[医药卫生]speed training 2 血液透析原理和血透导管的应用

,血液透析工作原理和血管通路,Aaron Luo1/9/2018,Contents,血管通路的类型和特点,血液透析的工作原理,肾脏功能的解剖结构基础,Covidien | 9 January 2018 | Confidential,肾脏的解剖与生理,肾脏的主要功能是肾单位（Nephron)完成的。每个肾脏大约有1百万个肾单位。过多的水分和毒素在血液流经肾单位的过程中，从血液中滤出、收集到肾小管、集合管内，最后汇集到输尿管排出体外。,肾静脉：滤过后的血液流出肾脏,肾动脉：携带废物的血液进入肾脏,输尿管：废物（尿液）通过输尿管流到膀胱,每个肾单位由一个肾小体（肾小球肾小囊）和肾小管组成,Covidien | 9 January 2018 | Confidential,肾脏的解剖和生理,肾小球 由微小的血管和毛细血管构成 与收集尿液的微小的管道（肾小管）相互缠绕复杂的化学交换就在肾小球进行 废物和多余的水分离开血液并进入泌尿系统。,Contents,血管通路的类型和特点,血液透析的工作原理,肾脏功能的解剖基础,Covidien | January 9, 2018 | Confidential,6 |,人工肾作为治疗终末期肾病的一种方法，基本概念就是替代严重受损的上述肾脏功能（不完全，内分泌功能无法替代）。,血液透析人工肾概念,透析液和透析液管路尿液和输尿管,Covidien | 9 January 2018 | Confidential,一般每次持续4小时. 间隔一天透析一次. 透析器（滤器）: 8000-12000根空心纤维组合成的罐（25CM）. 透析液：在透析器内，隔着透析膜与血液反向对流 渗透作用促使血液内毒素进入透析液.,血液透析治疗方式,Concentration Gradient - Flow Geometry 浓度梯度 HD液流动力学,透析器（滤膜）,Covidien | 9 January 2018 | Confidential,透析膜两侧的物质转运,Covidien | 9 January 2018 | Confidential,10 |,弥散与透析So, a good vascular access which provides enough blood flow is importantto hemodialysis.,Covidien | 9 January 2018 | Confidential,11 |,弥散,Covidien | 9 January 2018 | Confidential,12 |,弥散是溶质从高浓度一侧向低浓度一侧运动的过程。是半透膜两侧溶质分子随机运动的结果。在单位时间内被完全清除溶质及毒素的血液容量被称为“清除率”,弥散是溶质转运的过程，不涉及溶液（水）的转运。,弥散作用是各种溶质跨膜转运，血细胞和大分子物质不能跨膜转运,Covidien | 9 January 2018 | Confidential,13 |,钙盐,Covidien | 9 January 2018 | Confidential,对流与滤过,Movement of the solvent (water) from the side of low concentration to the side of higher concentration,对 流,Covidien | 9 January 2018 | Confidential,对流（Ultrafiltration）是溶液携带溶质转运的过程。,Movement of solvent across a semi-permeable membrane in response to a pressure differences applied across the membrane,当水通过膜运动时，溶质在膜两侧浓度相等的情况也也随着水做跨膜运动。,Also called solute drag 也称为“溶质拖曳”,水和中分子毒素：主要靠对流清除,Covidien | January 9, 2018 | Confidential,16 |,Dialysate 透析液,Dialysate 透析液,Covidien | 9 January 2018 | Confidential,吸附与灌注,吸 附,吸附作用示意图,Covidien | January 9, 2018 | Confidential,18 |,评价透析充分性的参数,Covidien | January 9, 2018 | Confidential,19 |,Covidien | 9 January 2018 | Confidential,Kt/V,Example: If the dialyzers clearance is 300mL/min and a dialysis session lasts for 180 minutes (3 hours), Kt will be 300mL/min x 180min. This equals 54,000mL, or 54 litersKt = 300mL/min x 180 minKt = 54,000mL x 1L/1,000mL = 54 litersThe body is about 60 percent water by weight. If a patient weighs 70 kilograms, V will be 42 litersSo the ration (K x t) to V, or Kt/V compares the amount of fluid that passes through the dialyzer with the amount of fluid in the patients body. The Kt/V for this patient would be 1.3.Kt/V = 54L/42L = 1.3,怎样提高透析充分性？,Covidien | January 9, 2018 | Confidential,21 |,Summary,Covidien | January 9, 2018 | Confidential,22 |,1,2,Contents,血管通路的类型和特点,血液透析的工作原理,肾脏功能的解剖基础,Covidien | 9 January 2018 | Confidential,血液透析的血管通路Access for Hemodialysis,为了进行血液透析，必须有一条血管路径连接血管和透析机，完成血液的透析循环回路。