血液净化原理,模式及治疗的选择ppt课件

Tips for improving filter life Aquarius System Copyright 2015 NIKKISO Co., LTD. All rights reserved. PM-0063-11/2015-1 肾脏替代治疗“的内容 1. 肾脏替代治疗的基本内容 2. 滤器的选择 3. 抗凝剂的应用 3 CRRT命名的发展 CRRT： Continuous renal replacement therapy（连续肾脏替代治疗） ICBP: Intensive care blood purification（重症血液净化） CBP： Continuous Blood purification （连续血液净化） MOST：Multi Organ Support Therapy （多脏器支持疗法） 4 CRRT 的特点和优越性 CRRT是缓慢、连续排除水分，模拟尿的排泄方式。更 符合生理状态，能较好地维护血流动力学稳定；容量波 动小；溶质清除率高；有利于营养改善及能清除细胞因 子，从而改善危重ARF患者的预后，更好的血液动力学 稳定性 更好的溶液控制能力和清除多余水分 累积的更好溶质清除性 维持尿排泄并保存残余肾功能 清除炎症介质 改善营养支持 5 CRRT的分类 SCUF-缓慢连续超滤 CAVH-连续动静脉血液滤过 CVVH-连续静静脉血液滤过 HVHF高容量血液滤过 CAVHD-连续动静脉血液透析 CVVHD-连续静静脉血液透析 CVVHFD连续静静脉高通量透析 CAVHDF-连续动静静脉血液透析滤过 CVVHDF-连续静静脉血液透析滤过 MPS- 血浆置换 HP- 血液灌流和免疫吸附 CRRT 以一种更符合机体生理特性的方式，连续地清除机体多余的水 分和毒素，调节酸碱和电解质的平衡，来有效地维持机体内环境的稳 定。不单用于急性肾衰，还是救治许多危重病症的有力辅助手段。 6 原理与机制 弥散 对流 吸附 500 5000 50000 Solute Classes by Molecular Weight Daltons Inflammatory Mediators (1,200-50,000) “small” “middle” “large” Jean-Michel Lannoy Nikkiso ABP Director 8 炎症介质的特征 介质质分子量 C3a2500 C5a2800 TNF-a17500x3 C5a2800 IL-62125000 IL-1Ra 14000 IL- 89000 LPS100000 Factor D 23000 23000 Jean-Michel Lannoy Nikkiso ABP Director 9 炎症介质的特征 介质质蛋白结结合分子量 C3ano2500 C5ano2800 TNF-a部分17500x3 STNRFIyes55000 STNRFIIyes75000 IL-621yes25000 IL-1Ra no14000 IL- la no89000 PAF部分450 Factor D yes23000 4/11/201710 PSHF系列滤器筛选系数/高截留分子量 如何选择血滤器 ？ Jean-Michel Lannoy Nikkiso ABP Director11 Molecular Weights （分子的重量或分子量的大 小） 12 Copyright 2015 NIKKISO Co., LTD. All rights reserved. Ashley et all. The Renal Drug Handbook, 2nd Ed. 2004, Medical Press, Abingdon, UK. ISBN: 1857758730 New functional membrane with defined larger pore size HCO membrane 12h) using heparin Appropriately trained nursing staff available Contra-indications to RCA in pilot Requirement for systemic anticoagulant (other than prophylaxis) Chronic Liver Disease - Childs B or C Acute Liver Injury with INR 2 or Lactate 4mol/L Post-hepatic resection Severe shock: Noradrenaline 0.5mcg/kg/min and/or Lactate 4mol/L Arterial Blood Ionized Calcium 7.5 or HCO3- 40mmol/L at commencement of RCA Serum Sodium 160 at commencement of RCA Uncontrolled hyperglycaemia 6U/h Insulin IBW 90kg 35ml/kg/h CVVH RCA Protocol All patients will start at 35ml/kg/h unless directed by physician Dose includes citrate volume pre-filter Filtration Ratio is 20% Pre-filter citrate concentration will be 2.8mmol/L IBW kg Post dilution mL/h Blood Pump mL/min ACD-A (Citrate) mL/h 802700230350 Protocol 1 Calcium Replacement Accusol replacement solution contains 1.75mmol/L Calcium which will provide most or all of the Calcium replacement A 10mmol/L Calcium Chloride solution will be used for additional Calcium replacement if required: 1x10ml ampule of Calcium Chloride (10mmol) in 990ml Normal Saline given via integrated Calcium Pump on Aquarius-Citrate device only Infusion rate 0-175ml/h Initial Calcium Rate Then check arterial Cai in 1h Systemic iCa Initial rate of CaCl solution 1.00mL/h (0mmol/h) Use this table only when first starting RCA Adjusting Calcium Infusion iCaCaCl infusion adjustment (MAXIMUM RATE = 175mL/hr):Reche ck 1.3 1.Decrease CaCl infusion by 25ml/h 2.If CaCl infusion off then check systemic iCa in 3 hours 3.Inform Doctor if iCa rises to 1.5 3h * Likely to change to check in 6h in final protocol Monitoring Baseline ABG for iCa2+ Total Ca2+; Mg2+ (Aim Mg 1mmol/L) Post Filter iCa2+ (Take from return-line sample port) Record all Results on RCA Pro-forma * Likely to change to check in 6h in final protocol Start 35ml/kg/h CVVH If pH 7.5 or HCO3- 40 Reduce to 25ml/kg/h If pH 7.5 or HCO3- 40 Use 25ml/kg/h with 25% FR If pH 7.5 or HCO3- 40 Stop RCA Metabolic Alkalosis Monitor pH and Bicarbonate 3 hly* * Likely to change to