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H ow to performed dialysis circuit with ECMO

H ow to performed dialysis circuit with ECMO. 蔡壁如 2011-8-25. 1996-2010 ECMO + Dialysis data. ECMO Data base ： 900 / 400 ( 44.4% ). Outline. Case presentation Critical dialysis in ECMO patients Data report. Case Presentation. 林 x x Chart NO:4462271 NTUH Admission date:2011-5-14

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H ow to performed dialysis circuit with ECMO

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  1. How to performed dialysis circuit with ECMO 蔡壁如 2011-8-25

  2. 1996-2010 ECMO + Dialysis data ECMO Data base：900 / 400( 44.4% )

  3. Outline • Case presentation • Critical dialysis in ECMO patients • Data report

  4. Case Presentation • 林 x x Chart NO:4462271 • NTUH Admission date:2011-5-14 • SICU Admission date:2011-5-14 • Severe septic shock with ARDS • Expired date:2011-6-13 • Total SICU stay :30 days

  5. Patient history • This 44 yrs man had no systemic disease before. • Suffered general malaise and joint pain (3月) •  中山醫學院附設醫院：with bilateral dorsal hands swelling, local heat and pain were found. •  visited 中國 hospital where lab data showed rheumatic factor 400. • Rheumatoid arthritis was diagnosed.

  6. Patient Course • Symmetric polyarthitis of hands was found. • Body weight loss 6kg in one month. • Under the impression of acute RA, he was admitted and systemic steroid and Mabthera infusion. • MTX (Methotrexate 4# Q7D) was also added. • The symptoms of RA improved after treatment.  Discharge

  7. Patient Course • 4/28 ER • Shortness of breath, dry cough were noted. • CXR showed diffuse bilateral alveolar infiltration. • Hypoxia was noted. • Chest CT showed diffuse peribronchial parenchyma and alveolar inflammatory change. • Acute lung injury was impressed. • 4/30 Admitted to MICU

  8. Patient Course • BiPAP and relative clear bilateral breathing sound and scanty sputum was noted. • Tazocin was given (2011/04/30~2011/05/04). • Tamiflu 75mg for 5 days (2011/04/30~2011/05/04). • Hydrocortisone 100mg Q8H for RA and ARDS. • 5/4 • Intubated SpO2 90%, FiO2：0.9, PEEP15,TV 600ml. • Gancyclovir 500mg Q12h for possible CMV infection. • 5/5 • IVIG. • Antibiotics were then shifted to Vancomycin and Tienam. • Diflucan.

  9. Patient Course • 5/10 • MTX related interstitial pneumonitis was suspected. • CDC reported CMV RT-PCR positive • 5/11 • Cytotect 2ml/kg • On ECMO due to severe ARDS • OI: 41.6, AaDO2:610 • FiO2:1.0, PaO2 :48 • 5/13 • Sputum culture showed MDRAB • Tygacil was added

  10. Treatment Course

  11. 2011-5-14

  12. SLEDD-f on ECMO

  13. Early goal-directed hemofiltration therapy • Pulse high volume therapy：96hr • 1. 100 cc/Kg/hr X 4hr, then 50cc/Kg/hr X 92hr • 2. Simultaneous APC (Xigirs) therapy • 1+2 keep 96hr • 5/18 CAVH on ECMO：2000 cc//hr

  14. Treatment Course • 5/18 • Xigris finish ： SLEDD-f shift to CAVH • IVIG given ：hypogammaglobulinemia 5/18 ~ 5/22 • C3：53.2、C4：13.9 • IgA：94.1、IgG：630、IgM：24.3 • RA Factor (Nephelometry)(IU/mL) ：32.30 • 5/24 • Septic shock • CVP： Acinetobacter baumannii (MDRAB)3+ • CVP：Enterobacter cloacae •  bronchial washing：Acinetobacter baumannii(MDRAB)3+ • CAVH shift to 5008HF (70cc/kg/hr)

  15. Treatment Course • 6/5 • V-A ECMO A-cannula clot：removal and re-on • 6/9 • X-ray ：Bilateral hemothorax and empyema • CT：large hyperdense hematoma (18.4cm) in left subphrenic area and basal lung. • 6/10 OP • VATS exploration and decortication, bilateral • The blood loss is about 1300(L) + 700(R)ml • Tracheostomy • 2011/06/11~06/13 • Bleeding tendency and profound shock • Expired