内瘘为永久性通路，血管导管为临时通路。,血管通路的一些定义：,永久性血管通路：指动静脉内瘘及移植血管内瘘，永久的含义也是相对的，意思是数年或更久。临时性血管通路：指血透导管，包括长期导管（慢性导管）和短期导管（急性导管）。长期导管适用1周以上，至数月或数年；短期导管适用于1周以内。半永久通路：以前的一些称呼，指的是长期导管，意思是使用时间较长。其实也是临时通路。永久性导管：以前的误称。相应的称短期导管为临时管。导管都属于临时性通路，现在一般做永久性的定义动静脉瘘内瘘：常指原位动静脉吻合形成的瘘管。瘘管：动静脉直接相通（未经过毛细血管）的管道。移植血管瘘：常指利用非造瘘部位的血管（如身体其他部位的血管或动物、尸体血管）或人工合成血管，连接动静脉形成的瘘。,Covidien | January 9, 2018 | Confidential,25 |,中国透析血管通路构成状况 血透导管市场状况,Covidien | January 9, 2018 | Confidential,26 |,Shanghai Renal Registry Network,2009 USRDS 2009,Shaghai Renal Registry Network,2009,血透导管,Covidien | 9 January 2018 | Confidential,动静脉内瘘（AV Fistula Access）,动静脉吻合，以获得更大内径的血管，从而获得更大血流和易于穿刺。内瘘需要约8周才能成熟，过早穿刺会导致瘘失败。瘘成熟期使用血管导管过渡。,Look at the direction of the needles why this way? Its important!,Covidien | 9 January 2018 | Confidential,移植血管内瘘（AV Graft Access）,动静脉通过移植血管连接，形成内瘘。移植血管应该在使用前36周植入。过渡期使用血管导管进行透析。,Covidien | 9 January 2018 | Confidential,透析导管（Catheter Access）,分短期和长期导管，有两腔或三腔。插管部位推荐为颈内静脉，其他部位包括股静脉和锁骨下静脉。短期导管 (Polyurethane材料) 插入后即可使用，建议留置时间不超过7天。 长期导管 (一般为 Silicone or Carbothane) 插入后即可使用，推荐用于预计留置期超过7天的患者。,Source:The National Kidney Fundation-KDOQI Guidelines, Vasculuar Access. Clinical Practice Guidelines and Clinical Practice Recommendations 2006 Updates. Catheters and Port Catheter Systems (CPG 2.4),Covidien | January 9, 2018 | Confidential,31 |,短期导管,长期导管,Covidien | January 9, 2018 | Confidential,32 |,Covidien | January 9, 2018 | Confidential,33 |,透析管,短期管(ST)长期管(LT),600ml/min 血管导管血流速度 300ml/min 动静脉常规对接导管，血流再循环率必须 5% 动静脉反接导管时，再循环率 5% 血压 (esp. 动脉端) 250mmHg Cleaning, treatment, complications, etc. National Foundations typically acknowledge these guidelines.,Covidien | 9 January 2018 | Confidential,再循环概念和再循环对透析的影响,概念,影响,发生率,Covidien | 9 January 2018 | Confidential,再循环示意图（动静脉正接时）,Covidien | 9 January 2018 | Confidential,再循环示意图（动静脉反接时）,反接时，再循环率明显增加，可达3040！,Covidien | 9 January 2018 | Confidential,血透时为什么要反接动静脉端？,Covidien | 9 January 2018 | Confidential,动静脉端反接和再循环,MJ Oliver et al. Randomized study of temporary hemodialysis catheters. International Journal of Artificial Organs, Vol.25,no.1,2002Lynne Senecal et al. Blood flow & recirculation rates in tunneled hemodialysis catheters. ASAIO Journal, Vol.50,pp94-97, 2004Twardowski, ZJ et al. All currently used measurement of recirculation in blood access by chemical methods are flawed due to intradialytic disequilibrium or recirculation at low flow. AJKD, Vol32,no. 6,1998,反接率高,再循环发生率高,Covidien | January 9, 2018 | Confidential,47 |,再循环的不良影响,再循环的不良影响,Covidien | January 9, 2018 | Confidential,48 |,Reference:Hakim RM, Breyer J, Ismail N, Schulman G: Effects of dose of dialysis on morbidity and mortality. Am J Kid