- Renal replacement therapies are important in critical care for managing complications of renal failure such as fluid, electrolyte and acid-base imbalances. There are many questions around optimal therapy including timing, dose and modality.
- Acute kidney injury is common in the ICU and associated with worse outcomes. Continuous renal replacement therapies may provide more stable volume and chemistry control compared to intermittent therapies.
- High volume hemofiltration shows promise for removing inflammatory mediators in sepsis but optimal dose is still unclear. Renal replacement therapies have an important role beyond renal support as blood purification techniques.
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.
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!"
Establishing and maintaining normal extracellular volume (ECV) is required to achieve normotension. The achievement of an optimal fluid status, as expressed by "dry weight" (DW), should allow for controlling blood pressure (BP) in the large majority of HD patients
From metabolic syndrome to cachexia: what’s new about metabolic biomarkers?Bertin Pharma
What does Metabolic Syndrom really mean? What impact on world population? Which biomarkers can serve your studies? What treatments for tomorrow?...
These are just some of the questions Virginie Tolle and Odile Viltart, researchers at the INSERM (The French National Institute for Health and Medical Research ) answered in this very complete article for Bertin Pharma.
Good reading!
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!"
Establishing and maintaining normal extracellular volume (ECV) is required to achieve normotension. The achievement of an optimal fluid status, as expressed by "dry weight" (DW), should allow for controlling blood pressure (BP) in the large majority of HD patients
From metabolic syndrome to cachexia: what’s new about metabolic biomarkers?Bertin Pharma
What does Metabolic Syndrom really mean? What impact on world population? Which biomarkers can serve your studies? What treatments for tomorrow?...
These are just some of the questions Virginie Tolle and Odile Viltart, researchers at the INSERM (The French National Institute for Health and Medical Research ) answered in this very complete article for Bertin Pharma.
Good reading!
We have been manufacturing a broad range of self-adhesive labels and stickers since 1990. We have a number of different types of printers as to give our customers endless flexibility, so that they can get the labels they need.
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AKI in the ICU
Principles of RRT
Modes of RRT
Indications for RRT
Optimal timing: When to start
Optimal modality: What Modality and Where ??
Optimal dosing- How Much?
Summary and Conclusions
What is an electrolyte imbalance?
An electrolyte imbalance means that the level of one or more electrolytes in your body is too low or too high. It can happen when the amount of water in your body changes. The amount of water that you take in should equal the amount you lose. If something upsets this balance, you may have too little water (dehydration) or too much water (overhydration). Some of the more common reasons why you might have an imbalance of the water in your body include:
1. Certain medicines
2. Severe vomiting and/or diarrhea
3. Heavy sweating
4. Heart, liver or kidney problems
5. Not drinking enough fluids, especially when doing intense exercise or when the weather is very hot
6. Drinking too much water
journal club and critical appraisal checklist
intensive recruitment versus moderate recruitment strategy in postop cardiac surgery patients to avaoid postop pulmonary complications
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
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!
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
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
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.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
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
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
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
2. TOO MANY QUESTIONS?
• What therapy should we use?
• When should we start it?
• What are we trying to achieve?
• How much therapy is enough?
• When do we stop/switch?
• Can we improve outcomes?
Does the literature help us?
3. RENAL FAILURE OF ANY CAUSE
Many physiologic derangements:
• Homeostasis of water and electrolytes as the excretion of the daily
metabolic load of fixed hydrogen ions is no longer possible.
• Toxic end-products of nitrogen metabolism (urea, creatinine, uric acid,
among others) accumulate in blood and tissue.
• Endocrine organ dysfunction and failing production of erythropoietin and
1,25 dihydroxycholecalciferol (calcitriol).
4. EVALUATING ARF
• Severity of ARF/AKI should not be estimated from measurements of blood urea
or creatinine alone .
• Cockcroft & Gault equation or MDRD eGFR or reciprocal creatinine plots should
not be used when the GFR is <30 mL/min or to determine the need for acute
RRT.
5. AKI CLASSIFICATION SYSTEMS 1: RIFLE
Bellomo R, Ronco C, Kellum JA, et al. Acute renal failure - definition, outcome measures, animal models, fluid therapy and information
technology needs: the second International Consensus Conference of the Acute Dialysis Initiative (ADQI) group. Crit Care 2004; 8: R204–R212.
6. AKI CLASSIFICATION SYSTEMS 2: AKIN
Stage Creatinine criteria Urine output criteria
1
1.5 - 2 x baseline (or rise > 26.4
mmol/L)
< 0.5 ml/kg/hour for > 6 hours
2 >2 - 3 x baseline < 0.5 ml/kg/hour for > 12 hours
3
> 3 x baseline (or > 354 mmol/L
with acute rise > 44 mmol/L)
< 0.3 ml/kg/hour for 24 hours or
anuria for 12 hours
Patients receiving RRT are Stage 3 regardless of creatinine or urine output
Mehta RL, Kellum JA, Shah SV, et al. Acute Kidney Injury Network: report of an
initiative to improve outcomes in acute kidney injury. Crit Care 2007;11:R31.
