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PD_in_ARF - PD in ARF PD Brad Weaver MD PD vs HD PD PD...

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Unformatted text preview: PD in ARF PD Brad Weaver, MD 2/19/08 PD vs. HD PD PD often overlooked as treatment option in PD ARF ARF Most useful compared to HD in patients Most who are: who Hemodynamically unstable - alternative to Hemodynamically CVVH CVVH Coagulopathic – avoids venous puncture and Coagulopathic systemic anticoagulation Other advantages of PD Other Avoids disequilibrium syndrome because Avoids of slow solute removal of Widely available Hyperalimentation via diffusion of glucose Hyperalimentation (in malnourished patients) (in Can be used to treat concomitant Can hypothermia or hyperthermia hypothermia Contraindications to PD in acute setting setting Severe hyperkalemia Abdominal and thoracic surgery – Abdominal hydrothorax may develop after thoracic surgery surgery Respiratory problems – increases Respiratory intraabdominal pressure intraabdominal GERD Pregnancy Access Access Semirigid (Cook) catheter Can be done at bedside without surgeon Must be removed within 72 hours because of Must risk of bowel perforation and infection risk Cuffed permanent catheter More comfortable Avoids repeated punctures Avoids Cuffed permanent catheters Cuffed Acute PD Rx Acute Short dwell times Can be done manually or by automated Can cycling device cycling Warm PD fluid to body temperature Often dialysate volume 2-3L and dialysate Often flow rate 2-6L/hr flow Important to ensure complete outflow at Important finish finish Popovich, Ann Intern Med 1978; 88:449 Standard PD solution Standard Volume (L) Sodium (mEq/L) 0.25, 0.5, 1.0, 1.5, 2.5, 3.0, 5.0, 6.0 132 Potassium (mEq/L) 0­2, mostly 0 Glucose (g/dL) 1.5, 2.5, 4.0, 25 Calcium (mEq/L) 2.5­3.5 Magnesium (mEq/L) 0.5­1.5 Lactate (mEq/L) 35­40 Additives Additives Heparin – 200 to 500u per liter, not Heparin absorbed systemically absorbed Potassium Potassium Insulin 4-5u/L for 1.5% dextrose 5-7u/L for 2.5% dextrose 7-10u/L for 4.5% dextrose Hypernatremia Hypernatremia A possible complication of acute PD Aquaporin 1 channels on peritoneal membrane Aquaporin are activated by hypertonic dialysate are Free water moves into peritoneal space Sodium then diffuses down its concentration Sodium gradient but may be limited by short exchange time time Treat by increasing exchange time or by Treat decreasing dialysate tonicity decreasing Phu, N Engl J Med 2002 Phu, 70 patients in Vietnam with ARF from 70 malaria or sepsis malaria Randomized to acute PD or CVVH Increased mortality in PD group vs. CVVH Increased (47 versus 15 percent, odds ratio 5.1, 95 percent CI 1.6 to 16). ...
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