparin protocols. Selection of the optimal anticoagulation method requires consideration of individual patient
Cerebral physiology and effects of anaesthetic agentsRicha Kumar
The document discusses cerebral physiology and the effects of anesthetic agents. It covers topics such as:
- Anatomy of the cerebral circulation including the circle of Willis.
- Regulation of cerebral blood flow including chemical, myogenic, and neurogenic factors.
- Effects of increased intracranial pressure on cerebral perfusion.
- How different anesthetic agents like barbiturates, propofol, etomidate, narcotics, benzodiazepines, ketamine, and volatile anesthetics affect cerebral blood flow and cerebral metabolic rate.
This document discusses fluid management in surgery. It begins by introducing the importance of fluid and electrolyte balance for maintaining homeostasis. Different types of fluids are indicated for various purposes like rapid resuscitation, total parenteral nutrition, and fluid maintenance. Common fluids discussed include normal saline, Ringer's lactate, plasmalyte, dextrose solutions, and dextrose saline. The document explains the composition, indications, advantages/limitations of each fluid. It also covers fluid distribution in the body, osmolality, tonicity, and the role of colloids in fluid balance.
Therapeutic hypothermia, or targeted temperature management, has been shown to improve outcomes for patients who remain unconscious after resuscitation from cardiac arrest. Two key studies from 2002 demonstrated improved mortality and neurological function when patients' temperatures were cooled to 32-34°C for 12-24 hours after cardiac arrest. Subsequent meta-analyses and clinical guidelines have supported induced hypothermia for unconscious cardiac arrest survivors. However, the optimal target temperature range was still unclear. A 2013 randomized controlled trial compared outcomes between unconscious cardiac arrest survivors treated with targeted temperature management at 33°C versus 36°C and found no significant difference in mortality or neurological function between the two temperature targets.
This document provides an overview of regional anesthesia techniques including spinal anesthesia, epidural anesthesia, and Bier block. Spinal anesthesia involves injecting local anesthetic into the subarachnoid space, while epidural anesthesia involves injection into the epidural space. Bier block, also called intravenous regional anesthesia, involves exsanguinating a limb and injecting local anesthetic near the tourniquet. The document describes anatomy, procedures, indications, advantages, complications, and pharmacology for each technique.
د/عاصم محرم
Blood product transfusion & Principles of Fluid Therapy
المحاضرة التي قدمت يوم الثلاثاء 8 ابريل 2014 في دار الحكمة بالقاهرة
من فعاليات مشروع اعداد طبيب حكيم ناجح بالتعاون مع معتمد باتحاد الاطباء العرب
و ضمن موديول الطوارئ و التخدير و العناية المركزة
This document discusses mechanical ventilation and the weaning process. It outlines the 7 stages of weaning and indicators for readiness to wean, including parameters like respiratory rate, tidal volume, rapid shallow breathing index, and maximum inspiratory pressure. It describes methods for spontaneous breathing trials and criteria for weaning failure. Difficult weaning can be caused by respiratory, cardiac, psychological, ventilator or nutritional factors. Daily assessment is important to evaluate readiness and avoid complications from prolonged mechanical ventilation.
PC mode uses pressure control ventilation where the ventilator controls the inspiratory pressure and the patient controls the respiratory rate and inspiratory time. The tidal volume depends on the inspiratory pressure set, lung compliance, and airway resistance. Key settings include inspiratory pressure, respiratory rate, inspiratory time, and PEEP. Plateau pressure and driving pressure should be monitored to avoid overinflation and volutrauma. PEEP is used to prevent alveolar collapse and improve oxygenation but can impact hemodynamics at higher levels by decreasing venous return and cardiac output.
Spinal anesthesia involves injecting local anesthetic into the subarachnoid space to temporarily numb sensation and motor function in the lower body. The anesthesiologist inserts the needle below L2 to access the spinal fluid and avoid the spinal cord. Spinal anesthesia provides excellent surgical conditions for various abdominal, pelvic, and lower extremity procedures. It has been used since the late 1800s and involves carefully positioning the patient and needle to safely access the spinal fluid and distribute the anesthetic in the spinal canal.
