Seminars in dialysis
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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.
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Seminars in dialysis · Jan 2009
ReviewHemoglobin control, ESA resistance, and regular low-dose IV iron therapy: a review of the evidence.
Anemia management in hemodialysis patients has progressed following the introduction of erythropoiesis-stimulating agents (ESAs) and intravenous (IV) iron. However, maintaining a stable hemoglobin (Hb) level can be challenging. ⋯ Fluctuating Hb levels is associated with increased complications. This article reviews factors that affect Hb control, with a focus on management practices (e.g., regular low-dose administration of IV iron) that can help improve anemia management.
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Seminars in dialysis · Sep 2008
Secondary arteriovenous fistulas: converting prosthetic AV grafts to autogenous dialysis access.
As existing arteriovenous grafts (AVGs) fail, the National Kidney Foundation KDOQI Guidelines and the AV Fistula First Breakthrough Initiative ("Fistula First") project recommend that each patient be re-evaluated for conversion to an arteriovenous fistula (AVF). AVFs created following failure of an AVG have been termed secondary fistulas (SAVF). We review our experience and outcomes converting AVGs to SAVFs, utilizing the mature outflow vein of the AVG when possible, otherwise creating a new AVF at a remote site. ⋯ Vessel mapping is critical in the evaluation of failing AVGs and in preparation for a SAVF. Cumulative patency rates exceeded 90% at 12 months for SAVFs in both patient groups in this report. The need for catheters was dramatically less in the patient group with an established SAVF conversion plan.
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Seminars in dialysis · Sep 2008
A modified supraclavicular approach for central venous catheterization by manipulation of ventilation in ventilated patients.
Because of overuse and multiple implantations of hemodialysis catheters through internal jugular or subclavian vein (SCV) in patients with chronic hemodialysis, these veins often become stenotic or occlude, therefore necessitating alternative access. We introduce a new technique in ventilated patients for placement of tunneled cuffed chronic hemodialysis catheter: modified supraclavicular approach by cease of ventilation. ⋯ The modified supraclavicular approach with lung deflation for tunneled cuffed chronic hemodialysis catheter in ventilated patients is at least as effective as traditional approach and can be easily performed by surgeons as well as experienced physicians. Based on the results, this simplified technique using lung deflation may be particularly useful to decrease procedural complications.