连续性肾脏替代治疗在临床中的应用及护理

目的通过连续性肾脏替代治疗及护理达到提高多功能脏器衰竭患者的生存率。方法 66例患者采用CVVH、CVVHD、CVVHDF。结果 66例患者通过连续性肾脏替代治疗,均延长生命。其中,好转55例,占80%,病死11例,占20%。结论做到细致、认真的观察和护理;缓慢、均匀的超滤;及时、及早的连续性肾脏替代治疗是降低多功能脏器病死的保障。     

连续性肾替代疗法在老年多器官功能衰竭救治中的应用

目的评估连续性肾脏替代疗法(CRRT)在救治老年多器官功能衰竭(MOFE)患者中作用.方法对我院应用CRRT救治27例MOFE患者作回顾分析,并对CRRT的血管通路、装置、治疗方法及抗凝剂的使用等方面作了改进.结果改进方法后,血管通路以颈内静脉单针双腔导管为主;治疗时间改在白天8～12时、血流量100～200ml/min;根据病情设定的超滤量;调整抗凝剂的应用等,使MOFE患者救治成功率提高(改进前25%,改进后73.6%).结论CRRT是MOFE伴有急性肾功能衰竭的首选方法.CRRT可以改善MOFE患者的预后.     

Continuous Renal Replacement Therapies

Continuous Renal Replacement Therapy (CRRT) is frequently used in patients admitted to intensive care units with multiple organ failure and acute renal failure. These patients are prone to developing hypotension making it very difficult to use conventional haemodialysis for their treatment. When compared to conventional haemodialysis CRRT has obvious clinical advantages. These advantages are mostly due to slow volume and uraemic toxin removal leading to better haemodynamic tolerability for such patients. In our unit during the year 2000, 58 patients were submitted to CRRT: 14 of the patients underwent treatment with continuous veno‐venous haemofiltration and 44 were submitted to continuous veno‐venous haemodiafiltration. The mean patient age was 61.7 years (range: 20–87), 36 male and 22 females. Twenty patients (43.1%) had sepsis, 18 (31%) were post open‐heart surgery, 7 (12%) had multiple organ failure, 4 (6.9%) were polytraumatised, 3 (5.2%) were post neurosurgery and 1 (1.8%) was a liver transplant patient. Despite the grave prognosis of these patients, 22 (37.8%) survived and 36 (62.2%) died. Of the patients that survived, 10 (17.2%) recovered renal function and 12 (20.6%) remained on a regular haemodialysis programme. The authors conclude that CRRT seems to be an alternative to conventional haemodialysis for the treatment of those patients with acute renal failure.     

Effluent Volume in Continuous Renal Replacement Therapy Overestimates the Delivered Dose of Dialysis

Summary

Background and objectives

Studies examining dose of continuous renal replacement therapy (CRRT) and outcomes have yielded conflicting results. Most studies considered the prescribed dose as the effluent rate represented by ml/kg per hour and reported this volume as a surrogate of solute removal. Because filter fouling can reduce the efficacy of solute clearance, the actual delivered dose may be substantially lower than the observed effluent rate.

Design, setting, participants, & measurements

Data were examined from 52 critically ill patients with acute kidney injury (AKI) requiring dialysis. All patients were treated with predilution continuous venovenous hemodiafiltration (CVVHDF) and regional citrate anticoagulation. Filter performance was monitored during the entire course of therapy by measuring blood urea nitrogen (BUN) and dialysis fluid urea nitrogen (FUN) at initiation and every 12 hours. Filter efficacy was assessed by calculating FUN/BUN ratios every 12 hours of filter use. Prescribed urea clearance (K, ml/min) was determined from the effluent rate. Actual delivered urea clearance was determined using dialysis-side measurements.

Results

Median daily treatment time was 1413 minutes (1260 to 1440) with a total effluent volume of 46.4 ± 17.4 L and urea mass removal of 13.0 ± 7.6 mg/min. Prescribed clearance overestimated the actual delivered clearance by 23.8%. This gap between prescribed and delivered clearance was related to the decrease in filter function assessed by the FUN/BUN ratio.