This document discusses perioperative fluid therapy. It begins by defining fluid compartments and compositions. It then discusses fluid balance and exchange between compartments via diffusion, osmosis, and hydrostatic/oncotic pressures. Specific conditions like hyponatremia and hypernatremia are examined along with calculating fluid deficits and replacements. Intravenous fluid types and their properties are outlined as well as estimating fluid requirements. Surgical fluid losses and allowable blood loss calculations are provided. Patient positioning and essential anesthesia monitors are also mentioned.
This document provides information on spinal anesthesia techniques. It discusses the history, indications, contraindications, and proper procedures for spinal anesthesia. Key points include that spinal anesthesia involves injecting local anesthetic into the subarachnoid space to block nerve signals from the injection site down. The document outlines best practices for patient positioning, identifying anatomical landmarks, needle selection, introduction techniques, and managing complications that may arise. Proper administration of spinal blocks is outlined to achieve sufficient anesthesia height and duration.
This document discusses anticoagulation for continuous renal replacement therapy (CRRT). It begins by outlining factors that can lead to clotting of CRRT filters and circuits. The main anticoagulation modalities discussed are heparin, low molecular weight heparin, citrate, and no anticoagulation. For each option, the mechanisms of action, advantages, disadvantages, dosing protocols, and typical filter life spans are summarized. Regional citrate anticoagulation is highlighted as it avoids systemic anticoagulation effects while effectively preventing clotting. Details are provided on citrate metabolism and calcium replacement to maintain safe ionized calcium levels.
The document outlines the objectives and key concepts of a training course on continuous renal replacement therapy (CRRT). It defines CRRT and discusses the basic principles of CRRT, including solute transport mechanisms, clinical indications, machine setup and safety features, and fluid balance principles. It also summarizes evidenced-based research showing improved patient survival with early CRRT initiation and adequate dose delivery.
A woman with a history of anorexia nervosa and a BMI of 12 kg/m2 was admitted for investigation of weight loss. She deteriorated after initiation of enteral feeding and dextrose infusion, presenting with respiratory failure, hypotension, arrhythmia, and metabolic abnormalities. Given her history of malnutrition and rapid change in nutritional status with feeding, she had likely developed refeeding syndrome, a condition caused by shifts in electrolytes and metabolism during the reintroduction of nutrition to a malnourished patient. Proper identification of high-risk patients and gradual, monitored refeeding is key to preventing refeeding syndrome.
A 19-year-old female presented with a rapidly enlarging neck mass. Imaging revealed multiple enlarged cervical and mediastinal lymph nodes compressing the superior vena cava. Due to the risk of airway compromise, the anesthetic plan included difficult airway equipment and careful induction to avoid further compression. The mass was biopsied under general anesthesia without complications. Mediastinal masses can compress vital structures, so thorough preoperative evaluation is needed to identify high-risk patients and plan a safe anesthetic approach.
Regional intravenous anesthesia involves injecting local anesthetic into the venous system of an extremity isolated using a tourniquet. It was introduced in 1908 and became popular in the 1960s. The local anesthetic diffuses into surrounding veins, nerves, and skin to produce anesthesia in a centrifugal pattern. Indications include short surgeries of the upper or lower extremities. Complications can include systemic toxicity from rapid release of local anesthetic or tourniquet-related issues like compartment syndrome. Proper technique such as slow drug injection and tourniquet deflation aims to prevent complications.
This document summarizes a case presentation of a 74-year-old Thai female patient undergoing peritoneal dialysis who presented with increasing fatigue. Her peritoneal dialysis prescription was adjusted and tests revealed a left pleural effusion. Further imaging with nuclear scintigraphy confirmed omental wrapping around the peritoneal catheter. The patient was temporarily switched to hemodialysis and underwent catheter revision surgery. The importance of proper peritoneal catheter placement and design is discussed to reduce complications.
This document provides an overview of the anatomy of the epidural space. It discusses the boundaries, contents, size, and structures that must be penetrated to access the epidural space. Key points include that the epidural space lies between the spinal meninges and vertebral canal, contains connective tissue, fat, blood vessels and spinal nerves. It varies in size from 1-6mm depending on the spinal region. To access it requires penetrating the skin, ligaments and ligamentum flavum in the midline.
