Q.546. Can you please summarize the efficacy of these various measures and recent guide lines?
HEMODIALYSIS
Q.546. Can you please summarize the efficacy of these various measures and recent guide lines?
A. Comparative efficacy: The foll. results were
rep. in a comparative studies:
{High sodium Dzt, sodium modeling
& cool temperature DX.}⮞ Significant
fewer hypotensive events . Compared to other strategies, sequential
UF & isovolemic DX hd a signif. greater No. of
hypotensive episodes . Post-DX upright B.P. was best é sod. modeling & cool ºC DX,
comp. to standard & isolated UF DX. The best tolerated
& most effective strategy⮞👆 Sodium modeling. High sod. & cool
ºC DX were also effective, while sequential UF & isovol.
DX ⮞less
useful.
Guidelines: Resistant
intradialytic hypotension (K/DOQI 2005
guidelines):
1)
Midodrine &
Dzt ºC profiling.
2)
Dzt
ºC profiling
+ 3 meq/L Dzt Ca+.
3)
Dzt
ºC
& sodium modeling.
4)
Isolated
UF & other approaches may provide benefit.
The 2007 European best practice guidelines in HDX. recommend: 👍
First-line: dietary counseling (sod.🠉), no food intake dur. DX, revise DW, HCo3
as DX buffer, Dzt ºC
of 36.5ºC,
and/or adj. dosing/timing of
anti-H.T. drugs.
Second-line: objective
methods to assess DW., cardiac
clearance, gradual 🠟Dzt ºC fr. 36.5ºC (lowest 35ºC) or isothermic ttt (alternative is convective ttt), blood
volume controlled feedback, 🠉DX time/frequency, and/or Dzt Ca+: 1.50 mmol/L.
Third-line: consider [midodrine, L-carnitine or P.D.].
“Recommendations” for prevention: 👉
1) Exclude
non-DX related causes, e.g.
[myocardial ischemia & pericardial effusion].
2) Efforts shd be made to 🠟interdialytic
wt. gain.
3) DX prescription shd be thoroughly individualized :
I.
Accurate setting of
the dry wt.
II.
Consider cooler ºC DX.
III.
Bicarbonate
buffer.
IV.
Fixed sodium conc.>140 meq/L or sod. modeling
V.
Avoid low Mg & low
Ca+ Dzt.
4) Optimize UF: modeling
alone or+Na modeling or sequential UF & isovol. DX.
5) Avoidance of food &
anti-H.T. drugs on DX day.
6) Administration of midodrine.
Q547. What are the predictors👓of sudden cardiac death among hemodialysis patients?
A. Predictors of sudden
cardiac death among HDX were evaluated using data fr. HEMO study. Among 1745 enrolled HDX ptns., there were 808 deaths over 2.5 y.s, 22 % of wch were due to sudden cardiac death. {Age, D.M.,
peripheral vasc. dis., isch. heart dis., a low s. cr. (reflecting decrease msc mass & poor
nutrition) & an increase ALP.}
predicted ⮞a higher risk for
sudden cardiac death.
Q.548. What are the technical 💢 considerations regarding CVVHD ?
A. Both convection-based (H.F.)
& diffusion-based (H.D.) solute removal techniques are incl. in CRRT.
CVVHD provides diffuse solute clearance for management
of R.F. in critically ill ptns. To perform CVVHD, a system requires only
two fluid management pumps to regulate Dzt inflow &
effluent (spent Dzt +U.F.) outflow. A No. of "integrated" CRRT
machines represent the standard of care.
Any hemoDzer or hemofilter tht provides sufficient diffusive solute clearance cn be utilized in CVVHD. Synthetic, biocompatible membranes are preferred over cellulosic ones. However AN-69 membranes shd be used é caution é ACEI due to incr. incidence of anaphylactoid reactions. Dzt. composition ⮞same as for other CRRT modalities. Heparin is the most widely used anticoagulant. Regional citrate hs bn used as an alternative to heparin in all modalities of CRRT, incl. CVVHD, é minimum total effluent flow rates for CVVHD = 20-25 mL/kg /h..
Q.549. What
is the general considerations of HDX. in the elderly?
A. Many
elderly hv a high quality of life on DX, despite expected limited
survival, lending support to offer ESRD therapy to them. Most elderly wd choose
DX. if given the therapeutic option, esp. if Sm. were relieved
& independence ws maintained.DX
should therefore not be denied to elderly, even the very old, if there’s
hope for prolongation of an enjoyable span of life. However, DX shd not
be used merely to prolong the dying process. When there’s doubt about chances
of recovery fr. sev. underlying dis., a "trial " of DX may be offered. Withdrawal of DX é
later time is preferable to withholding it fr. the start. Major
C.I. to DX: advanced malignancy (except
multiple myeloma), irreversible dementia or advanced
liver dis.. P.D. or HDX. are the two principal options for RRT
in most ptn.s.
Q.550. What are the strategies to minimize dialysis-induced hypotension in the elderly? 🥺🥺
1) Frequent
assessment of D.W.
2) Avoid
excessive interdialytic Wt. gain (<5 %
body Wt.)
3) Avoid
anti-H.T. drugs prior to DX or altogether.
4) Reduce
intake of narcotic analgesics & sedative hypnotics
5) No heavy meals on, or just prior to DX.
6) Incr.
hematocrit to 33%
7) Evaluate
for silent pericardial effusion
8) Use
Dzt sod. of >140 meq/L
9) High
Dzt calcium.
10)
Use bicarbonate DX. (esp.
é high QB)
11)
Prox. O2,
esp. é cardiac or respiratory dis. & preDX PaO2 of
< 80mmHg
12)
Use biocompatible membrane
13)
In selected ptn, use a cool Dzt (34°C!!).
14)
Use DX machines é UF controls
15)
Use sequential UF-DX; occasionally needed when high UF rates are
retired.
16)
Ameliorate risk f.s for LVH (anemia, hyperpara., aluminum
overload)
17)Improve
nutritional status & hypoalbuminemia if present .
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