This document discusses continuous renal replacement therapy (CRRT). It defines CRRT as an extracorporeal blood purification therapy intended to substitute impaired renal function over an extended period of 24 hours. It describes the requirements, indications, principles, and modalities of CRRT including vascular access, semi-permeable membranes, transport mechanisms, dialysate, replacement fluids, and different types of CRRT like CVVH, CVVHD, and CVVHDF. It also discusses dosing of CRRT, anticoagulation methods, and some complications.
A very simple yet comprehensive presentation to understand the concept of CRRT and its implementation in Intensive Care Unit. Intended for the very beginners in ICU. After going through the presentation you will be able to say "Now I know it!"
A very simple yet comprehensive presentation to understand the concept of CRRT and its implementation in Intensive Care Unit. Intended for the very beginners in ICU. After going through the presentation you will be able to say "Now I know it!"
Renal Replacement Therapy: modes and evidenceMohd Saif Khan
Renal replacement therapy is a supportive care often required in critically ill patients who develop acute renal failure and its complications. Complexity arises when such patients become hemodynamically unstable and pose special challenge to critical care clinicians in ICU to carefully choose dialytic modality to tackle volume and solute overload. This presentation is about short description of modalities of RRT and current evidence regarding initiation, dose and type of modality.
Renal Replacement Therapy: modes and evidenceMohd Saif Khan
Renal replacement therapy is a supportive care often required in critically ill patients who develop acute renal failure and its complications. Complexity arises when such patients become hemodynamically unstable and pose special challenge to critical care clinicians in ICU to carefully choose dialytic modality to tackle volume and solute overload. This presentation is about short description of modalities of RRT and current evidence regarding initiation, dose and type of modality.
he Citrate Story
David Gattas gives an update on today's go-to anti-coagulant for renal replacement therapy: Citrate
David is a key figure in the ANZICS CTG, with a growing list of publications and was involved in the RENAL and POST-RENAL studies.
Long-Term Survival and Dialysis Dependency Following Acute Kidney Injury in Intensive Care: Extended Follow-up of a Randomized Controlled Trial is available free.
This talk was recorded live at an ICN NSW / ANZICS meeting in September 2014.
RENAL DIALYSIS.
RRT
Renal Replacement Therapy.
Dialysis is the artificial process of eliminating waste (diffusion) and unwanted water (ultra filtration) from the blood.
Dialysis is a procedure that cleans and filters the blood. It rids the body of harmful wastes and extra salt and fluids. It also controls blood pressure and helps our body keep the proper balance of chemicals such as potassium, sodium, and chloride.
Dialysis is a Greek word meaning "loosening from something else".
Hemodialysis is a treatment to filter wastes and water from your blood; In hemodialysis, the blood is cleaned outside the body using a dialysis machine and then sent back into the body.
Hemodialysis is a treatment to filter wastes and water from your blood, as your kidneys did when they were healthy. Hemodialysis helps control blood pressure and balance important minerals, such as potassium, sodium, and calcium, in your blood.
Hemodialysis is one way to treat advanced kidney failure and can help you carry on an active life despite failing kidneys.
Mechanism of Hemodialysis:
Hemodialysis is a procedure by which waste products and excess water are removed from a patient’s blood. This is done by directly removing blood from the patient’s circulation, passing it through the dialysis filter, and then returning it directly back into the circulation.
Apparatus needed:
Dialyzer or dialysis filter
Dialysate (dialysis solution)
Tubing for transport of blood and dialysate
Machine that powers and monitors the filtration
Hemodialysis has 5 main steps which are as follows:
1.Two sets of tubing are connected to the patient’s dialysis access:
Connected directly to central venous catheter
Two needles inserted into AVF/AVG and taped down
2. Azotemic blood pumped from patient into dialysis filter
3. Dialysis filter removes toxins primarily through diffusion:
Dialysis filter is a plastic cylinder filled with thousands of tiny individual tubes composed of the filtering material.
Blood flows through the inside of the tiny tubes in one direction.
Dialysis fluid (dialysate) flows on the outside of the tiny tubes (but still within the single plastic cylinder that contains them) in the opposite direction.
The opposing directions of blood and dialysate result in maximal concentration gradients that drive the diffusion of toxins:
Known as “countercurrent” mechanism
Also results in correction of electrolyte/acid–base abnormalities via diffusion.
4. Dialysis filter removes excess water from the blood through ultrafiltration.
Suction force is applied by the dialysis machine across the dialysis filter.
Water is pulled from the blood side into the dialysate side.