Atracurium is a non-depolarizing neuromuscular blocking agent used for intubation and muscle relaxation during surgery. It has a quaternary ammonium structure and acts by competitively binding to nicotinic receptors at the motor end plate. Atracurium has a moderately rapid onset and duration of action. It is metabolized rapidly by Hofmann elimination and ester hydrolysis in the liver and excreted in urine. Common side effects include hypotension, tachycardia, and potential allergic reactions.
Hemodialysis in children has some differences from adults. Dialysis should start when the estimated GFR is below 15 mL/min/1.73m2 with symptoms of uremia, fluid overload, or malnutrition despite medical management, or below 6 mL/min/1.73m2 without symptoms. Clinical factors like growth, development, and nutrition are also important considerations. Hemodialysis facilities for children should be located within 30 minutes of patients' homes and have age-appropriate decorations to create a comfortable environment. Vascular access may include temporary catheters or arteriovenous fistulas created 6-12 months before dialysis. Hemodialysis prescriptions consider factors like dry weight estimation, dial
This document discusses various protocols for anticoagulation during hemodialysis. It begins by noting that patients on hemodialysis are at risk of both bleeding and thrombosis. It then outlines several protocols for anticoagulation including unfractionated heparin (UFH) administered via constant infusion or intermittent bolus, and low molecular weight heparin (LMWH). LMWH has benefits over UFH like longer half-life and more predictable effects, but is also more expensive. The document also discusses heparin-free dialysis, regional citrate anticoagulation, and other alternatives to standard heparin protocols. Selection of the optimal anticoagulation method requires consideration of individual patient
Cerebral physiology and effects of anaesthetic agentsRicha Kumar
The document discusses cerebral physiology and the effects of anesthetic agents. It covers topics such as:
- Anatomy of the cerebral circulation including the circle of Willis.
- Regulation of cerebral blood flow including chemical, myogenic, and neurogenic factors.
- Effects of increased intracranial pressure on cerebral perfusion.
- How different anesthetic agents like barbiturates, propofol, etomidate, narcotics, benzodiazepines, ketamine, and volatile anesthetics affect cerebral blood flow and cerebral metabolic rate.
This document discusses fluid management in surgery. It begins by introducing the importance of fluid and electrolyte balance for maintaining homeostasis. Different types of fluids are indicated for various purposes like rapid resuscitation, total parenteral nutrition, and fluid maintenance. Common fluids discussed include normal saline, Ringer's lactate, plasmalyte, dextrose solutions, and dextrose saline. The document explains the composition, indications, advantages/limitations of each fluid. It also covers fluid distribution in the body, osmolality, tonicity, and the role of colloids in fluid balance.
Therapeutic hypothermia, or targeted temperature management, has been shown to improve outcomes for patients who remain unconscious after resuscitation from cardiac arrest. Two key studies from 2002 demonstrated improved mortality and neurological function when patients' temperatures were cooled to 32-34°C for 12-24 hours after cardiac arrest. Subsequent meta-analyses and clinical guidelines have supported induced hypothermia for unconscious cardiac arrest survivors. However, the optimal target temperature range was still unclear. A 2013 randomized controlled trial compared outcomes between unconscious cardiac arrest survivors treated with targeted temperature management at 33°C versus 36°C and found no significant difference in mortality or neurological function between the two temperature targets.
This document provides an overview of regional anesthesia techniques including spinal anesthesia, epidural anesthesia, and Bier block. Spinal anesthesia involves injecting local anesthetic into the subarachnoid space, while epidural anesthesia involves injection into the epidural space. Bier block, also called intravenous regional anesthesia, involves exsanguinating a limb and injecting local anesthetic near the tourniquet. The document describes anatomy, procedures, indications, advantages, complications, and pharmacology for each technique.
د/عاصم محرم
Blood product transfusion & Principles of Fluid Therapy
المحاضرة التي قدمت يوم الثلاثاء 8 ابريل 2014 في دار الحكمة بالقاهرة
من فعاليات مشروع اعداد طبيب حكيم ناجح بالتعاون مع معتمد باتحاد الاطباء العرب
و ضمن موديول الطوارئ و التخدير و العناية المركزة
This document discusses mechanical ventilation and the weaning process. It outlines the 7 stages of weaning and indicators for readiness to wean, including parameters like respiratory rate, tidal volume, rapid shallow breathing index, and maximum inspiratory pressure. It describes methods for spontaneous breathing trials and criteria for weaning failure. Difficult weaning can be caused by respiratory, cardiac, psychological, ventilator or nutritional factors. Daily assessment is important to evaluate readiness and avoid complications from prolonged mechanical ventilation.
