血液净化原理,模式及治疗的选择PPT课件

Tipsforimprovingfilterlife AquariusSystem Copyright 2015NIKKISOCo LTD Allrightsreserved PM 0063 11 2015 1 肾脏替代治疗 的内容 肾脏替代治疗的基本内容滤器的选择抗凝剂的应用 3 CRRT命名的发展 CRRT Continuousrenalreplacementtherapy 连续肾脏替代治疗 ICBP Intensivecarebloodpurification 重症血液净化 CBP ContinuousBloodpurification 连续血液净化 MOST MultiOrganSupportTherapy 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 SoluteClassesbyMolecularWeight Daltons Jean MichelLannoyNikkisoABPDirector 8 炎症介质的特征 Jean MichelLannoyNikkisoABPDirector 9 炎症介质的特征 10 PSHF系列滤器筛选系数 高截留分子量 Jean MichelLannoyNikkisoABPDirector 11 如何选择血滤器 12 MolecularWeights 分子的重量或分子量的大小 Copyright 2015NIKKISOCo LTD Allrightsreserved Ashleyetall TheRenalDrugHandbook 2ndEd 2004 MedicalPress Abingdon UK ISBN 1857758730 Newfunctionalmembranewithdefinedlargerporesize HCOmembrane 0 01 m 0 02 m 0 09 m 0 30 m porediameter highflux highcut off proteinseparationmembrane plasmaseparationmembrane Variationofmembraneporesize Electronmicrographsofinnermembranesurface HighCut OffHemofilter 16 SievingCoefficient Asievingcoefficientisthemeasureofhoweasilyasubstancepassesfromthebloodcompartmenttothedialysatecompartmentinahaemofilter Thus asievingcoefficientof1 0meansthesoluteis100 filterable i e inahaemofilter thesolutewillequilibrateonbothsidesofthemembrane So thereturningbloodandtheeffluentbothhavethesameconcentration 50 50 Anexampleispotassium sievingcoefficientis1 0 Asievingcoefficientof0meansthesolutedoesnotcrossthemembrane eg albumin Ofcourse thisalldependsonthemembrane andsievingcoefficientswillvarydependingontheporesize DEFINITION Thecut offpointofasoluteforanymembraneisasievingcoefficientof0 1 Thismeansthat10 ofthemoleculeswillpassand90 willnotpass Copyright 2015NIKKISOCo LTD Allrightsreserved MolecularWeight Da StandardHighFlux HighCut Off HF UF 1L h t 2h Median 25th 75thpercentiles ICM 2002 28 651 655 HCOMembranewithincreasedpermeabilityforinflammatorymediators membranecharacteristics 18 Molecularweight Ashleyetall TheRenalDrugHandbook 2ndEd 2004 MedicalPress Abingdon UK ISBN 1857758730Copyright 2015NIKKISOCo LTD Allrightsreserved HF1200HaemofilterCut Off55000daltons 19 ComparisonofInterleukin 6RemovalPropertiesamongHemofiltersConsistingofVaryingMembraneMaterialsandSurfaceAreas RecentStudiesinMembrane 20 全身抗凝 局部抗凝 无肝素抗凝肝素低分子肝素钙 鱼精蛋白枸橼酸 抗凝的选择 Copyright 2015NIKKISOCo LTD Allrightsreserved 21 积极主动预防管路的凝血 利用重新预冲和循环模式清除管路及滤器中的气泡仔细观察预冲后管路的通畅 保持静脉壶的血液水平在二分之一以上 减少气血接触防止静脉小壶的凝血 静脉小壶的凝血影响了血液的流速压力降 Copyright 2015NIKKISOCo LTD Allrightsreserved 22 预防滤器内的凝血 FiltrationRatio 保持超滤比率在25 一下 超滤比率是衡量滤器中血液浓度 血流速率与滤出是百分比 是多少血夜进入滤器和多少液体排除的比较 目标血流速度的目的制定达到低的超滤比率 从而达到更长的滤器使用寿命 高的血流速度可以达到低的超滤比率如果临床需求允许可以提高血流速10 15 当连接病人时 可以延长治疗直到血流速度达到要求尽可能的在病人开始治疗时防止血液的浓缩 Copyright 2015NIKKISOCo LTD Allrightsreserved 23 预防滤器内的凝血 Recirculation 重复循环模式 连接病人之前重复循环20 40 min 重复循环可以侵泡滤器的纤维 同时排空纤维中的空气 滤器的纤维经过侵泡更加的饱满 改善血流通过纤维的流量 排除极小的气泡防止早期的凝血 一个循环时间在20 20 minutes 滤器和管路基本可以72小时使用 但这包括重复使用的时间 Copyright 2015NIKKISOCo LTD Allrightsreserved 24 FiltrationFraction 滤过分数 FiltrationFraction滤过分数是总液体通过滤器的量与超滤量的相比滤过分数通常是尽可能的低 理想是25 FiltrationFraction滤过分数是不会受到前稀释泵的影响FiltrationFraction滤过分数是会受到血流速的影响 Copyright 2015NIKKISOCo LTD Allrightsreserved 25 超滤比率FiltrationRatio Copyright 2015NIKKISOCo LTD Allrightsreserved FiltrationRatio是表示滤器中血液浓度增加 理想的超滤比率在低于25 FiltrationRatio是受到前稀释泵的影响 FiltrationRatio是受到血流速的影响 26 FiltrationRatioandbloodpumpspeed Postdilution l h BloodPumpSpeed mls min 60 mins FiltrationRatio 10003l hExchange31100mls minx60mins 6 2 50 FiltrationRatio 10003l hExchange31200mls minx60mins 12 4 25 FiltrationRatio3l hrExchange31300mls minx60mins 18 6 17 FiltrationRatio Copyright 2015NIKKISOCo LTD Allrightsreserved 肝素是如何工作的 Heparin肝素抑制导致血液凝固和纤维蛋白凝块形成的反应 肝素在抗凝系统中是多部位的作用 小剂量的肝素 