5. Clean blood and waste-filled dialysate exit the dialysis filter.
Clean blood is pumped back into the patient’s Circulation.
Waste-filled dialysate is disposed of (including the excess water from the patient’s body that was removed during ultrafiltration).
Chronic dialysis
3–4 hours each session
3 times a week (Monday/Wednesday/Friday or Tuesday/Thursday/Saturday)
Acute dialysis:
Treatment duration and daily schedule are
Variable.
Priscriptions: The nephrologist may control many variables within the dialysis procedure:
Duration of treatment
Ultrafiltration goal
Anticoagulation
Electrolyte composition of the dialysate
Speed of blood flow and dialysate flow
Presented by: Mohammadsaleh Moallem
Hemodialysis: management of chronic kidney diseaseSapana Shrestha
Hemodialysis is a mechanical process of removing waste products (toxic nitrogenous substances) and replacing essential substances by the process of diffusion and removal of excess water from body by the process of osmosis by means of artificial kidney (made with modified cellulose or synthetic) through semi-permeable membranes.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
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Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
New Drug Discovery and Development .....NEHA GUPTA
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New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
3. Continuous Renal Replacement Therapy
(CRRT)
Is an 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 24
hours a day.
4. Requirements for CRRT
A central double-lumen veno-venous
hemodialysis catheter
An extracorporeal circuit and a
hemofilter
A blood pump and a effluent pump.
With specific CRRT therapies dialysate
and/or replacement pumps are required.
5. Indications
• CRRT is better tolerated by
hemodynamically unstable patients
because fluid volume, electrolytes and pH
are adjusted slowly and steadily over a 24
hour period rather than a 3 – 4 hour
period.
6. • Hemodynamically unstable patients with the
following diagnoses may be candidates for
CRRT:
fluid overload
acute renal failure
chronic renal failure
life-threatening electrolyte imbalance
major burns with compromised renal function
drug overdose
7. Principals of CRRT
• Vascular access.
• Semi-permeable membrane.
• Transport mechanism.
• Dialysate and replacement fluid.
9. Access Location
• Internal Jugular Vein
–Primary site of
• Femoral Vein
–Patient immobilized, the femoral vein
is optimal and constitutes the easiest
site for insertion.
• Subclavin Vein
–The least preferred site
10. Choosing the right catheter
• The length of the catheter chosen will
depend upon the site used
– Size of the catheter is important in the
pediatric population.
• The following are suggested guidelines
for the different sites:
– RIJ= 15 cm
– LIJ= 20 cm
– Femoral= 25 cm
11. II- Semi-permeable membrane
• The basis of all blood purification
therapies.
• Water and some solutes pass through
the membrane, while cellular
components and other solutes remain
behind.
12. II- Semi-permeable membrane
• 2 types: cellulose and synthetic.
• Synthetic membranes allow clearance
of larger molecules and are the
primary type used in CRRT.
• Filters are changed when they become
contaminated, clogged or clotted.
13. Molecular size: Both molecule size and pore size determine the solute flow
through the semi-permeable membrane.
16. III- Transport mechanisms
a) Ultrafiltration
• The passage of water through a
membrane under a pressure gradient.
• Driving pressure can be +ve (push fluid
through the filter), or –ve (pull fluid to
other side of filter).
• Pressure gradient is created by
effluent pump.
17. Here is a visual example of how ultrafiltration works. On the blood side of the
hemofilter you have a positive pressure gradient. on the fluid side of the hemofilter
you have a negative pressure gradient. The effluent pump applies pressure on the
membrane causing the fluid to move from the positive pressure gradient to the
lower pressure gradient.
18. b) Convection
• Movement of solutes through a membrane by
the force of water “solvent drag”.
• The water pulls the molecules along with it as it
flows through the membrane.
• can remove middle and large molecules, as well
as large fluid volumes.
• maximized by using replacement fluids.
19. To better understand this phenomenon, think of a quiet stream as compared to a raging
river. The stream could never shift a boulder, but the powerful raging river could easily
drag a boulder downstream. So it is with convection; the faster the flow through the
membrane, the larger the molecules that can be transported
20. This visual will provide you with a better understanding of how convection works.
From the picture you can see a faucet which represents replacement solution.
The top faucet is an example of pre-filter dilution, which means that the
replacement solution mixes with the blood as it enters the filter. The bottom
faucet is an example of post-filter dilution and is delivered as the blood is
returning to the patient.
Now the effluent pump is removing ultrafiltration (just like SCUF), or patient
plasma water and replacement solution.
21. c) Adsorption
Adsorption is the removal of solutes from the
blood because they cling to the membrane.