PC mode uses pressure control ventilation where the ventilator controls the inspiratory pressure and the patient controls the respiratory rate and inspiratory time. The tidal volume depends on the inspiratory pressure set, lung compliance, and airway resistance. Key settings include inspiratory pressure, respiratory rate, inspiratory time, and PEEP. Plateau pressure and driving pressure should be monitored to avoid overinflation and volutrauma. PEEP is used to prevent alveolar collapse and improve oxygenation but can impact hemodynamics at higher levels by decreasing venous return and cardiac output.
This document discusses nutrition guidelines for critically ill patients. It recommends starting enteral nutrition within 24-48 hours of admission to provide 25 kcal/kg/day and over 1.2 g/kg/day of protein. Enteral nutrition is preferred over parenteral nutrition when possible. Guidelines suggest not stopping nutrition without a definite medical cause and consulting nutrition support teams.
1. The patient is a 75-year-old male admitted to the EICU for septic shock due to pneumonia and colitis. He received TPN for nutrition support from admission until signs of bowel recovery were seen.
2. Enteral nutrition was started with 500 kcal/day of tube feeding once bowel sounds returned, but was reduced due to distension. IV fluids were given initially until TPN was started providing over 1300 kcal per day.
3. Laboratory findings and the patient's clinical status including hemodynamics, mottling, and ventilator settings are discussed to determine the adequacy and progression of nutrition support and management of septic shock. Further suggestions may be considered.
This document discusses different types of mechanical ventilation and ventilation modes. It begins by outlining four types of respiratory failure that may require mechanical ventilation. It then discusses goals of mechanical ventilation related to oxygenation and ventilation. The document goes on to explain various ventilation modes including volume control, pressure control, pressure support, and APRV. It provides details on settings for tidal volume, minute ventilation, and initial mechanical ventilation settings. Overall, the document provides an overview of mechanical ventilation types, goals, modes, and initial settings.
1. Mechanical ventilation settings like PEEP aim to reduce ventilator-induced lung injuries from atelectrauma and overdistension while improving oxygenation.
2. The optimal PEEP level can be determined through methods like the ARDSnet table, transpulmonary pressure measurements, lung compliance curves, and stress indexes. Higher PEEP recruits more alveoli but may affect hemodynamics.
3. Pressure-volume curves can help identify the lower inflection point and lower deflection point to guide PEEP setting, along with recruitment maneuvers. Slow-flow curves more accurately detect inflection points.
1. Mechanical ventilation can be associated with significant morbidity and mortality if prolonged. Weaning patients from mechanical ventilation in a timely manner is important.
2. There are seven stages of weaning which include assessing patient readiness, conducting spontaneous breathing trials, and using various ventilator modes like pressure support to gradually reduce support.
3. Spontaneous breathing trials for 30 minutes to 2 hours are generally preferred for weaning but gradual reduction over days may be better in some cases. Daily assessment of readiness and trials are recommended with prompt reintubation if trials fail.
1. Mechanical ventilation troubleshooting involves identifying the cause of a patient's sudden respiratory distress by analyzing monitor alarms, physical signs, and ventilator graphs.
2. Common causes include ventilator issues like leaks, circuit blocks, or setting errors as well as patient issues such as pneumonia or pneumothorax.
3. The document outlines steps for troubleshooting including disconnecting the patient to manually bag and assess response, then treating the most likely problem by procedures like suctioning, adjusting settings, or emergency thoracostomy.
This document provides an overview of electrolyte disorders including hypernatremia, hyponatremia, hyperkalemia, hypokalemia, and hyperglycemia. It discusses the etiology, clinical effects, and approaches to management. Specifically, it covers how these disorders disrupt osmotic balance and cell volume, outlines factors that influence electrolyte concentrations, and provides guidelines for treatment including shifting electrolytes between intra and extracellular compartments or removing excess amounts. The document compares US and European guidelines for hyponatremia and concludes by thanking the reader.
