???????:CRRT?HDF?On-line monitoring?HP?HF?Plasma exchange

1
???????CRRT?HDF?On-line monitoring?HP?HF?Plasma
exchange

• ?????? ?????? ????????

2
????

• ????????? (Continuous renal replacement
  therapies, CRRT)
• ?????? (Hemodiafiltration, HDF)
• ???? (On-line monitoring)
• ???? (Hemoperfusion, HP)
• ????? (Hemofiltration, HF)
• ????? (Plasma exchange, PE)

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????????? CRRT
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Continuous Renal Replacement Therapy (CRRT)

• CAVH Continuous arteriovenous hemofiltration
• CAVHD Continuous arteriovenous hemodialysis
• CAVHDF Continuous arteriovenous
  hemodiafiltration
• CVVH Continuous venovenous hemofiltration
• CVVHD Continuous venovenous hemodialysis
• CVVHDF Continuous venovenous hemodiafiltration
• AVSCUF Arteriovenous slow continuous
  ultralfiltration
• VVSCUF Venovenous slow continuous
  ultralfiltration

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HD
???
???
???(??)
HF
???(?????)
???
???
6
???????????????????
?? ?? ?? ????? (ml/min)
?????????? CAVH ?? 7-10
?????????? CVVH ?? 15-17
?????????? CAVHD ?? ???? 16-21
?????????? CVVHD ?? ???? 24-29
???????????? CAVHDF ?? ?? ??18-20 ??10
???????????? CVVHDF ?? ?? ??18-20 ??10-13
???????????? AVSCUF ?? 2-5
???????????? VVSCUF ?? 2-5
7
V X
X
8
Multi-mode continuous renal replacement
machine
9
???????

• 1. ????????
• 2. ??????
• 3. ?????(1.5?????????)
• ???????????????????
• ?????????????35???,???????????

10
?????

• ?????????? (heparin)
• ??????(Activated clotting time,
  ACT)?????200-250???
• ?aPTT???40-45???
• ????????????,???????????????,??????????????

11
???(??????)

• ??????????????
• ??????????????????????
• ???????????????

12
???(???????)

• ????????????(???SCUF)
• ??????????
• ????????(ammonia)??????????????
• ???????(Cardiopulmoary bypass)???????(cytokines)??
  
• ??????????
• ???????(acute respiratory distress syndrome,
  ARDS)???
• ?????????????CRRT???????(hyperammonemia)

13
(No Transcript)
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???

• ?????
• ????
• ?????
• ?????
• ?????????
• ????
• ??????????????????????
• ???????????????????????

15
???? (CRRT Order)

• Diagnosis
• CVVH Solution A 3000 cc 15 KCl __ cc IVF
  (500 cc/hr)
• CVVH Solution B 3000 cc 7 NaHCO3 240 cc
  IVF(500cc/hr)
• Record I/O Q1h and Keep I/O _____
• Check BUN,Cr, Na, K, Cl, Ca, P QD Mg QW1,4
• Blood flow 120 ml/min
• Check ACT Q6h and Keep ACT at 200250 sec
• P.S. 15 KCl

6 cc/3L 7.5 cc/3L 9 cc/3L 10.5 cc/3L 12 cc/3L 2.012 meq/L K 2.515 meq/L K 3.018 meq/L K 3.521 meq/L K 4.024 meq/L K
16
????
Desired volume change (ml/hr)
PAWP lt 6 PAWP 6-8 PAWP 9-11 PAWP 12-14 PAWP 15-17 PAWP 18-20 PAWP 21-22 PAWP gt22 175 ml ???????? 125 ml 75 ml Zero balance ? 50 ml ? 75 ml ? 100 ml ? 125 ml ????????
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(No Transcript)
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Chest radiograph demonstrated an 11-year-old
female with advanced cardiac failure before and
after treated with extracorporeal membrane
oxygenation combined with continuous renal
replacement therapy.
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?????? HDF
20
????

• ??????(HDF) ????(HD) ????(HF)
• ????(HD)????????????
• ????(HF)????????
• ???????????,????????

21
???
HD
???
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????

• ????????(ultrafiltration)????????
• ????(ultrapure)????
• ????????(double RO)?????(RO)??????(DI)??
• ?????????????????
• ?????????????????

23
On-line HDF
???(???)
???
???
???
24
????

• ??????????????????????????????
• ?????????????????????????70?????????????????????
  ?????????
• ?????????
• ?????????2?????????
• ?????????,??????????????????(URR)
  ???????70???80?
• EPO??????

25
???? On-line monitoring
26
???????????

• ??????
• ??????
• ???????
• ?????????
• ????????
• ???????
• ?????????????????
• ????
• ?????????
• ???EPO?????
• ???????????
• ????????????
• ???????????,?????????