Think of an air filter. As the air passes through
it, impurities cling to the filter itself. Eventually
the impurities will clog the filter and it will need
to be changed.
The same is true in blood purification. High
levels of adsorption can cause filters to clog and
become ineffective
22. some molecules will attach to the membrane surface. While other molecules
may permeate the membrane, but become stuck within the fibers. It is believed
that inflammatory mediators are effectively removed via adsorption.
23. d) Diffusion
Diffusion is the movement of a solute across a membrane
via a concentration gradient. For diffusion to occur,
another fluid must flow on the opposite side of the
membrane. In blood purification this fluid is called
dialysate. When solutes diffuse across a membrane they
always
shift from an area of higher concentration to an area of
lower concentration until the solute concentration on both
sides of the membrane is equal.
24. The patients blood contains a high concentration of unwanted solutes that can be
effectively removed by diffusion. Diffusions key mechanism is to move a solute
from a higher concentration gradient to a lower concentration gradient.
For example, let us assume the blood in the filter has a high concentration of
potassium molecules and on the fluid/dialysate compartment has a low
concentration of potassium. The potassium gradually diffuses through the
membrane from the area of a higher potassium concentration to the area of a
lower potassium concentration until it is evenly distributed.
25. IV- Dialysate and replacement
fluid
Dialysate is any fluid used on the
opposite side of the filter from the
blood during blood purification.
As with traditional hemodialysis
therapy, the dialysate is run on the
opposite side of the filter,
countercurrent to the flow of the
patient’s blood. The countercurrent
flow allows a greater diffusion
gradient across the entire membrane,
increasing the effectiveness of solute
removal.
Typical dialysate flow rates are
between 600 – 1800 mL/hour.
26. Replacement fluid
• Used to increase the amount of convective
solute removal in CRRT.
• Replacement fluids do not replace
anything.
• Fluid removal rates are calculated
independently of replacement fluid rates.
• The most common replacement fluid is 0.9%
Normal Saline.
• Can be pre or post filter.
27. The decision to infuse replacement fluids
before or after the filter is made by the
physician.
Replacement fluids administered pre-
filter reduce filter clotting and can be
administered at faster rates (driving higher
convection) than fluids administered post-
filter.
28. The downside of pre-filter replacement
fluids is that they invalidate post-filter lab
draws; the lab results will
show the composition of the replacement
fluid rather than that of the effluent.
32. Slow Continuous Ultrafiltration
(SCUF)
• The primary indication for SCUF is fluid
overload without uremia or significant
electrolyte imbalance.
• The main mechanism of water transport is
ultrafiltration.
• Other solutes are carried off in small amounts,
but usually not enough to be clinically
significant.
33. Slow Continuous Ultrafiltration
(SCUF)
• The amount of fluid in the effluent bag is the
same as the amount removed from the patient.
• Fluid removal rates are typically closer to 100
mL/hour.
• No dialysate or replacement fluid is
used.
34.
35. SCUF
• Blood flow: 80 – 200 ml/min
• Duration
• Ultrafiltration: 20-100 ml/hr (or total
volume)
• Anticoagulation
• NO dialysate, NO replacement fluid
36. Continuous Veno-venous Hemofiltration
(CVVH)
• An extremely effective method of solute removal
and is indicated for uremia or severe pH or
electrolyte imbalance with or without fluid
overload.
• Particularly good at removal of large molecules,
because CVVH removes solutes via convection,
• Many theories exist regarding the removal of
pro-inflammatory mediators by CVVH.
37. Continuous Veno-venous Hemofiltration
(CVVH)
• Solutes can be removed in large quantities while
easily maintaining a net zero or even a positive
fluid balance in the patient.
• The amount of fluid in the effluent bag is equal
to the amount of fluid removed from the patient
plus the volume of replacement fluids
administered.
•No dialysate is used.
38.
39. CVVH
• Blood flow:80 – 200 ml/min
• Duration
• Ultrafiltration: 20-100 ml/hr
• RF: 1000 – 2000 ml/hr , pre or post filter
(up to 3 lit/hr).
• Anticoagulation
• NO dialysate
40. Continuous Veno-venous Hemodialysis
(CVVHD)
• Effective for removal of small to medium sized
molecules.
• Solute removal occurs primarily due to diffusion.
• No replacement fluid is used.
• Dialysate is run on the opposite side of the filter.
• Fluid in the effluent bag is equal to the amount
of fluid removed from the patient plus the
dialysate.