Cardiogenic shock is a serious condition where the heart cannot pump enough blood to vital organs, causing hypotension and end-organ damage. The most common cause is acute myocardial infarction with left ventricular dysfunction. In-hospital mortality from cardiogenic shock is high, around 27-51%. Treatment involves stabilization, vasopressor support, mechanical circulatory support if needed, and identifying and treating the underlying cardiac cause, such as through coronary angiography and PCI. Despite aggressive treatment, cardiogenic shock remains a medical emergency with high mortality.
1. The document discusses definitions of sepsis, severe sepsis, septic shock from 1992, 2001, and 2016. It describes the criteria for systemic inflammatory response syndrome, sepsis, and septic shock.
2. Guidelines for management of sepsis from the Surviving Sepsis Campaign are summarized, including early goal directed therapy, resuscitation bundles, and antimicrobial therapy recommendations.
3. Key aspects of the updated 2018 Surviving Sepsis Campaign guidelines are highlighted, such as initial fluid resuscitation, hemodynamic support, antimicrobial administration, and duration of therapy.
This document discusses post-cardiac arrest syndrome (PCAS), which refers to the pathology caused by complete whole body ischemia and reperfusion following cardiac arrest. PCAS involves (1) post-cardiac arrest brain injury, (2) post-cardiac arrest myocardial dysfunction, (3) systemic ischemia/reperfusion response, and (4) persistent precipitating pathology. The document outlines recommendations for targeted temperature management, hemodynamic goals, prognostication of outcome, and organ donation for patients experiencing PCAS.
This document discusses acute kidney injury (AKI). It notes that AKI is common in ICU patients and associated with increased mortality. Sepsis and postoperative/toxic causes are common. It defines AKI and discusses causes including prerenal, postrenal, and intrarenal. For intrarenal causes, it mentions glomerulonephritis, vasculitis, interstitial nephritis, acute tubular necrosis, and sepsis-induced AKI. It reviews diagnosis and novel biomarkers. Prevention and treatment sections discuss volume expansion, diuretics, vasopressors, vasodilators, sedation, hormonal manipulation, metabolic interventions, statins, and renal replacement therapy.
This document provides an overview of acid-base principles and disorders. It discusses the normal ranges for pH, PCO2, and HCO3 and defines acid-base disorders. Primary acid-base disorders are classified as respiratory or metabolic based on changes in PCO2 or HCO3. Secondary responses to primary disorders and mixed acid-base disorders are also covered. Evaluation of acid-base disorders follows a stepwise approach identifying the primary disorder and any secondary responses. Metabolic acidosis is further evaluated using anion gap, delta gap, and urine anion gap. Causes and treatments of various acid-base disorders are outlined.
2. CRRT
• Continuous renal replacement therapy
• 지속적 신기능 대체 요법
• 간헐적 혈액투석 (iHD, intermittent HD)
• 단 몇 시간 이내에 체내 수분 제거, 전해질 조절, 노폐물 제거를 시행
