ICU中的血液净化指南之我见VIP免费

ICU中的血液净化指南之我见ICU中的血液净化指南之我见ContentsIntroduction1Typeoftherapy2TimingofCRRT3DoseofCRRT4Conclusions56IntroductionMethodsofextracorporealrenalreplacementtherapy(RRT)havebeenusedforthesupportivetreatmentofAKIforover60years.CRRTforthecriticallyillpatientwithARFwasintroducedin1977byKrameretal.Sincethen,manystudieshavereportedonCRRTinthecriticallyill.KlinWochenschr1977;55:1121-1122.IntroductionButforseveralreasonscomparisonamongstudiesisdifficult:Varioustreatmentmodalitieshavebeenappliedinheterogeneouspopulations.DifferencesinclinicalsettingandunderlyingmolecularbiologicalmechanismsthatinitiateandmaintainARF.Furthermore,morethan35definitionsofARF.Practicepatternsvarywidelybetweenindividualcenters.Uptonow,therearenostandardguidelinesfortheapplicationofCRRTincriticallyillpatients.CurrOpinCritCare2002;8:509-514.IntroductionTheRIFLEClassificationforacuterenalfailureCritCare2004;8:R204-R212.IntroductionConclusions:Morethen200differentdefinitionsofARFandabout90RRTstartcriteriawerereported.OliguriaandRIFLEwerethemostfrequentcriteriausedtodefineARF.RIFLEcriteriamightshowaclinicalimpactonfuturedailypracticeandresearch.DifferentRRTtechniquesareavailableinmostcenters,butagenerallackoftreatmentdosestandardizationisnotedbyoursurvey.Non-renalindicationstoRRTstillneedtofindadefinitiveroleinroutinepractice.NephrolDialTransplant(2006)21:690–696Inthepast,theinteractionbetweennephrologyandintensivecarewasminimal.Today,thereiscontinuousinteractionwithseveralmomentsofhighinteractionduetocommonpatientsandcomplexsyndromes,andmuchofthetreatmentofAKIhasmovedfromtherenalwardintoICUs.IntroductionContribNephrol.Basel,Karger,2010(166):1–3ContentsIntroduction1Typeoftherapy2TimingofCRRT3DoseorintensityofCRRT4Conclusions56TypeoftherapyClassificationofbloodpurificationincriticalcare(BPCC)technologyPMX=polymyxin-Bimmobilizedfiber;PMMA=polymethylmethacrylate;PAN=polyacrylonitrile;PEPA=polyetherpolymeralloyContribNephrol.Basel,Karger,2010(166):11–20TypeoftherapyAsacontinuoustherapy,CRRTcanberapidlytailoredtochangesinapatient’sclinicalconditionduringcriticalillnessBloodpurificationincriticalcareContribNephrol.Basel,Karger,2010(166):11–20HDF=hemodiafiltrationTypeoftherapyTheseadvantageshavecontributedtothewidespreaduptakeofCRRTasthefirst-choiceRRTinICUsthroughoutAustralia,JapanandEurope.Intheseregions,CRRTisusuallyinitiatedandmanagedwithintheICU,withRRTbeingintegratedwithotheraspectsofthemanagementofcriticalillnessNat.Rev.Nephrol.2010:6:521–529.TypeoftherapyInnorthAmerica,however,traditionalstructuresofICUmanagementfavoran‘open-ICU’approach:Withinthismodel,RRTisusuallyprescribedbyanephrologistintheICUandisinitiatedbyadialysisnurseInthisenvironment,IHDhastheadvantageofrequiringonlydailyoralternate-dayattendancebytherenalteamConversely,therelativelaborcostsofprovidingCRRTareincreased,aneffectthatiscompoundedbythelargerfixedcostsandhigherconsumablerequirementsofCRRTTheselogisticfactorshaveledtoapreferenceforIHDoverCRRTbeingmaintainedinICUsthatusethenorthAmerican.Nat.Rev.Nephrol.2010:6:521–529.TypeoftherapyClinicalstudiesofCRRTintheICUThediversityofclinicalapproachestothetreatmentofAKIintheICUisillustratedbytheresultsoftheBESTKidneystudy,ThemultinationalepidemiologicalstudyofRRTpracticeintheICUStudydocumentedthetreatmentofAKIin1,73...