43. Continuous Veno-venous Hemodiafiltration
(CVVHDF)
• The most flexible of all the therapies, and
combines the benefits of diffusion and
convection for solute removal.
• The use of replacement fluid allows
adequate solute removal even with zero or
positive net fluid balance for the patient.
44. Continuous Veno-venous Hemodiafiltration
(CVVHDF)
• Amount of fluid in the effluent bag equals
the fluid removed from the patient plus the
dialysate and the replacement fluid.
• Dialysate on the opposite side of the filter
and replacement fluid either before or after
the filter.
45.
46. CVVHDF
• Blood flow: 80 – 200 ml/min
• Duration
• Ultrafiltration: 20-100 ml/hr
• Anticoagulation
• Dialysate: 600 – 1800 ml/hr (up to 3 lit/hr).
• Replacement fluid: 1000-2000 ml/hr, pre
or post filter (up to 3 lit/hr).
47. Anticoagulation & CRRT
• Low-dose pre-filter unfractionated
Heparin: any dose less than 5 units/kg/hour.
• Medium-dose pre-filter unfractionated
Heparin: a dose between 8-10 units/kg/hour.
• Systemic unfractionated Heparin is
administered intravenously and titrated to achieve an
activated partial thromboplastin time (aPTT) ordered
by the physician, for patients who have another
indication for heparinization, such as. DVT
48. Anticoagulation & CRRT
• Regional unfractionated Heparin: a pre-
filter dose of 1500 units/hour of Heparin,
with administration of Protamine post-
filter at a dose of 10-12 mg/hour.
• Low-molecular-weight Heparins
• Prostacyclin: rarely used (expensive, hypotension)
• Citrate: infused pre-filter, Ca must be replaced.
49. No Anticoagulation
• Platelet count < 50,000/mm3
• INR > 2.0
• aPTT > 60 seconds
• Actively bleeding or with an active bleeding
episode in the last 24 hours
• Severe hepatic dysfunction or recent liver
transplantation
• Within 24 hours post cardiopulmonary bypass or
extra-corporeal membrane oxygenation (ECMO)
50. Complications of CRRT
• Bleeding
• Hypothermia
• Electrolyte imbalance
• Acid-base imbalance
• Infection
• Dosing of medications
56. • The concept of RRT dose is As is the
case for antibiotics, vasopressors, anti-
inflammatory drugs, mechanical
ventilation, etc.
• In chronic kidney disease, urea often has
been used as a marker molecule.
• The amount (dose) of delivered RRT can
be described by various terms: efficiency,
intensity, frequency, and clinical
efficacy.
57. Efficiency (K)
• The volume of blood cleared of a given solute
over a given time.
(mL/min, mL/hr, L/hr, L/24 hrs, etc.)
• During RRT, K depends on solute molecular
size and diffusivity, transport modality
(convection or diffusion), and circuit
operational characteristics such as blood flow
rate, ultrafiltration rate, dialysate flow rate,
and membrane and hemodialyzer type and
size.
58. Intensity (Kt)
• Defined as: The product of K X time.
• (Kt: mL/min X 24 hrs, L/hr X 4 hrs, etc.)
• Kt is more useful than K in comparing various
RRTs.
• Nevertheless, equal Kt products may lead to
different results if K is large and t is small or if
K is small and t is large.
59. Efficacy (Kt/V)
• The effective outcome resulting from the
administration of a given treatment dose to a
given patient.
• V: is the volume of distribution of the marker
molecule in the body.
• Kt/V is a dimensionless number(e.g., 3 L/hr X
24 hrs/45 L = 72 L/45 L = 1.6)
60. Limitations
• The marker solute cannot and does not
represent all of the solutes that accumulate in
renal failure.
• Its kinetics and volume of distribution are also
different from other solutes.
• Finally, its removal during RRT is not
representative of the removal of other solutes.
• This is true for both end-stage renal failure and
acute renal failure.
62. Why ?
• Prevent clotting of the circuit.
• Preserve filter performance.
• Optimize circuit servival.
• Prevent loss of blood due to
circuit clotting.
63. Ideal anticoagulant
• Should prevent filter clotting without
inducing hemorrhage.
• Should have a short half-life, and action
limited to extracorporeal circuit.
• Should be easily monitored.
• Should have No systemic side effects.
• Should have an antidote.
64. Anticoagulation & CRRT
• Low-dose pre-filter unfractionated
Heparin: any dose less than 5
units/kg/hour.
• Medium-dose pre-filter unfractionated
Heparin: a dose between 8-10
units/kg/hour.