Conclusions

Effluent volume significantly overestimates delivered dose of small solutes in CRRT. To assess adequacy of CRRT, solute clearance should be measured rather than estimated by the effluent volume.     

连续性肾脏替代疗法抢救急危重症43例疗效分析

目的 :总结连续性肾脏替代疗法 (CRRT)对各类重症疾病的疗效 ,旨在总结经验 ,提高疗效。方法 :CRRT治疗的 4 3例重症患者按病因分类 ,并分析各类疾病CRRT前后神志、肝、肾功能、电解质及生命体征的变化。结果 :8例肾移植后急性肾功能衰竭者经CRRT治疗后 8～ 16hSCr、BUN逐渐下降。 7例肝性脑病、肝肾综合征及 4例多脏器衰竭者经CRRT治疗后 ,2例肝昏迷者神志恢复 ,4例肾功改善 ,治疗中生命体征稳定。 8例因脑卒中高钠血症者在行CRRT治疗 8～12h后血钠下降。结论 :①肾移植后急性肾功能衰竭患者经CRRT治疗后肾功能恢复时间明显缩短。②对肝性脑病、肝肾综合征患者 ,CRRT可改善神志及肾功能 ,延长存活时间 ,为行肝移植赢得时间。③CRRT能降低脑卒中高钠血症 ,疗效好     

连续性肾替代治疗在多器官功能障碍综合征的应用

总结21例多器官功能障碍综合征(MODS)患者采用连续性肾替代治疗(CRRT)的临床资料,观察患者治疗前后血压、心率改变及血气、电解质和肌酐、尿素氮的变化,结果治愈7例(33.3%),死亡14例(66.7%).本法优点是设备简单,能有效纠正危重患者液体平衡、纠正酸中毒和电解质紊乱,甚至在严重休克状态下,也能保持血流动力学稳定,适用于急性肾功能衰竭合并MODS患者.     

连续性肾脏替代疗法治疗胰腺炎肾损害的研究

急性胰腺炎年人均发病率达到5~80/10万,且有逐年增加趋势。其中,重症急性胰腺炎（severe acute pancreatitis,SAP）的发生率为20%,总体病死率约为10%~30%。临床上,在该病的发展中病死率呈现出2个高峰。其中,51%~73%的患者在发病第1周死于多种细胞因子释放所致的继发性多器官功能障碍（multiphe organ failure,MOF）和全身性     

Comparison of Blood Compatibility in Various Membrane Materials for Continuous Renal Replacement Therapy

Because hemofilters used for continuous renal replacement therapy contact with blood over a prolonged period during treatments, platelet activation may occur stronger. The purpose of this study is to clarify the blood compatibility in three hemofilters mostly used in Japan. We compared the blood compatibility of the two polysulfone (AEF: Asahi Kasei Medical Co., Tokyo, Japan and SHG: Toray Medical Co., Ltd., Tokyo, Japan) and one polymethylmethacrylate membranes (CH: Toray Medical Co., Ltd.). First, test blood was collected from healthy volunteers. Subsequently, the blood was circulated by a roller pump at the rate of 100 mL/min. We measured the platelet counts and platelet factor 4 (PF4). The platelet counts at 48 h in polymethylmethacrylate membrane were significantly less than that in polysulfone membranes. Levels of the PF4 after the circulation were 978.5 ± 200.0 ng/dL with AEF, 863.0 ± 233.9 ng/dL with SHG and 1780.0 ± 465.1 ng/dL with CH, respectively. Hemofilters with polysulfone membranes showed less platelet activation. It was inferred that the amount of PVP, the smoothness of the membrane surface, and the inner diameter of the hollow fiber affect the blood compatibility in the hemofilter.     

