40 Years of Continuous Renal Replacement Therapy. Группа авторов. Читать онлайн. Newlib. NEWLIB.NET

Автор: Группа авторов
Издательство: Ingram
Серия: Contributions to Nephrology
Жанр произведения: Медицина
Год издания: 0
isbn: 9783318063073
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approach in the critical care setting. In this way, the CRRT machine becomes a platform for multiple organ support via extracorporeal therapies carried out with specific biomaterials and devices [28].

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      Latest Generation of CRRT Machines

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      Innovation and Consensus on CRRT Technology Requirements

      AKI management is a continuum from detection to treatment, which must include continuous reevaluation of treatment prescription and delivery. The use of modern information technology tools was recommended to improve practice and patient care. The process of patient evaluation and identification of therapy targets should lead to a “precision” (personalized) prescription according to patient needs and desired physiological targets. The concept of a gap between capacity (of the native organ) and (metabolic) demand is emerging as an important element to prescribe personalized therapy. In the process of dynamic prescription (frequently adjusted on the basis of actual delivery results), full-treatment reassessment should be made at least every 6 h while dedicated equipment (CRRT machines) should be used to deliver specific techniques. Adoptive technologies should be avoided. When prescribing CRRT, availability, training, and environmental and staffing issues should be considered, and prescription should be made according to local conditions and usage. Several technological tools have been developed to monitor target achievement and to suggest modifications in prescription. Manual, authorized, or automatic feedback technology is now available in chronic dialysis machines and it should be promoted in future CRRT machines. Integration of patient and machine signals through information technology tools and connectivity with EMR and data collection systems will be required to allow pragmatic trials and to make big data registries available for analysis. Data can then be used for QA and CQI purposes in the center, in the region, and even in multinational data collection studies.

      The nature of the critically ill patient requires a continuous control of CRRT delivery and strict adherence to prescription, as well as maximization of patient tolerance. The treatment should avoid sudden and sharp variations of physiological parameters, and allow slow and precise correction of fluid, electrolyte, and metabolic imbalances. To prevent complications, the systems currently used in chronic dialysis for online intradialytic monitoring continuously measure various hemodynamic and biochemical parameters. Such online monitoring systems are particularly useful in short intermittent dialysis techniques, where the risk of “unphysiology” is greater due to the high efficiency of the treatment. The development of such systems is based on a 3-step analysis that can be summarized as follows: (1) Each patient is different (this requires precision CRRT and personalized prescription). (2) Patient characteristics vary during treatment (this requires that dynamic prescription also changes over time). A solution to this problem has been attempted with the use of preset profiles of ultrafiltration and dialysate composition, but instead of being based on actual signals from the patient, the profiles are blind to the patient needs and outcomes. (3) Patient and machine signals, describing actual clinical and technical conditions, should be used to drive the delivery of therapy and to reassess prescription (today, this is possible through multi-input/multi-output controllers and actuators, which constitute the basis of a “smart” biofeedback).

      In CRRT, patient and machine data collection should also feed into electronic medical records. Data should be used immediately to fulfill specific objectives:

      •Achievement of an adequate ultrafiltration rate and profile over time, optimizing fluid balance (with minimal deviations from prescribed values) and cardiovascular response to fluid withdrawal while ensuring maximal hemodynamic stability. This is possible through the integration of bioimpedance and online hematocrit measurements resulting in important input on overall patient fluid status and actual circulating blood volume changes. Maintenance of hemodynamic stability and smooth operation of the CRRT machines with