7. PROPOSED INDICATIONS FOR RRT
• Oliguria < 200ml/12 hours
• Anuria < 50 ml/12 hours
• Hyperkalaemia > 6.5 mmol/L
• Severe acidaemia pH < 7.0
• Uraemia > 30 mmol/L
• Uraemic complications (pericarditis, nausea, vomiting, poor appetite,
hemorrhage, lethargy, malaise, somnolence, stupor, coma, delirium, asterixis,
tremor, seizures)
• Dysnatraemias > 155 or < 120 mmol/L
• Hyper/(hypo)thermia
• Drug overdose with dialysable drug
• Refractory hypertension
Lameire, N et al. Lancet 2005; 365: 417-430
8. “NON-RENAL” INDICATIONS
• TO GET RID OF Substances with higher degrees of protein binding
and sometimes for substances with very long plasma half-lives.
• In general, the size of the molecule and the degree of protein
binding determines the degree to which the substance can be
removed (i.e. smaller, nonprotein bound substances are easiest to
remove).
• RRT can be used as sorbent hemoperfusion for substances that
include drugs, poisons, contrast agents, and cytokines.
9. ACUTE KIDNEY INJURY IN THE ICU
• AKI is common: 3-35%* of admissions
• AKI is associated with increased mortality
• “Minor” rises in Cr associated with worse outcome
• AKI developing after ICU admission (late) is associated
with worse outcome than AKI at admission
• AKI requiring RRT occurs in about 4-5% of ICU
admissions and is associated with worst mortality risk
**
* Brivet, FG et al. Crit Care Med 1996; 24: 192-198
** Metnitz, PG et al. Crit Care Med 2002; 30: 2051-2058
10. MORTALITY BY AKI SEVERITY
Clermont, G et al. Kidney International 2002; 62: 986-996
11. THE IDEAL RENAL REPLACEMENT
THERAPY
• Allows control of intra/extravascular volume
• Corrects acid-base disturbances
• Corrects uraemia & effectively clears “toxins”
• Promotes renal recovery
• Improves survival
• Is free of complications
• Clears drugs effectively (?)
12. INTERMITTENT THERAPIES - PROS
(Relatively) Inexpensive
Flexible timing allows for mobility/transport
Rapid correction of fluid overload
Rapid removal of dialyzable drugs
Rapid correction of acidosis & electrolyte
abnormality
Minimises anticoagulant exposure
14. INTRADIALYTIC HYPOTENSION:
RISK FACTORS
• LVH with diastolic dysfunction or LV systolic dysfunction / CHF
• Valvular heart disease
• Pericardial disease
• Poor nutritional status / hypoalbuminaemia
• Uraemic neuropathy or autonomic dysfunction
• Severe anaemia
• High volume ultrafiltration requirements
• Predialysis SBP of <100 mm Hg
• Age 65 years +
• Pressor requirement
15. MANAGING INTRA-DIALYTIC
HYPOTENSION
• Dialysate temperature modelling
• Low temperature dialysate
• Dialysate sodium profiling
• Hypertonic Na at start decreasing to 135 by end
• Prevents plasma volume decrease
• Midodrine if not on pressors
• Colloid/crystalloid boluses
• Sertraline (longer term HD)
2005 National Kidney Foundation K/DOQI GUIDELINES
16. CONTINUOUS THERAPIES - PROS
Haemodynamic stability => ?? better renal
recovery
Stable and predictable volume control
Stable and predictable control of chemistry
Stable intracranial pressure
Disease modification by cytokine removal
(CVVH)?
17. Continuous Therapies - CONS
Anticoagulation requirements
Higher potential for filter clotting
Expense – fluids etc.
Immobility & Transport issues
Increased bleeding risk
High heparin exposure
19. SEMI-PERMEABLE MEMBRANES
• Semi-permeable membranes are the basis of all
blood purification therapies.
• They allow water and some solutes to pass
through the membrane, while cellular
components and other solutes remain behind.
• The water and solutes that pass through the
membrane are called ultrafiltrate.
• The membrane and its housing are referred to as
20. ULTRAFILTRATION
• Ultrafiltration is the passage of fluid through a membrane under
a pressure gradient.
• Pressures that drive ultrafiltration can be positive, that is the
pressure pushes fluid through the filter.
• They can also be negative, there may be suction applied that
pulls the fluid to the other side of the filter.
• Also osmotic pressure from non-permeable solutes.
• The rate of UF will depend upon the pressures applied to the
filter and on the rate at which the blood passes through the filter.
• Higher pressures and faster flows increase the rate of
ultrafiltration.
• Lower pressures and slower flows decrease the rate of
ultrafiltration.
21. Blood Out
Blood Into waste
(to patient)
(From patient)
HIGH PRESSLOW PRESS
Fluid Volume
Reduction
ULTRAFILTRATION
22. 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 semi-permeable membrane. In
blood purification this fluid is called dialysate.
• Solutes always diffuse across a membrane from an
area of higher concentration to an area of lower
concentration until equilibration.
24. CONVECTION
• Convection is the movement of solutes through a
membrane by the force of water (“solvent drag”).
• Convection is able to move very large molecules if the
flow of fluid through the membrane is fast enough.