check in 6h in final protocol IBW kg Post dilution mL/h Blood Pump mL/min ACD-A (Citrate) mL/h 801900160240 IBW kg Post dilution mL/h Blood Pump mL/min ACD-A (Citrate) mL/h 801900130200 Step 2: if pH7.5 or HCO3- 40mmol/L on Protocol 2 change settings to Protocol 3 (25ml/kg/h with increased filtration ratio) below and monitor every 3h* Step 3: if still pH40mmol/L DISCONTINUE RCA Step 1: if pH7.5 or HCO3- 40mmol/L on Protocol 1 Change the settings to Protocol 2 (25ml/kg/h) below and continue to monitor every 3h*. (Protocol 2 may also be selected for dose reduction) Protocol 2 Protocol 3 * Likely to change to check in 6h in final protocol How it works Jean-Michel Lannoy Nikkiso ABP Director 44 THANKS!THANKS! 4/11/201745 Indications for Citrate Anticoagulation Requiring RRT within the ICU (either new or on-going treatment) for conventional Renal indications Considered by the treating Physician to have a contraindication to heparin anticoagulation Appropriately trained nursing staff available 8Palsson R ,Niles JL, Regional citrate anticoagulation in continuous venovenous hemofiltration in critically ill patients with a high risk of bleeding Kidney Int 1999, 55: 1991-1997. 9Flanigan M et al. Reducing the hemorrhagic complications of hemodialysis: A controlled comparison of low-dose heparin and citrate anticoagulation. Am J Kidney Dis 1987; 2: 147-153 Copyright 2015 NIKKISO Co., LTD. All rights reserved. Contraindications Chronic Liver Disease - Childs B or C Acute Liver Injury with INR 2 or Lactate 4mol/L Post-hepatic resection Severe shock: Noradrenaline 0.5mcg/kg/min and/or Lactate 4mol/L Arterial Blood Ionized Calcium 7.5 or HCO3- 40mmol/L at commencement of RCA Reduction of requirements for systemic anticoagulant (other than prophylaxis) Serum Sodium 160 at commencement of RCA Uncontrolled hyperglycaemia 6U/h Insulin IBW 90kg Citrate intolerance Clinical situation where citrate metabolism becomes uncertain. Copyright 2015 NIKKISO Co., LTD. All rights reserved. 10Prowle et al. Service Development Plan and Protocol for Regional Citrate Anticoagulation , The Royal London Hospital Therapy monitoring Ionised Calcium: Ionized calcium is a measure of free calcium. After hemofilter typically 0.25 - 0.35 mmol/l From patient typically 1.05 - 1.3 mmol/l Total Calcium: Total calcium includes both protein-bound and free calcium. Total Calcium (from patient) typically less than 2.5 mmol/l Acid/base monitoring: Systemic pH will be monitored 3-6hrly. Glucose monitoring: Blood glucose monitored for hyperglycaemia 3-6hrly Electrolyte monitoring: Levels to be monitored 3-6hrly. Fluid balance monitoring. Any other clinical signs? Copyright 2015 NIKKISO Co., LTD. All rights reserved. Optimize Vascular Access Consider using a high flow silicone vascular access catheter that does not have “kink memory” , and with an appropriate length for the chosen site. Avoid attaching the Aquarius to a catheter with poor flow. For example, being able to withdraw 20ml of blood in 6 seconds or 10ml of blood in 3 seconds without hesitancy or interruption may help a catheter assessment. Consider rotating the hub of the catheter 90 so that the holes on the access lumen are facing the flow of blood, not against the vessel wall (you may need to momentarily stop the blood pump to do this). Consider the patients intravascular volume. Even though the patient may be fluid overloaded, if their intravascular space is dehydrated, there may be poor flow through the catheter which will encourage clotting. 