Seminars in dialysis
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Volume management is an integral component of the care of critically ill patients to maintain hemodynamic stability and optimize organ function. The dynamic nature of critical illness often necessitates volume resuscitation and contributes to fluid overload particularly in the presence of altered renal function. Diuretics are commonly used as an initial therapy to increase urine output; however they have limited effectiveness due to underlying acute kidney injury and other factors contributing to diuretic resistance. ⋯ Complications related to excessive ultrafiltration can occur and have serious consequences. A careful monitoring of fluid balance is therefore essential for all patients. This review provides an overview of the appropriate assessment and management of volume status in critically ill patients and its management with CRRT to optimize organ function and prevent complications of fluid overload.
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Seminars in dialysis · Mar 2009
ReviewContinuous renal replacement therapy in sepsis and multisystem organ failure.
This study reviews the role of continuous renal replacement therapy (CRRT) in sepsis with acute kidney injury (AKI) and septic shock with multiple organ failure. In addition to the conventional aim of replacing renal function in AKI, CRRT is often used with the concept of modulating immune response in sepsis. ⋯ These include high volume hemofiltration, high adsorption hemofiltration, use of high cut-off membranes, and hybrid systems like coupled plasma filtration absorbance. One of the most promising concepts may be the development of renal assist devices using renal tubular cells for implementing renal tubular function into CRRT.
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A working vascular access is essential for performing continuous renal replacement therapy (CRRT) efficiently and without interruption. Dual-lumen temporary hemodialysis catheters are the catheters of choice, although tunneled catheters can also be utilized if therapy is expected to be prolonged. ⋯ Catheter malfunction and catheter-related infections can be reduced by adhering to preventive guidelines such as ultrasound guidance for placement, strict hand hygiene, gauze dressings, and sterile techniques during catheter handling. Antibiotic or antiseptic-coated catheters and lock solutions may be beneficial in certain patients, but these are not widely used due to the concern for resistant organisms and allergic reactions.
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Continuous renal replacement therapy (CRRT) has emerged as the preferred dialysis modality for critically ill patients with acute kidney injury, particularly those with hemodynamic instability. Anticoagulation is necessary for effective delivery of CRRT, but this requirement can also present challenges, as many critically ill patients with sepsis and inflammation already have a higher risk of bleeding as well as clotting. Without anticoagulation, CRRT filter and circuit survival are diminished, and therapy becomes less helpful. ⋯ Because of the potential side effects of heparin, alternative methods of anticoagulation have been investigated, including regional heparin/protamine, low molecular weight heparins, heparinoids, thrombin antagonists (hirudin and argatroban), regional citrate, and platelet inhibiting agents (prostacyclin and nafamostat). Each of these techniques has unique advantages and disadvantages, and anticoagulation for CRRT should be adapted to the patient's characteristics and institution's experience. Of the alternative methods, citrate anticoagulation is gaining wider acceptance with the development of simplified and safer protocols.