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Dialysis - Getting it Right

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by

Celia Bradford

on 9 October 2014

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Transcript of Dialysis - Getting it Right

Dr Celia Bradford
Intensivist
Royal North Shore Hospital Sydney
Subject
Your information here
Ideas
Divide your ideas
Divide your ideas
Ideas
The Case
PRESENTS TO ED
62 YEAR OLD MAMIL
Reduced exercise tolerance


1/Pancytopenia;WCC 3, HB 71, PLT 40

2/Acute Kidney Injury; Cr 160, K+ 5.6, BE -6

3/CXR; bilateral infiltrates

4/CT Chest; non-specific interstitial changes, with nodular opacities and patchy ground glass changes

Background;
1/AF on dabigatran
Progress
Respiratory
deterioration
Haemodynamic
compromise
Anuria
Admission
to ICU

Monday
Tuesday
Problems to think about today
Mode of Dialysis
Wednesday
Thursday
20 days
later
The Heparin
Citrate Trial
Over 3 years,
the filter life of 857 dialysis filters were examined when patients were randomised to citrate
OR
heparin-protamine
Results
Progress
Freedom
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circle
ideas
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Separate elements
Dialysis;
Getting
it Right

VASCULAR ACCESS
MODES OF DIALYSIS
SETTING THE FLOWS
ANTICOAGULATION

MAMIL
Intubated; difficult to ventilate
Central line and vascath placed
Platelet count
a/>100
b/>80
c/>50
d/>20
Dabigatran
a/Ignore and go ahead
b/FFP
c/rFVIIa
d/PCC
There is no specific antidote
Cease treatment
Haemodiafiltration effective
Life threatening bleeding use
-PCC
-APCC
-rFVIIa

BMAT performed; Diagnosis AML
Vasopressor support commenced
VASCATH LOCATION
a/RIJ
b/FV
c/LIJ
d/SUBCLAVIAN
VASOPRESSORS
a/Dopamine
b/Adrenaline
c/Noradrenaline
d/Vasopressin
INVESTIGATIONS
Dose of Dialysis
Anticoagulation
Mode of Dialysis
1/CRRT

2/IHD

3/SLEDD
CRRT
CVVHF
CRRT
CVVHD
Dose of Dialysis
RENAL study
HVHF
DOSE = REPLACEMENT FLUID + DIALYSATE + FLUID REMOVED
ANTICOAGULATION
Nothing
Heparin with protamine reversal
Citrate
CARING FOR THE FAILED KIDNEY
Fluids
Nutrition
Avoid Nephrotoxic Drugs
Contrast
Intubated for 10 days
Dialysed for 14 days
Induction chemoRx
Full transcript