• 급격한 체중 변화, 전해질 농도 변화, 체내 노폐물 제거로, 환자에게 hemodynamic
burden을 주게 됨
• iHD에서 hemodynamic burden을 줄이기 위해
• 단시간이 아닌 천천히 체내 수분 조절, 전해질 농도 조절, 체내 노폐물 제
거 등 신장 기능을 생리적으로 비슷하게 제공하는 방법
3. 적응증
• iHD가 필요하나 iHD의 hemodynamic burden을 견딜 수 없는 중환자들
• + Sepsis, ARDS 등…
N Engl J Med 2012;367:2505-14
6. When to start
• Early RRT
• 중환자에서 과도한 체내 수분은 나쁜 예후와 관련 있음이 알려져 있음
• 이미 산-염기 균형과 전해질 균형이 무너져 가는 환자에서, 임계점까지 기다
릴 이유는 없다
• Early RRT의 기준이 명확하지 않아 논문마다 다른 기준을 사용 중
• 임계점까지 기다렸을 때 신기능이 돌아와서 RRT를 받지 않아도 될 환자들이
RRT 에 노출되고, 신기능 회복의 기회를 놓치며, RRT 관련 합병증이 늘어난다
• 현재까지 증거로는 명확한 RRT 시작 시점 (volume overload, intractable
hyperK, uremic Sx.) 이 보이지 않을 때 RRT의 시작은 임상의사의 판단에 맡
겨짐
Journal of Intensive Care Medicine 2019, Vol. 34(2) 94-103
CHEST 2019; 155(3):626-638
7. Mechanism of CRRT
• Ultrafiltration (초여과)
• 반투막을 통해 수분이 압력(정수압)에 의해 제거
• 수분이 너무 많이 제거되면 안되기 때문에 보충액(replacement)이 필요
• CVVH
• Convection (대류)
• 초여과와 함께 용질이 제거되는 것
• Middle molecular wt. 와 cytokine 등
• CVVH
• Diffusion (확산)
• 반투막을 통해 용질의 농도차에 의해 용질이 이동
• Low molecular wt. 등
• CVVHD
• Adsorption (흡착)
• CVVHDF = CVVH + CVVHD
• 원칙적으로 제거를 원하는 물질에 따라 mode 선택이 필요함
• 나는 잘 모르겠다 -> CVVHDF
11. CRRT dose
• Target clearance (단위 : ml/kg/hr)
• Clearance in CVVHDF = Dialysate + Replacement + Water removal
• GFR과 비슷한 의미로 생각할 수 있다
• 성인에서 Bwt. 를 대략 60kg으로 생각하면 60분과 약분되서 ml/min 으로 바뀜
• 30ml/min 의 의미 : 1분당 혈액 30ml 에서 노폐물을 제거했다
• Clearance를 높이면 수분 제거량도 높일 수 있고, 노폐물 제거속도도
증가할 수 있음
• Filtration fraction (뒤에 설명) 으로 인해 clearance가 늘어나려면
blood flow rate를 늘려야 하기 때문에 혈역학적으로 더 불안해진다
13. CRRT dose
AKI 를 동반한 critically ill patient
Survival benefit (+)
14. N Engl J Med 2008;359:7-20
USA, multicenter RCT
15. N Engl J Med 2009;361:1627-38
호주, 뉴질랜드
35 ICUs multicenter RCT
16. CRRT dose
• 현재까지의 증거로는 높은 청소율(>25ml/kg/hr)이 중환자에서 생존율에 도움이 된다는 증거는 명
확하지 않다
• 따라서 청소율 목표는 일반적으로 KDIGO에서 권고한 20~25 ml/kg/hr면 될 것으로 판단됨
• acidosis 및 electrolyte imbalance 등 metabolic demand가 심한 환자에서 상태에 따라 높은 dose
를 처방할 수 있다
• 또한 blood flow 가 줄어들면 그 만큼 filter가 막히게 될 가능성도 높아지기에, 너무 낮은 flow를 유
지하기 보다는, 환자가 tolerable 하다면 조금 더 높은 blood flow를 고려할 수 있다
17. CRRT in sepsis
• CVVH로 cytokine modulation을 통해 sepsis에서 도움이 될 것
이라는 idea로 CRRT를 sepsis에서 사용하는 경우가 있었으나,
현재까지 증거로는 sepsis 환자에서 CRRT가 신기능을 대체한다
는 의미 이상을 보여준 적은 없다
18. • IVOIRE study
• Septic shock 환자에서 HVHF(high-volume hemofiltration)이 standard dose
보다 효과가 있는지 확인해보고자 한 RCT
• 70mL/kg/h dose 에서 35mL/kg/h 보다 28-d mortality를 감소시키지 못함을
보임
Intensive Care Med (2013) 39:1535–1546
19. CRRT dose
• Filtration fraction
• 필터를 통해 제거되는 수분의 분획이 20% 이하로 유지되어야 함
• ∵ 혈액의 과농축을 예방 -> filter의 clot 과 pore 의 오염 방지
• 이를 0.2 이하로 만드는 blood flow rate를 계산하여 사용
21. Anticoagulation in CRRT
• CRRT 에서 anticoagulation 의 목적
• CRRT 필터 에 clot 이 생기는 것을 늦춰서
• 필터교체로 인한 CRRT 의 중단, 그로 인한 CRRT 의 효율성 저하를 막
고
• CRRT 구동 중에도 효율적인 CRRT 가 유지되도록 함
22. Anticoagulation
• No anticoagulation
• Coagulopathy 가 있을 때
• Bleeding complication 이 우려될 때
• Systemic anticoagulation
• Heparin (UFH, LMWH)
• UFH는 aPTT monitoring 필요
• 원하지 않는 systemic effect
• Regional anticoagulation
• Nafamostat (Futhan)
• 반감기가 짧다 (8분) -> circuit 에서 사용하면 몸에 들어가기 전 대부분 사라진다
• Citrate
• Circuit 내에서 칼슘을 chelation 하여 coagulation cascade 억제
23.