  16. Xigirs CAVH (35cc/kg/hr) c-SLEDD-f 5008 HF (70cc/kg/hr) IVIG

  17. Xigirs：5/14 ~ 5/17 Tygacil Colistin IVF+IH Sevatrim Cravit Diflucan Sputum 5/14 ~ 6/12：Acinetobacter baumannii(MDRAB) 1+ ~ 3+ Blood culture：5/22 Acinetobacter baumannii(MDRAB)1+ ~ 3+ Sputum & wound ：6/9 Pseudomonas aeruginosa 3+ CVP culture 5/26 ： Enterobacter cloacae

  18. ARDS data 5/15 Left Pneumothorax 5/25 Right Pneumothorax 6/9Bilateral hemothorax and empyema

  19. Nutrition Cal : 120014402160 2400 2880 Protein: 1g/Kg 1.5g/Kg2.0g/Kg Alb:5/14(3.3) 5/20(2.8) 5/29(2.2) 6/12 (2.2) P : 5/16(1.0) 5/19(2.6) 5/23(2.8) 5/25(2.0) 6/2(2.4) 6/6(1.4) 6/9(2.1) 6/12(2.8)

  20. Critical dialysis in ECMO patient • CAVH on ECMO • 5008 c-SLEDD-f on ECMO • 5008 HF on ECMO

  21. Continuous dialysis by gravity through the filter of extracorporeal membrane oxygenation Nephrol Dial Transplant. 2007 Dec;22(12) : 3676-7.

  22. 血流方向：動脈導管側孔到靜脈導管 (PG:120~150 mmHg) CAVH flow by Transonic HT100 transducer measure and by screw control: 300~400cc/min UF rate: 2000 cc/hr Replacement fluid: Sintom A + B solution Net UF rate: as titration

  23. 血流方向：氧合器側孔到靜脈導管 (PG:120~150 mmHg) CAVH flow by Transonic HT100 transducer measure and by screw control: 300~400cc/min UF rate: 2000 cc/hr Replacement fluid: Sintom A + B solution Net UF rate: as titration

  24. 血流方向：氧合器側孔到動脈導管 (PG: mmHg) Blood flow : 300 cc/min Dialysate: 100 ~ 800 cc/min HCO3: 26 ~ 32 K+: 2 ~ 4 Replacement fluid:35 cc/kg/hr Duration : Method : c-SLEDD-f, HF(CVVH)

  25. Guideline • CAVH：不需額外機器驅動，不佔空間 • Standard UF 35 cc/kg/hr • BW ≒ ↓60Kg • Sintom A + B solution缺K+ • 5008 HF ：全自動，第一線護理師滿意度高 • High volume UF • Early goal-directed hemofiltration therapy • Big BMI ↑60Kg • 大系統+RO機

  26.  Early goal-directed hemofiltration therapy

  27. Early goal-directed hemofiltration therapy Pulse high volume therapy：96hr 1. 100 cc/Kg/hr X 4hr, then 50cc/Kg/hr X 92hr 2. Simultaneous APC (Xigirs) therapy 1+2 keep 96hr, then 35cc/Kg/hr

  28. HF-400 or Prismaflex • 可不可以接ECMO X • 驅動感應器不同: artery sensor一定要負壓 • 引流管線接在負壓區(V-cannula) ？ • 小系統≠大系統負值太小Alarm • 獨立系統：Double lumen • 選項問題

  29. ECMO + Dialysis data report • Inclusion criteria • 1996-2010 ECMO + Dialysis • ≥ 16yrs • ≥ 3 days ICU stay • Exclusion criteria • ≤15 yrs • ECMO + Dialysis ≦ 48hrs

  30. 1996-2010 ECMO + Dialysis data ECMO Data base：900 / 400( 44.4% )

  31. Two stage data

  32. CAVH CVVH IHD CAVH CVVH SLEDD SLEDD-f C-SLEDD-f Plasmaphresis 兩個時期不同處

  33. Data • 1996-2005 data • 2006-2010 data • 1996-2010 data

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