Excessive fluid is not needed: So why is Dr. Durward so wasteful? Timothy E Bunchman MD Professor &...
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Transcript of Excessive fluid is not needed: So why is Dr. Durward so wasteful? Timothy E Bunchman MD Professor &...
![Page 1: Excessive fluid is not needed: So why is Dr. Durward so wasteful? Timothy E Bunchman MD Professor & Director Pediatric Nephrology tbunchman@mcvh-vcu.edu.](https://reader035.fdocuments.net/reader035/viewer/2022070401/56649f1f5503460f94c381e1/html5/thumbnails/1.jpg)
Excessive fluid is not needed: So why is Dr. Durward so wasteful?
Timothy E Bunchman MDProfessor & DirectorPediatric Nephrology
[email protected]@gmail.com
www.pcrrt.com
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Comparison of Urea Clearance: CVVH vs CVVHD
(Maxvold et al, Crit Care med. 2000 Apr;28(4):1161-5)
0
5
10
15
20
25
30
CVVH CVVHD
U
rea
Cle
aran
ce(m
ls/m
in/1
.73
m2)
BFR = 4 mls/kg/minFRF/Dx FR = 2 l/1.73 m2/hrSAM = 0.3 m2
p = NS
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Dialysis Dose and OutcomeRonco et al. Lancet 2000; 351: 26-30
• Conclusions:– Minimum UF rates should be ~ 35
ml/kg/hr– Survivors had lower BUNs than non-
survivors prior to commencement of hemofiltration
425 patientsEndpoint = survival 15 days
after D/C HF
146 UF rate 20ml/kg/hrsurvival significantly lower
in this group compared to the others
139 UF rate 35ml/kg/hrp=0.0007
140 UF rate 45ml/kg/hrp=0.0013
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Intensive vs non Intensive RRT
HD and CRRT at 6 days per week and 35 mls/kg/hr daily
Vs. HD and CRRT at 3 days per week and 20
mls/kg/hr daily Intensity of Renal Support in Critically Ill
Patients with Acute Kidney Injury The VA/NIH Acute Renal Failure Trial Network* NEJM july 3, 2008 vol. 359 no. 1
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The VA/NIH Acute Renal Failure Trial Network. N Engl J Med 2008;359:7-20
Kaplan-Meier Plot of Cumulative Probabilities of Death (Panel A) and Odds Ratios for Death at 60 Days, According to Baseline Characteristics (Panel B)
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Copyright restrictions may apply.
Lins, R. L. et al. Nephrol. Dial. Transplant. 2009 24:512-518; doi:10.1093/ndt/gfn560
Survival curves in patients randomized to intermittent (IRRT) or continuous (CRRT) renal replacement therapy investigating ICU mortality and hospital
mortality
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Meta Analysis-8 Studies(Clin J Am Soc Nephrol 5:956-963, 2010)
Intensity of Dialysis result in the following No difference in death rate No difference in outcome based upon APACHE
score No difference in renal recovery No difference in outcome based upon weight
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Look at data on nutritional loss! Look at data on drug loss!
Wasteful
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Comparison of Total Amino Acid losses: CVVH vs CVVHD
(Maxvold et al, Crit Care Med 2000 Apr;28(4):1161-5 )
12.4 11.6
0
2
4
6
8
10
12
14
16
CVVH CVVHD
Am
ino
Aci
d L
oss
es
(g
/day
/1.7
3 m
2)
NS
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Sieving Coefficients
Solute (MW) Convective Coefficient Diffusion Coefficient
Urea (60) 1.01 ± 0.05 1.01 ± 0.07
Creatinine (113) 1.00 ± 0.09 1.01 ± 0.06
Uric Acid (168) 1.01 ± 0.04 0.97 ± 0.04*
Vancomycin (1448) 0.84 ± 0.10 0.74 ± 0.04**
Calcium (protein bound) 0.67 + 0.1 0.61 + 0.07
Cytokines (large) adsorbed minimal clearance
*P<0.05 **P<0.01
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Rebottled slide to follow
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Why not save on resources?