Название: 40 Years of Continuous Renal Replacement Therapy
Автор: Группа авторов
Издательство: Ingram
Жанр: Медицина
Серия: Contributions to Nephrology
isbn: 9783318063073
isbn:
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Claudio Ronco, MD
Department of Nephrology Dialysis and Transplantation International Renal
Research Institute of Vicenza (IRRIV) St. Bortolo Hospital
Viale Rodolfi 37
IT–36100 Vicenza (Italy)
E-Mail [email protected]
This article has already been published in: Contrib Nephrol. Basel, Karger, 2017, vol 189, pp 114–123. Reproduced here with permission from the publisher.
Bellomo R, Kellum JA, La Manna G, Ronco C (eds): 40 Years of Continuous Renal Replacement Therapy.
Contrib Nephrol. Basel, Karger, 2018, vol 194, pp 15–24 (DOI: 10.1159/000485597)
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Evolution of Vascular Access and Anticoagulation
Patrick M. Honorea · Herbert D. Spapenb
aProfessor of Intensive Care Medicine, Deputy Chairman of ICU Department, Director of ICU Research, Centre Hopitalier Universitaire Brugmann, Brussels, and bProfessor of Intensive Care Medicine, Director of Research Unit and ICU, ICU Department, Universitair Ziekenhuis Brussel, Vrije Universiteit Brussel, Brussels, Belgium
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Abstract
Continuous renal replacement therapy (CRRT) is an important and widely used adjuvant treatment in critically ill patients. However, any CRRT protocol can be adhered to only when the technique is correctly installed and functioning properly. Within this context, an appropriate vascular access and a safe and effective circuit anticoagulation method are key requisites. The right internal jugular (RIJ) vein is the preferred route for insertion with the tip of the catheter placed in the right atrium. Both femoral veins offer a valuable alternative access, but catheters must be longer to avoid recirculation and circuit blood flow is lower as compared with that of the RIJ approach. The location of the catheter is not associated with differences in bacterial colonization/infection rate or filter/circuit lifespan. Adequate anticoagulation is imperative to avoid a system “shutdown” due to the early clotting of the filter. For a long time, unfractionated heparin (UFH) was the anticoagulant of choice. UFH is associated with an increased bleeding risk and requires the use of high circuit blood flows. The introduction of regional citrate anticoagulation (RCA) created a paradigm change in CRRT anticoagulation. RCA can be applied safely in patients with increased bleeding risk and may enhance filter and circuit survival as compared with UFH. RCA requires close monitoring for potentially serious metabolic side effects. Future perspectives include improved catheter technology and development of novel citrate solutions with less severe metabolic impact.
© 2018 S. Karger AG, Basel
Vascular Access
Vascular Access Site and Catheter Positioning
A well-functioning vascular access is imperative to avoid premature failure of the continuous renal replacement therapy (CRRT) circuit [1–3]. According to Poisseuille’s law, flow through a catheter is related to the fourth power of its radius and inversely related to its length. Thus, the ideal catheter is short and has a large (13–14 Fr) diameter [1–3]. СКАЧАТЬ