24. CRRT dose
• Filter lifespan
• Average filter life span
• 23.0 ± 13.0 hours
https://www.hindawi.com/journals/ccrp/2019/3737083/
Crit Care Resusc 2014; 16: 225–231
26. Replacement
• UF를 통한 체액 소실이 급격하게 일어나므로 보충하기 위해 replacement를 시행
• Filter 전 또는 후에 주느냐에 따라 pre/post-replacement
• Pre-replacement (전희석)
• filter 를 통과하기 전에 replacement 를 주는 것
• 필터의 clotting 을 줄인다
• 청소율(clearance)를 감소시킨다
• Filtration fraction 을 낮추는데 유리
• Post-replacement (후희석)
• filter 를 통과한 후 replacement
• 희석에 따른 청소율(clearance)의 감소는 없다
• Clot 이 생길 확률이 높아진다
• Post-dilution이 단기적으로는 효율적으로 보이나 장기적으로는 filter 막힘이 적은 pre-dilution이 효율적 -> pre-dilution을 선호하
게 됨
• FMC 에서는 Pre만 사용
• Prismaflex 에서는 Pre 와 Post 를 병행하여 사용
• 따라서 Pre와 Post의 비율을 결정해 주어야 함
28. Vascular access
• 기본적으로 central venous access (c-line) 과 동일한 곳에 HD
catheter를 넣으면 되나
• Subclavian vein은 잘 사용하지 않는다
• 높은 stricture 가능성
• 주행상 꺾이기도 쉽다
• Compression이 어려운 구조적 문제
• AVF formation에 악영향이 있을 수 있다
29. Vascular access
• Rationale
• 낮은 infection rate (비슷한 rate를 보인 논문도 있음)
• 낮은 malfunction rate (이것도 차이가 없다는 논문도 있음)
• 낮은 recirculation rate
30. Crit Care Resusc 2014; 16: 127–130
호주 Single center observational study
31. HD cath. With c-line
• ICU 환자를 보면 HD cath와 c-line 을 동시에 넣어야 하는 환자
가 있을 때 어느 catheter를 femoral로 어느 catheter를 c-line으
로 넣을지 고민
• 개인적인 생각
• HD cath에 비해 c-line이 환자가 더 오래 가지고 있을 가능성이 높다
• CRRT 의 효율 자체에 차이가 없다는 가정 하에, infection rate를 고려
하면 HD cath를 femoral로, c-line을 jugular로 insertion 하는 것이 좋
지 않을까…
33. CRRT dose 평가
• Clearance in CVVHDF = Dialysate + Replacement + Water
removal
• Dialysate + Replacement + Water removal 은 모두 CRRT
effluent에 모이므로, 하루동안 나온 effluent 를 확인하면 실제
환자에게 시행된 CRRT clearance를 알 수 있다
• 예를 들어 70kg 환자에서 50400 mL의 effluent 가 나왔다면
• 50400 / 70kg / 24hr = 30 ml/kg/hr가 실제 CRRT 된 양
35. Potassium
• hyperK가 있는 환자에서 RRT를 시작할 때, CRRT dose 20~25
mL/kg/hr 정도에서 대부분의 hyperK는 dialysate/replacement에 K
가 2 mEq/L 농도에서 조절이 가능하다
• 만약 K를 0 mEq/L의 농도로 사용한다면, hypoK에 대한 monitoring
이 필요하다
• CRRT 환자에서 hypoK는 CRRT 하지 않는 환자의 Mx. 와 동일하며,
dialysate/replacement fluid에 K 를 4 mEq/L 로 사용하면 K loss를
막을 수 있다
Yessayan et al. Advances in Chronic Kidney Disease, Vol 23, No 3 (May), 2016: pp 203-210
36. Discontinuation of RRT
• 현재까지 RRT 종료를 결정하는 명확한 기준은 없다
• Urine output의 증가
• RRT 종료가 가능할 수 있겠다는 지표
• 한 Observational study : Diuretics 사용 없이 > 400 mL/day
• Mendu et al : > 500 mL/day
• Creatinine clearance
• ATN study
• Urine output 이 하루 750 mL/day 이상일 때
• 6hr 동안의 creatinine clearance 측정 -> > 20mL/min 이상일 시 CRRT off
CHEST 2019; 155(3):626-638
37. Reference
• Continuous Renal-Replacement Therapy for Acute Kidney Injury, N Engl J Med 2012;367:2505-14.