• Systemic unfractionated Heparin is
administered intravenously and titrated to achieve an
activated partial thromboplastin time (aPTT) ordered
by the physician, for patients who have another
indication for heparinization, such as. DVT
65. Anticoagulation & CRRT
• Regional unfractionated Heparin: a pre-
filter dose of 1500 units/hour of Heparin,
with administration of Protamine post-
filter at a dose of 10-12 mg/hour.
• Low-molecular-weight Heparins
• Prostacyclin: rarely used (expensive,
hypotension)
• Citrate: infused pre-filter, Ca must be replaced.
66. Current Opinion
• 5000 – 20000 U of UFH added to the
priming solution.
• Continuous infusion of 3-5 u/kg/hr.
• 50 – 100 % prolongation of aPTT.
• Incidence of bleeding varied between 0 – 50 %
67. Regional anticoagulation
using Citrate
• Pre-filter citrate inhibits coagulation
by chelating Ca+
• As a result iCa decreases.
• An iCa concentration below 0.35
mmol/L is required to inhibit
coagulation.
69. Argatroban
Argatroban loading dose of 100 µ/kg
Followed by maintenance infusion rate
( µ/kg/min)
Maintenance infusion calculated
by:
2.15 – 0.06 X APACHE II score
70. Argatroban loading dose of 100 µ/kg
Followed by maintenance infusion rate ( µ/kg/min)
Maintenance infusion calculated by:
2.15 – 0.06 X APACHE II score
In critically ill patients with HIT and necessity for
CRRT , APACHE II can help to predict the
required argatroban maintenance dose for
anticoagulation.
This predictor identifies decreased argatroban
dosing requirements.
Resulting in effective and safe CRRT.
Argatroban
71. What’s the point ?
• Anticoagulation during CRRT should be
individualized.
• The first goal should be the safety of the
patient.
• Attention should be paid to non-
pharmacological means of prolonging filter
life (blood flow, wide pore cath, pre-filter
replacement fluid).
73. Nutrition Implications of ARF
• ARF causes anorexia, nausea, vomiting,
bleeding
• ARF causes rapid nitrogen loss and lean body
mass loss (hypercatabolism)
• ARF causes ↑ gluconeogenesis with insulin
resistance
• Dialysis causes loss of amino acids and protein
• Uremia toxins cause impaired glucose
utilization and protein synthesis
74. Nutrient Requirements in ARF
• Calories: 25-45 kcals/kg dry weight or
REE
• Protein: about 10-16 g amino acids lost
per day with CRRT
–Acute HD: 1.2-1.4 g/kg; acute PD: 1.2-
1.5 g/kg; CRRT: 1.5-2.5 g/kg
75. Nutrient Requirements in ARF
• CHO: ~60% total calories; limit to 5
mg/kg/min; peripheral insulin resistance may
limit CHO
– In CWHD(F) watch for CHO in dialysate or
replacement fluids
• Fat: 20-35% of total calories; lipid
clearance may be impaired
76. Vitamins in ARF
• Vitamin A: elevated vitamin A levels are known
to occur with RF
• Vitamin B – prevent B6 deficiency by giving 10
mg pyridoxine hydrochloride/day
• Folate and B6: supplement when homocysteine
levels are high
• Vitamin C: < 200 mg/day to prevent ↑ oxalate
• Activated vitamin D
• Vitamin K: give Vitamin K especially to pts on
antibiotics that suppress gut production of K
77. Minerals in ARF
• ↑ potassium, magnesium, and phos occur often
due to ↓ renal clearance and ↑ protein
catabolism
• ↓ potassium, mg and phos can occur with
refeeding
• CRRT pts can have ↓ K+, phos
• Mg deficiency can cause K+ deficiency
resistant to supplementation
• Vitamin C, copper, chromium lost with CVVH
78. Fluid in ARF
• Depends on residual renal function, fluid
and sodium status, other losses
• Usually 500 mL/day + urine output
• Fluid replacement needs can be ↑
with CRRT
80. • only the drug in the central
compartment ( plasma ) is available for
extracorporeal removal
• drugs with a large Vd have less access to the
hemofilter or dialyzer
• Extracorporeal treatmentdeeper
compartments
the rate of extracorporeal removal
the rate of transfer between the peripheral and
central compartment.
Extracorporeal removal
81. Factors determining
extracorporeal drug removal
a) Pharmacological
• Molecular weight.
• Volume of distribution.
• Plasma protein binding.
• Drug charge (Gibbs-Donnan effect).
Gibbs-Donan effect ( the behavior of charged particles near a
semi-permeable membrane to sometimes fail to distribute evenly
across the two sides of the membrane )