(持续性肾脏替代治疗crrt英文)renal-replacement-therapy(63p)课件.ppt
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- 持续性肾脏替代治疗crrt英文 持续性 肾脏 替代 治疗 crrt 英文 renal replacement therapy 63 课件
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1、 Measurement Renal hypoperfusionAcute renal failureUrinary sodium(mmol/l)40Urine:plasma urea ratio202 48 hours is very good 24 hours is acceptable 12 hours is problematic 24hrs.If patients are on Drotrecogin alpha Xigris and are receiving RRT they rarely need additional heparin to achieve acceptable
2、 filter life.The default position is no heparin whilst on Xigris.Platelet counts inevitably fall when on RRT.They fall further on anticoagulant free RRT c.f.than with the use of heparin.In a patient with thrombocytopenia e.g.from sepsis where one chooses to avoid heparin consideration can be given t
3、o the use of epoprostenol in a bid to prolong filter life and attenuate the anticipated fall in platelets c.f.heparin free RRT.GROUP 1-Patient at moderate risk of bleedingRegard this as the standard option-the typical ITU RRT patient e.g.1 Average 2 or more organ failures 4.Surgery 48 hours ago2 No
4、florid coagulopathy 5.No evidence of active bleeding3 Platelets 50 6.No ureamic complicationsHEPARIN BOLUS DOSEINITIAL HEPARIN INFUSION RATETARGET APTT and ratio20-25 units/kg maximum 3000 units10 units/kg/hr35 45 1.3 1.7GROUP 2-Patients at low risk of bleeding or where standard approach results in
5、poor filter life One may require to gradually escalate to this approach where the standard approach has failed and the risk is judged worthwhile.There will be the rare patient who justifies this approach from the start e.g.primary renal problem,another requirement for formal anticoagulationHEPARIN B
6、OLUS DOSE INITIAL HEPARIN INFUSION RATE TARGET APTT and ratio 50 units/kgmaximum 5000 units 15 units/kg/hr 50-65 1.9 2.4Aim for the lower end of this range at first if escalating from the standard approachGROUP 3-Patient at high risk of bleedingWith problems such as 1.Within 48 hours of surgery4.Pla
7、telets 25.Recent active bleeding3.APTT 506.Urea 45 or ureamic complicationGenerally it is worth trying anticoagulant free RRT in the first instance GROUP 3-Patient at high risk of bleeding If filter life is thereafter judged unacceptable and/or the risk considered worthwhile then starting heparin or
8、 epoprostenol as below is reasonable.If thrombocytopenia is a particular problem then perhaps Flolan should be the initial choice greater platelet sparing.If filter life is poor on either of these strategies then the use of them in conjunction may be worthwhile,alternatively it may be judged necessa
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