Factors Affecting Circuit Life During Continuous Renal Replacement Therapy in Children With Liver Failure

Despite abnormal clotting, circuits clot during continuous renal replacement therapy (CRRT) in children with acute liver failure (ALF). We report our experience. All children with ALF needing CRRT were studied over 2 years. Patient and circuit factors associated with circuit use were evaluated. Thirty‐one children in liver failure (median age 7.4 years) underwent CRRT, of which 17 (54.8%) died. A total of 98 filtration episodes were used. The smallest access catheter was 6.5 Fr, while the largest was 13.5 Fr. The most common filter used was HFO7 (63%). Mean duration (SD) of circuit use was 33.13(30.83) hours. Of the 98 filtration episodes, circuits blocked in 25, whereas the access catheter blocked in 25. Fifty‐two circuits were changed electively for a variety of reasons. Prostacyclin was the anticoagulant in 62 filtration episodes. The remaining filtration episodes had either no anticoagulation or heparin. The mean (SD) “downtime” was 5.13 (9.15) hours. We found a significant association between fresh frozen plasma (FFP) use with circuit blockade. Neither the duration of CRRT nor the “downtime” influenced mortality. The CRRT circuits blocked in children despite deranged clotting in liver disease. Circuits are changed for a variety of reasons other than clotting. The use of FFP reduces circuit life.     

High Phenobarbital Clearance During Continuous Renal Replacement Therapy: A Case Report and Pharmacokinetic Analysis

Phenobarbital is an old antiepileptic drug used in severe epilepsy. Despite this, little is written about the need for dose adjustments in renal replacement therapy. Most sources recommend a moderately increased dose guided by therapeutic drug monitoring.A 14 year old boy with nonketotic hyperglycinemia, a rare inborn error of metabolism, characterized by high levels of glycine, epilepsy, spasticity, and cognitive impairment, was admitted to the emergency department with respiratory failure after a few days of fever and cough. The boy was unconscious at admittance and had acute renal and hepatic failure.Due to the acute respiratory infection, hypoxic hepatic and renal failure occurred and the patient had a status epilepticus.The patient was intubated and mechanically ventilated. Continuous renal replacement therapy was initiated. Despite increased phenobarbital doses, therapeutic levels were not reached until the dose was increased to 500 mg twice daily. Therapeutic drug monitoring was performed in plasma and dialysate. Calculations revealed that phenobarbital was almost freely dialyzed.Correct dosing of drugs in patients on renal replacement therapy may need a multidisciplinary approach and guidance by therapeutic drug monitoring.     

Therapy of Severe Heatshock in Combination With Multiple Organ Dysfunction With Continuous Renal Replacement Therapy: A Clinical Study

This study aimed to compare the clinical effects of continuous renal replacement therapy (CRRT) and routine therapy in heatshock (HS) patients.We retrospectively reviewed the clinical information of 33 severe exertional HS patients who were treated from February 1998 to October 2013. On the basis of whether or not CRRT therapy was used in addition to conventional therapy, patients were divided into a CRRT group (n = 15) and a control group (n = 18). Body temperature, blood gas analysis, routine blood tests, blood eletrolytes, enzymes and kidney function data, and APACHE II scores were obtained and compared between the 2 groups on admission and 3, 5, and 7 days after admission. Mortality was also compared between the 2 groups.CRRT treatment combined with conventional treatment resulted in a higher hospital-discharge rate, a faster return to normal of body temperature, greater increase in platelets, a greater decrease in WBC, neutrophils, and serum markers for liver and kidney dysfunction, greater improvement of organ dysfunction, and lower APACHE II scores than conventional treatment used alone.The addition of CRRT to conventional treatment for HS improves survival and causes a faster return to normal of serum markers and organ function.     

Hormone Replacement Therapy and Cardiovascular Risk

Hormone replacement therapy (HRT) is effective in suppressing postmenopausal symptoms and, in the past, many have claimed that it is cardioprotective. It was thought that the lower incidence of cardiovascular disease in premenopausal women was related to the cardioprotective effect of estrogen. Many of these studies were, however, observational studies. HRT alters many cardiovascular parameters, most beneficially. The mixed effect on these parameters make the overall result on cardiovascular risk difficult to predict. However, recent randomized, placebo-controlled trials have shown not only that HRT does not confer cardioprotection, but that it actually increases one's cardiovascular risk in the short term. Based on the current evidence, HRT should not be recommended in the hope that it will protect postmenopausal women against coronary heart disease.