The document discusses continuous renal replacement therapy (CRRT) modalities for acute kidney injury (AKI) patients in the intensive care unit (ICU). It provides details on different CRRT modalities including CVVH, CVVHD, and CVVHDF. CVVHDF is described as the safest combination as it utilizes both diffusion and convection. The document also discusses indications for specific CRRT therapies and notes that patient hemodynamic stability is the main determinant for choice of dialysis modality.
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.
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.
Hyertension in patients on regular hemodialysisEhab Ashoor
Everything about hypertension in patients on regular hemodialysis, including management, Resistant hypertension, Intra-dialytic hypertension and Hypertensive urgencies.
Continuous renal replacement therapy is a recently introduced modality for renal replacement therapy in hemodynamic unstable patients with AKI in ICU
THIS lecture was represented in Mansoura international hemodialysis course
Hyertension in patients on regular hemodialysisEhab Ashoor
Everything about hypertension in patients on regular hemodialysis, including management, Resistant hypertension, Intra-dialytic hypertension and Hypertensive urgencies.
Continuous renal replacement therapy is a recently introduced modality for renal replacement therapy in hemodynamic unstable patients with AKI in ICU
THIS lecture was represented in Mansoura international hemodialysis course
Here is the updated list of Top Best Ayurvedic medicine for Gas and Indigestion and those are Gas-O-Go Syp for Dyspepsia | Lavizyme Syrup for Acidity | Yumzyme Hepatoprotective Capsules etc
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
ABDOMINAL TRAUMA in pediatrics part one.drhasanrajab
Abdominal trauma in pediatrics refers to injuries or damage to the abdominal organs in children. It can occur due to various causes such as falls, motor vehicle accidents, sports-related injuries, and physical abuse. Children are more vulnerable to abdominal trauma due to their unique anatomical and physiological characteristics. Signs and symptoms include abdominal pain, tenderness, distension, vomiting, and signs of shock. Diagnosis involves physical examination, imaging studies, and laboratory tests. Management depends on the severity and may involve conservative treatment or surgical intervention. Prevention is crucial in reducing the incidence of abdominal trauma in children.
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAkankshaAshtankar
MIP 201T & MPH 202T
ADVANCED BIOPHARMACEUTICS & PHARMACOKINETICS : UNIT 5
APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS By - AKANKSHA ASHTANKAR
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
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
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
Novas diretrizes da OMS para os cuidados perinatais de mais qualidade
Crrt indications and modalities [autosaved]
1. Prof Yasser M. Abdelhamid MD
Professor of Nephrology
Cairo University
Prof. Yasse Abdelhamid
2. • 80% of patients with AKI in the ICU are
currently treated with continuous therapies,
• 17% with intermittent Therapies
• 3% with peritoneal dialysis or slow continuous
ultrafiltration
(Uchino et al, Intensive Care Med, 2007)
Prof. Yasse Abdelhamid
3. • Hemodynamic stability of the critically ill
patient is the main determinant of the choice
of dialysis modality
(Palevsky et al, N Engl J Med, 2008)
Prof. Yasse Abdelhamid
4. Advantages of CRRT
Hemodynamic Stability
Recovery of Renal Function
Correction of Metabolic Acidosis
Biocompatibility
Correction of Malnutrition
Removal of Cytokines
Solute Removal
Prof. Yasse Abdelhamid
5. • Gradual
• Gradual removal of solutes and metabolic
waste helps to clear inflammatory mediators
and ensure adequate nutrition for patients
Prof. Yasse Abdelhamid
6. IHD or CRRT
Deepa and Muralidhar, J Anaesthiology clin Pharmcol,2012,386-396Prof. Yasse Abdelhamid
7.
8. Why
• Maintenance of intravascular compartment volume
• Prolonged treatments permit lower fluid removal rates
– IHD: 3 L in 3 hours = 1 L/h UF rate
– CRRT: 3 L in 24 hrs = 0.125 ml/h UF rate
• Urea diffusion is faster with IHD than CRRT
– IHD: Urea clearance ~160 ml/min
– CRRT: Urea clearance ~15-30 ml/min
• Convective sodium removal rate
[hemofiltration/hemodiafiltration] is less than diffusive
removal rate [hemodialysis]
• Decreased core temperature.
• Convective removal of inflammatory mediators could
contribute to hemodynamic stability.