49 Copyright 2015 NIKKISO Co., LTD. All rights reserved. Optimize Anticoagulation High return pressure is one sign of under anti-coagulation. The blood pump wants to push the blood through the return chamber where partially formed blood clots may increase in size, making it difficult for the blood to squeeze through. A routine of regular observation, followed by a check of the patient clotting, and adjustment of anticoagulant where indicated, may prevent early return chamber clotting. Consider increasing the proportion of pre-dilution if anticoagulation adjustment is not indicated. For example: altering the pre-dilution to 90 % and reducing post-dilution to 10 % may thin the blood passing through the filter and reduce the effects of haemoconcentration. A gain in lifespan may be offset by a small loss in clearance, easily adjusted by using the Renal Dose display. 50 Copyright 2015 NIKKISO Co., LTD. All rights reserved. The effect of blood pump speed 51 Copyright 2015 NIKKISO Co., LTD. All rights reserved. Filtrate removed is a percentage of total flow through the filter fibres. Why is the total blood flow important? With a faster blood pump speed, the total flow is increased and effects of haemoconcentration are reduced. Increasing blood flow gives a reduced filtration ratio which may slow filter clogging and extend filter lifespan. The effect of Pre-dilution 52 Copyright 2015 NIKKISO Co., LTD. All rights reserved. Filtrate removed is a percentage of total flow through the filter fibres. The proportion of predilution flow may be adjusted to optimise treatment. With a greater proportion of predilution, the filtration fraction and effects of haemoconcentration are reduced. An improved filtration fraction may slow filter clogging and extend filter lifespan. Considerations 53 Copyright 2015 NIKKISO Co., LTD. All rights reserved. Diameter, length and types of catheters (II) Type: Material features Silicone elastomer catheters have lower thrombogenicity and better flexibility. Biocompatible and kink resistance Conform to vessel anatomy, therefore reduce risk of trauma Diameter and blood flow: 11 French : 250-300 ml/min Blood Flow 13.5 French : 450-500 ml/min Blood Flow Recirculation- up to 20% Especially if femoral access is less than 20 cm Avoid reverse AV connection Patient Preparation 54 Copyright 2015 NIKKISO Co., LTD. All rights reserved. Patient body status Coagulation and Intravascular filling Mobility influences Presence of other central lines Influences on catheter choice Clinician choice Availability of ultrasound guidance Assessment of catheter patency Connection techniques Special circumstances Catheter Characteristics 55 Copyright 2015 NIKKISO Co., LTD. All rights reserved. Ease of insertion: to avoid vessel trauma Good flow characteristics: to optimise blood flow Kink resistant: to avoid access pressure problems Biocompatible: to reduce complication risks Amenability to guide wire change: to optimise therapy Side-by-Side Polyurethane Catheters 56 Copyright 2015 NIKKISO Co., LTD. All rights reserved. Coaxial Polyurethane Catheters 57 Copyright 2015 NIKKISO Co., LTD. All rights reserved. Triple lumen Catheters 58 Copyright 2015 NIKKISO Co., LTD. All rights reserved. Silicone Catheters 59 Copyright 2015 NIKKISO Co., LTD. All rights reserved. Reversing the Lines 60 Copyright 2015 NIKKISO Co., LTD. All rights reserved. 1 Lewington A, Kanagasundaram S. Acute Kidney Injury. Renal Association guidelines: Guideline 8.1 AKI: Vascular access for RRT. Guideline 8.2, Page 45 of 59, Para 3 Rationale for 8.1-8.9 lines 7-9 /Clinical/GuidelinesSection/AcuteKidneyInjury.aspx Vascular Access 61 Copyright 2015 NIKKISO Co., LTD. All rights reserved. Vascular Access is continuously tested during CRRT treatment Practical understanding about vascular access is necessary for optimal treatment Catheter site, size, type and patient preparation may be considered Inadequacies in vascular acces