Blood purification
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Because of the potential side effects of heparin, methods of regional citrate anticoagulation (RCA) for continuous renal replacement therapy (CRRT) have been gaining wider acceptance with the development of simplified and safer protocols. Advantages of RCA include the avoidance of systemic anticoagulation and heparin-induced thrombocytopenia. The disadvantage is that citrate can add complexity and labor intensity to CRRT. ⋯ A variety of methods of delivering RCA are described in the literature. Overall, studies of RCA, as compared to unfractionated heparin, report better filter survival times and less bleeding. In this section, we summarize the characteristics of citrate as an anticoagulant and provide an update of citrate use in CRRT.
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Multicenter Study Clinical Trial
Time to initiation of treatment with polymyxin B cartridge hemoperfusion in septic shock patients.
We investigated whether early initiation of hemoperfusion with a polymyxin B cartridge (PMX) after the diagnosis of septic shock could improve the clinical outcome. ⋯ Early initiation of PMX shortened the duration of ventilator support and also reduced the catecholamine requirement, so early treatment of septic shock should achieve a better outcome.
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Dialysis patients account for 1-9% of all intensive care unit (ICU) admissions. As a result of the increasing prevalence of patients with end-stage renal disease (ESRD) and the changing demographics of this population, the number of dialysis patients requiring hospitalization and ICU support is expected to increase. ⋯ ESRD patients have been excluded from trials evaluating renal replacement therapy in the ICU, therefore little information is available about the optimal management of renal replacement therapy for dialysis patients in this setting. This review focuses on the epidemiology of chronic dialysis patients admitted to the ICU and discusses an approach to providing renal replacement therapy for critically ill patients with ESRD.
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Attempts at achieving cytokine homeostasis include blood purification to deliver cytokine removal. Assessment of ex vivo studies for optimal operating conditions is a vital step. ⋯ Ex vivo data support the view that HCO/HF is the most consistently effective approach in terms of sieving and clearance. Further investigation of HCO/HF in randomized controlled trials in animal models and humans seems desirable.
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Patients are at risk of haemodynamic instability when starting continuous renal replacement therapy (CRRT). ⋯ We cannot recommend a slower pump speed start based on our findings, but advocate for close haemodynamic monitoring, as haemodynamic changes in individual patients cannot be predicted in advance.