Blood purification
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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.
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To examine biochemical effects of phosphate-containing replacement fluid (Phoxilium(®)) for continuous venovenous hemofiltration (CVVH). ⋯ Phoxilium versus Accusol use during CVVH effectively prevented hypophosphatemia but contributed to mild hyperphosphatemia, and is associated with relative hypocalcemia and metabolic acidosis.
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Since the introduction of the new pathophysiological concept of pathogen-associated molecular patterns (PAMPS) and alarmins, endotoxin has been recognized as only one of the PAMPS. It is widely accepted that hypercytokinemia plays a pivotal role in the pathophysiology of sepsis. ⋯ We report that continuous hemodiafiltration (CHDF) with a cytokine-adsorbing hemofilter (CAH), such as polymethyl methacrylate hemofilter and AN69ST hemofilter (CAH-CHDF), can remove many kinds of cytokines and has been very effective in the treatment of severe sepsis and septic shock. Based on the understanding of the recent pathophysiology, we suggest that CAH-CHDF is an alternate therapy to direct hemoperfusion with endotoxin-adsorbing column in the treatment of sepsis.
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Renal replacement therapy (RRT) remains associated with a significant risk of serious complications, and critically ill patients requiring RRT continue to manifest particularly poor overall survival rates. These poor outcomes persist despite improvements in the modalities employed as well as an enhanced understanding of the effects of the extracorporeal circuit, anticoagulation, treatment doses, fluid replacement and dialysis membrane. More recently, there has been an emerging appreciation that intermittent RRT (in the chronic maintenance haemodialysis setting) is capable of generating sufficient circulatory stress to propagate additional widespread end-organ injury. The mitigation of this plethora of risks by the correct identification of complications, targeting of therapy refinements and prediction, whilst problems still remain occult, is desirable and becoming increasingly possible in the pursuit of improved outcomes in this high-mortality therapeutic field.