Prof. Yasse Abdelhamid
9. Renal Recovery
• Forty-nine studies were included
• Conclusion: Findings of the conducted
assessment show that initial CRRT is
associated with higher rates of renal recovery.
Potential long term effects on clinical
outcomes for more than three months could
not be analyzed and should be investigated in
further studies Prof. Yasse Abdelhamid
12. • All available RRT rely on two basic principles,
-Diffusion and Convection.
• Dialysis depends primarily on diffusion, while
hemofiltration uses convection.
• The two modalities may be combined (CVVHDF)
Principles
Prof. Yasse Abdelhamid
16. Intermittent Hemodialysis
Diffusion.
High clearance for
small molecules
Dialysate
High dialysate flow.
May be no anticoagulationProf. Yasse Abdelhamid
17. CRRT (SLOW, Continuous)
Convection + Diffusion.
Small and middle
molecules
Use of substitution fluid.
Continuous
anticoagulation.
Prof. Yasse Abdelhamid
19. • Limitations to use Kt/V in critically ill:
• High catabolic rate.
• Variable fluid volumes,
• Post-dialysis “rebound "of urea from hypo
perfused organs.
Dose of Dialysis (IHD)
20. • A significant survival benefit was seen in
patients who received middle (35 mL/kg/h)
and high ultrafiltration rates (45 mL/kg/h)
versus the low filtration (20 mL/kg/h rate)
group.
• No difference between the middle and high
filtration rate groups.
Ronco C, Bellomo R, Hommel P, et al. Effects of different doses in continuous veno-venous
hemofiltration on outcomes in acute renalfailure: A prospective, randomized trial.
Lancet2000;355:26-30.
Dose of Dialysis (CRRT)
22. Dose of Dialysis (CRRT)
In critically ill patients with acute kidney injury,
treatment with higher-intensity continuous renal-
replacement therapy did not reduce mortality at
90 days.
24. Dose of Dialysis (IHD)
• Intensive renal support
involving IHD, SLEDD 6
times / wk or CVVHDF
at 35 ml/kg/h in
critically ill patients with
AKI.
• As compared with less-
intensive therapy
involving a defined dose
of IHD 3 times per week
or CRRT at 20 ml/kg/h.
Did not decrease mortality, improve recovery of kidney
function, or reduce the rate of non-renal organ failure.
27. CRRT Membrane
• High-flux: high
permeability for water
• Low- and middle-
molecular weight
solutes (in the range of
1000–12,000Daltons)
• High ‘‘biocompatibility.’’
Prof. Yasse Abdelhamid
29. Anticoagulation
Drug Pro Cons
No anticoagulation No risk of bleeding Clotting
Short time circiut
Unfractionated heparin Routine Risk of bleeding
HIT
LMWH Could be used Risk of bleeding
HIT
Citrate Regional Hypocalcemia
Prostacyclin Short circuit life span Hypotension
New anticoagulants Insufficient data
Prof. Yasse Abdelhamid
39. Non Renal Indications (ICU)
• Cardiac failure.
• Large amount of IV intake.
• Hyperthermia (core temperature >39.5°C) or
hypothermia (core temperature <37°C)
• Overdose with a dialyzable toxin (e.g. Lithium)
Prof. Yasse Abdelhamid
40. •
– Hemodynamic instability
– Combined acute renal and hepatic failure
– Acute brain injury: Decreases cerebral edema
Non Renal Indications (ICU)
Prof. Yasse Abdelhamid
41. • Patients with intra cranial hypertension or cerebral edema
– Autoregulation is lost!
– Sudden changes in systemic or intra-abdominal pressure change
intracranial pressure
• Patients with abdominal compartment syndrome
• Correct azotemia slowly, to avoid dialysis disequilibrium
and worsened brain edema
• Urea protects against osmotic demyelination syndrome
• Patients with hyponatremia
– Correct Na very slowly to avoid osmotic demyelination
syndrome
Special Circumstances
Prof. Yasse Abdelhamid
42. Special Circumstances
• Acute fulminant liver failure or acute-on chronic
liver failure
• Partly determined by brain edema, so avoid brain
swelling
• Hyponatremia is common, causes brain edema
• Low blood urea concentration increases risk of
ODS.
Prof. Yasse Abdelhamid
43. • Initially, high volume hemofiltration offered
benefit over conventional hemodialysis.