• KDIGO Clinical Practice Guideline for Acute Kidney Injury 2012
• Timing of Renal Replacement Therapy for Acute Kidney Injury, Journal of Intensive Care Medicine 2019, Vol. 34(2) 94-103
• Continuous Renal Replacement Therapy, CHEST 2019; 155(3):626-638
• Effects of different doses in continuous veno-venous haemofiltration on outcomes of acute renal failure: a prospective randomised
trial, Lancet. 2000 Jul 1;356(9223):26-30
• Intensity of Renal Support in Critically Ill Patients with Acute Kidney Injury, N Engl J Med 2008;359:7-20.
• Intensity of Continuous Renal-Replacement Therapy in Critically Ill Patients, N Engl J Med 2009;361:1627-38
• High-volume versus standard-volume haemofiltration for septic shock patients with acute kidney injury (IVOIRE study): a multicentre
randomized controlled trial, Intensive Care Med (2013) 39:1535–1546
• Filter lifespan in critically ill adults receiving continuous renal replacement therapy: The effect of patient and treatment-related
variables, Crit Care Resusc 2014; 16: 225–231
• Vascular access site influences circuit life in continuous renal replacement therapy, Crit Care Resusc 2014; 16: 127–130
• https://www.youtube.com/watch?v=KXhLg8EmK1M
• 임상술기 연구회 강의
• https://www.youtube.com/watch?v=COKzm4pTPcs
• 36th international vicenza course on AKI on CRRT
ARDS - fluid 조절을 strict 하기 위해
sepsis - cytokine 조절을 위해
여러가지 mortality 가 있었는데, inhospital 만 뽑아 왔고 모든 mortality 차이 없음
Recovery of renal function 차이 없음
Hypotension event 자체는 차이가 없지만, MAP 자체는 CRRT 가 높았음
Life-threatening conidition 이 있다면 RRT 를 당연히 시작해야 하는 건 맞아
두번째로, RRT로 교정될 수 있는 condition 이 있거나, lab 결과의 trend 가 필요한 쪽으로 가고 있다면, RRT 결정에 고려할 수 있겠다
한때는 early RRT를 권하는 방향으로 갔다가
그 이후 다시 early RRT 와 late RRT 가 차이가 없다는 방향으로 나오고 있고 현재도 논란 중
현재도 큰 두개의 RCT가 진행 중에 있다
2016년 gaudry -> NEJM 논문
2016년 Zarbock -> JAMA
얇은 빨대
다소 오래된 논문이나 Ronco 등이 post dilution CVVH mode에서 적어도 Kg당 시간당 35mL 의 clearance 를 유지하는 것이 AKI를 동반한 critically ill patient에서 survival benefit이 있다고 보고한 바있습니다. 현재까지도 CRRT의 target dose는 본 연구에 기초하여 적어도 post dilution mode에서 35mL/hr/Kg 를 유지하는 것이 일반적으로 받아들여지고 있습니다
IVOIRE trial 찾아서 넣기
호주 Single center 에서 ICU 에서 CRRT 를 받았던 환자들을 대상으로 1년동안 했던 연구
CRRT input 이 음일 때 일단 임시방편으로 line 을 reversal 해서 CRRT 를 돌려볼 수는 있다
Side hole 과 end hole 의 차이로 일단 돌아가기는 하겠으나
Recirculation 이 발생하여 투석의 효율이 떨어지고
이미 catheter가 막히고 있다는 신호일 가능성이 높아 곧 사용하지 못하게 될 가능성이 높다.
BEST Kidney study
Mendu ML, Ciociolo GR, McLaughlin SR, et al. A Decision-making
algorithm for initiation and discontinuation of RRT in severe AKI.
Clin J Am Soc Nephrol. 2017;12(2):228-236.