• In CRRT this property is maximized by using
replacement fluids.
• Replacement fluids are crystalloid fluids administered
at a fast rate just before or just after the blood enters
the filter.
25. to waste
HIGH PRESSLOW PRESS
Repl.
Solution
HAEMOFILTRATION:
CONVECTION
Blood Out
Blood In
(to patient)
(from patient)
26. ADSORPTION
• Adsorption is the removal of solutes from the blood
because they cling to the membrane.
• In blood purification. High levels of solute/molecule
adsorption can cause filters to clog and become ineffective.
30. CRRT TREATMENT GOALS
• The concept behind CRRT is to dialyse patients in a
more physiologic way, slowly, over 24 hours, just like
the kidney
• Tolerated well by hemodynamically unstable patients
• Maintain fluid, electrolyte, acid/base balance
• Prevent further damage to kidney tissue
• Promote healing and total renal recovery
• Allow other supportive measures; nutritional support
31. RRT FOR ACUTE RENAL FAILURE
• Newer evidence from RENAL and ATN trials
suggest no difference between higher
therapy CRRT dose and better outcome
• There is no definitive evidence for
superiority of one therapy over another,
and wide practice variation exists
• Accepted indications for RTT vary
• No definitive evidence on timing of RRT
33. VASCULAR ACCESS AND THE
EXTRACORPOREAL CIRCUIT
• There are two options for vascular access for CRRT, venovenous and
arteriovenous.
• Venovenous access is by far the most commonly used in the modern ICU.
34. ELECTROLYTES & PH BALANCE
• Another primary goal for CRRT, specifically:
• Sodium
• Potassium
• Calcium
• Glucose
• Phosphate
• Bicarbonate or lactate buffer
• Dialysate and replacement solutions are used
in CRRT to attain this goal.
35. ANTICOAGULATION & CRRT
• Anticoagulation is needed as the clotting cascades are activated
when the blood touches the non-endothelial surfaces of the
tubing and filter.
• CRRT can be run without anticoagulation
36. SCUF
Primary therapeutic goal:
– Safe and effective management of fluid removal from the
patient
• No dialysate or replacement fluid is used
• Primary indication is fluid overload without uremia or
significant electrolyte imbalance.
• Removes water from the bloodstream through ultrafiltration.
• 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 100-300 mL/hour.
37. SCUF
• High flux membranes
• Up to 24 hrs per day
• Objective VOLUME control
• Not suitable for solute
clearance
• Blood flow 50-200 ml/min
• UF rate 2-8 ml/min
38. SLED(D) & SLED(D)-F : HYBRID THERAPY
• Conventional dialysis equipment
• Online dialysis fluid preparation
• Excellent small molecule detoxification
• Cardiovascular stability as good as CRRT
• Reduced anticoagulation requirement
• 11 hrs SLED comparable to 23 hrs CVVH
• Decreased costs compared to CRRT
• Phosphate supplementation required
Fliser, T & Kielstein JT. Nature Clin Practice Neph 2006; 2: 32-39
Berbece, AN & Richardson, RMA. Kidney International 2006; 70: 963-968
42. PEAK CONCENTRATION HYPOTHESIS
• Removes cytokines from blood compartment
during pro-inflammatory phase of sepsis
• Assumes blood cytokine level needs to fall
• Assumes reduced “free” cytokine levels leads
to decreased tissue effects and organ failure
• Favours therapy such as HVHF, UHVHF, CPFA
• But tissue/interstitial cytokine levels
unknown
Ronco, C & Bellomo, R. Artificial Organs 2003; 27: 792-801
43. THRESHOLD IMMUNOMODULATION
HYPOTHESIS
• More dynamic view of cytokine system
• Mediators and pro-mediators removed from blood to alter tissue
cytokine levels but blood level does not need to fall
• ? pro-inflammatory processes halted when cytokines fall to
“threshold” level
• We don’t know when such a point is reached
Honore, PM & Matson, JR. Critical Care Medicine 2004; 32: 896-897
44. MEDIATOR DELIVERY HYPOTHESIS
• HVHF with high incoming fluid volumes (3-6 L/hour)
increases lymph flow 20-40 times
• “Drag” of mediators and cytokines with lymph
• Pulls cytokines from tissues to blood for removal and
tissue levels fall
• High fluid exchange is key
Di Carlo, JV & Alexander, SR. Int J Artif Organs 2005; 28: 777-786
45. HIGH VOLUME HAEMOFILTRATION
• May reduce unbound fraction of cytokines
• Removes
– endothelin-I (causes early pulm hypertension in sepsis)
– endogenous cannabinoids (vasoplegic in sepsis)
– myodepressant factor
– PAI-I so may eventually reduce DIC
• Reduces post-sepsis immunoparalysis (CARS)
• Reduces inflammatory cell apoptosis
• Human trials probably using too low a dose (40 ml/kg/hour vs
100+ ml/kg/hour in animals)
46. SUMMARY
ARF is not an innocent bystander in ICU
We must ensure adequate dosing of RRT
Choice of RRT mode may not be critical
Septic ARF may be a different beast
We must strive to avert acute renal failure