• Meta-analysis (IVOIRE) suggested no
benefit (Borthwick et al, Cochrane Database Syst Rev. 2013, Joannes-Boyau et
al Intensive Care Med. 2013)
• High dose 80ml/kg/h was found to decrease level
of IL 1B, 6, 8 and 10 with no effect on mortality
than conventional dos of 40ml/kg/h
(Park et al, Am J Kidney Dis, 2016)
CRRT and Sepsis
Prof. Yasse Abdelhamid
44. • Use of hemoperfusion with Polymyxin B fiber
column was found to improve hemodynamics
and organ dysfunction and reduced 28-day
mortality (EUPHAS randomized controlled trial, JAMA ,2009).
• Use of some dialyzers was suggested to be of
benefit: AN69 Surface Treated (ST), SEPTEX,
polymethylmetacrylate. Oxiris® orToraymyxin®
CRRT and Sepsis
Prof. Yasse Abdelhamid
46. • Early initiation of RRT significantly reduced
– Occurrence of major adverse kidney events,
– Mortality, and
– Enhanced renal recovery at 1 year.
(Meersch et al, J Am Soc Nephrol. 2018)
Prof. Yasse Abdelhamid
48. • 231 patients, early group (n = 112), 108 of 119
patients (90.8%) in the delayed group received
RRT.
• Early initiation of RRT significantly reduced 90-
day mortality
• More patients in the early group recovered
renal function by day 90
• Duration of RRT and length of hospital stay
were significantly shorter in the early group
• No significant effect on requirement of RRT
after day 90, organ dysfunction, and length of
ICU stay.
Prof. Yasse Abdelhamid
49. • Conclusion: Among critically ill patients with
AKI, early RRT compared with delayed
initiation of RRT reduced mortality over the
first 90 days. Further multicenter trials of this
intervention are warranted.
Prof. Yasse Abdelhamid
51. • A total of 620 patients
• Conclusion: we found no significant difference
with regard to mortality between an early and
a delayed strategy for the initiation of renal-
replacement therapy. A delayed strategy
averted the need for renal-replacement
therapy in an appreciable number of patients.
Prof. Yasse Abdelhamid
52. • A total of 488 patients
• Conclusion: there was no significant difference
in overall mortality at 90 days between
patients who were assigned to an early
strategy for the initiation of renal-replacement
therapy and those who were assigned to a
delayed strategy. (Barbar etl,IDEAL-ICU Trial Investigators
and the CRICS TRIGGERSEP Network, NEJM 2018)
Prof. Yasse Abdelhamid
53. • Despite the presence of a plethora of studies in
this field, the lack of uniformity in study design,
patient population types, definition of early and
late initiation, modality of RRT, and results, the
optimal time for starting RRT in AKI still remains
unknown. (Nithin Karakala MD, Ashita J. Tolwani, MD, MSE, Journal
of Intensive Care Medicine, 2018)
Prof. Yasse Abdelhamid
54. Several trials have been largely disappointing
– Ant-inflammatory and pleiotropic drugs
(corticosteroids, statins, aspirin)
– Vasoactive or antiplatelet drugs
– Different fluid administration strategies
(Dr Chertow GM, Winkelmayer WC JAMA 2016;325:2171)
• Definition of early intervention
Prof. Yasse Abdelhamid
55. KDIGO
5.1.1: Initiate RRT emergently when life-threatening
changes in fluid, electrolyte, and acid-base balance
exist. (Not Graded)
5.1.2: Consider the broader clinical context, the
presence of conditions that can be modified with RRT,
and trends of laboratory tests, rather than single BUN
and creatinine thresholds alone, when making the
decision to start RRT. (Not Graded)
Prof. Yasse Abdelhamid
57. • The main mechanism with which clearance is
achieved.
Prof. Yasse Abdelhamid
58. Ideal Treatment Modality
• Preserves homeostasis
• Does not increase co-morbidity
• Does not worsen patient’s underlying
condition
• Is inexpensive
• Is simple to manage
• Is not burdensome to the ICU staff
Prof. Yasse Abdelhamid
60. • Many intensivists and nephrologists prefer to
use CVVH in the belief that pure convection
will remove a greater number of larger
molecules than diffusion-base CVVHD.
• CVVHDF in a safe combination
(Ricci et al, Crit Care, 2006)
Prof. Yasse Abdelhamid