27
(No Transcript)
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??????????

• ??????
• ????????
• ???
• ????
• ?????????

29
???? HP
30
???????

• ????????????????,??????????
• ???????,????????????
• ????????sorbent ?????????????????
• ???????????????????

31
????

• ?????????,??????????????????????????????(???)????
  ?
• ?????????????????
• ????
• ?????

32
???????

• ???????,???,?????????
• ???????30,???24?48?????????
• ??????,????(Cartridges)???????????????
• ???????,????????????
• ?????????????????
• ????(??1-2?)?

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???? (HP Order)

• Dialyzer active charcoal
• Duration 8 hours
• Vascular access bilateral femoral catheter
  puncture (Not FDL)
• Blood flow 250-300cc (Difficult now due to small
  catheter use)
• UF usually nature
• Medication for paraquat intoxication
• Endoxan 1gm D5W 100cc IVF Qd x 2 times
• Methylprednisolone 1gm D5W 100cc IVF Qdx 3days
• Then dexan 1amp IVF q8h x 11days (4th to 14th)
• Recheck 4 hours later after HP, another HP if
  Urine paraquat gt5PPM or no urine output
• Change to H/D if severe metabolic acidosis,
  hyperkalemia, pulmonary edema, or ARF

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???????????

• ?????????
• ????
• ???
• ??????
• ?????
• ?????????????????
• ?????

• ?????????
• ????
• ???
• ??????
• ???????????

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????? HF
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????????????

• ????????(diffusion)????(ultrafiltration)???????
• ????????????????????(convection)?????
• ????????????,????????,???????????????
• ???????????1,000???????,????????????????25,000?
• ??????????????????????

37
????????

• ????(Pre-dilution method)
• ????(Post-dilution method)
• ?/????(Pre/Post-dilution method)

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??????????

• ??????????
• ???
• ?????????????
• ?????????(iPTH)???,?????????????????
• ???????????????????????????
• ????????????(?2?????),?????????????(?2?????)???

39
????? PE
40
????????

• ?????(plasma exchange),?????????,??????????,??????
  ?,???????????????????
• ?????(plasmapheresis),??????????,?????????????,???
  ???

41
????????

• ???????(centrifugal plasma separation)
• ????????
• ??????????
• ???????(membrane plasma filtration)

42
???????
43
??????
???????
44
lt 0.2 µm
gt 0.7 µm
???????? ??????????
45
????????
? ? ? ?
??? (???????) ??????? ???? ? ABO ???? ???? ?????? ???????
??????(?????) ????? ????? ?????? ??????,????? ???????? ? ABO-????
????? ?? ????????
???? ?? ????
46
?????????
M.Wgt160KD
cascadeflo
BP
0.03µm
???????
0.2µm
???
???????
??50100c.c/ml
?????
BP
plasmaflo
????? ???? (????10)
BP
????
M.Wlt160KD
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lt 0.03 µm
gt 0.03 µm
48
Plasma Exchange (?????) ????
???(??)
Blood pump
?????
Double lumen
?????
???
49
??????????????
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???????

• ?????(Myasthenia gravis)
• ???????(Hperviscosity syndrome)
• ???(pemphigus)
• ???????????(TTP)
• ????????(Goodpastures syndrome)
• ????
• ??????(Coagulation inhibitors)
• ???????(Guillain-Barre syndrome)
• ???????????????(CIDP)
• ?????????
• ????????

51
????????
? (Lungs)
? (Kidneys)
? (Heart)
Extracorporeal organ support therapy
? (Liver) ? !!!
52
Molecular Adsorbent Recirculating System (MARS)
????????????
53
MARS - Membrane
54
The MARS Membrane
55
(No Transcript)
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(No Transcript)
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MARS???

• ?????????
• ?????
• ???????
• ?????????
• ????????????
• ??
• ???????15 mg/dl
• ?????
• ????????????
• ???????
• ??????????????8 mg/dl
• ????????
• Paracetamol ????????

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???? (MARS Order)

• Frequency 3 times
• Dialyzer MARS kit, heparin drain out
• Dialysate
• Albumin dialysate 10pc, 200 ml/min
• No 8, 500 ml/min
• Blood flow 200 ml/min
• Duration 6-8 hours
• UF nature
• Vascular acess FDL
• ACT 160-180 secs (if heparin use)

59
????????

• ?????????
• ??????????????????????,??????????????????????
• ?????????????Citrate?????????????????????????????
  ???
• ??????????????????????????????????????????
• ?????????????????????,??????????48???????
• ??????
• ??????
• ????????
• ???????????????????

60
Thanks for your attention