与抗凝血酶III结合 可以抑制凝血酶块的形成通过消除FactorX因子 减少了凝血素转化成凝血酶治疗剂量的肝素有利于血滤器的寿命 5Roncoetal Effectsofdifferentdosesincontinuousveno venoushaemofiltrationonoutcomesofacuterenalfailure aprospectiverandomisedtrial Lancet 2000Jul1 356 9223 26 30 Copyright 2015NIKKISOCo LTD Allrightsreserved 肝素 优势和劣势 优势 容易管理和监控ICU非常熟悉肝素抗凝 便宜 短的半衰期 肝素可以中和 缺点 增加出血的风险 血小板减少 增加肝素的剂量 抗凝血酶元水平下降会影响肝素的作用 Copyright 2015NIKKISOCo LTD Allrightsreserved 枸橼酸是如何工作的 枸橼酸螯合了血循中的钙 抑制了凝血 ACD A CitrateSolution What citratebindstocalciumwhichinhibitscoagulation Copyright 2015NIKKISOCo LTD Allrightsreserved 30 合适的枸橼酸剂量 图表显示钙在血浆中的分布情况 枸橼酸剂量考虑是TotalCalcium typically2 2 2 6mmol l andTotalMagnesium typically1 1 1 4mmol l 影响到选择枸橼酸的量Citratedosingbetween3 3 4 0mmol l Copyright 2015NIKKISOCo LTD Allrightsreserved WhatdoesthebodydowithCitrate Copyright 2015NIKKISOCo LTD Allrightsreserved 32 Therapymonitoring Theselectionandadjustmentoftherapyparameters replacementfluidsandanticoagulantfluidsremainsaprescriptionatthephysician sdiscretion Achangeinanindividualprescriptionwillrequirephysicianrevieworbeclearlydefinedinalocallyapproveddocument Tomonitorandadjustthetherapy thefollowingtypicalparametersmaybeconsideredintheindividualizedprescriber slocalprotocol IonisedCalcium afterhemofilter typically0 25 0 35mmol lIonisedCalcium frompatient typically1 05 1 3mmol lTotalCitrate frompatient typicallylessthan2 5mmol lCalciumRatio acomparisonofCalciumdistribution typicallylessthan2 3Acid basemonitoringElectrolytesmonitoringFluidbalancemonitoring Copyright 2015NIKKISOCo LTD Allrightsreserved AquariusRegionalCitrateAnticoagulationProtocol JohnRProwleMDFRCPFFICMAdultCriticalCareUnitRoyalLondonHospital EligibilityforRCA RequiringRRTwithintheICU eitherneworon goingtreatment forconventionalRenalindicationsConsideredbythetreatingPhysiciantohaveacontraindicationtoheparinanticoagulationorunabletoachieveadequatefilterlifespan 12h usingheparinAppropriatelytrainednursingstaffavailable Contra indicationstoRCAinpilot Requirementforsystemicanticoagulant otherthanprophylaxis ChronicLiverDisease ChildsBorCAcuteLiverInjurywithINR 2orLactate 4 mol LPost hepaticresectionSevereshock Noradrenaline 0 5mcg kg minand orLactate 4 mol LArterialBloodIonizedCalcium7 5orHCO3 40mmol LatcommencementofRCASerumSodium160atcommencementofRCAUncontrolledhyperglycaemia 6U hInsulinIBW 90kg 35ml kg hCVVHRCAProtocol Allpatientswillstartat35ml kg hunlessdirectedbyphysicianDoseincludescitratevolumepre filterFiltrationRatiois20 Pre filtercitrateconcentrationwillbe 2 8mmol L Protocol1 CalciumReplacement Accusolreplacementsolutioncontains1 75mmol LCalciumwhichwillprovidemostoralloftheCalciumreplacementA10mmol LCalciumChloridesolutionwillbeusedforadditionalCalciumreplacementifrequired 1x10mlampuleofCalciumChloride 10mmol in990mlNormalSalinegivenviaintegratedCalciumPumponAquarius CitratedeviceonlyInfusionrate0 175ml h InitialCalciumRate ThencheckarterialCaiin1h AdjustingCalciumInfusion Likelytochangetocheckin6hinfinalprotocol Likelytochangetocheckin6hinfinalprotocol MetabolicAlkalosisMonitorpHandBicarbonate3hly Likelytochangetocheckin6hinfinalprotocol Step2 ifpH 7 5orHCO3 40mmol LonProtocol2changesettingstoProtocol3 25ml kg hwithincreasedfiltrationratio belowandmonitorevery3h Step3 ifstillpH40mmol LDISCONTINUERCA Step1 ifpH 7 5orHCO3 40mmol LonProtocol1ChangethesettingstoProtocol2 25ml kg h belowandcontinuetomonitorevery3h Protocol2mayalsobeselectedfordosereduction Protocol2 Protocol3 Likelytochangetocheckin6hinfinalprotocol Howitworks Jean MichelLannoyNikkisoABPDirector 44 45 THANKS IndicationsforCitrateAnticoagulation RequiringRRTwithintheICU eitherneworon goingtreatment forconventionalRenalindicationsConsideredbythetreatingPhysiciantohaveacontraindicationtoheparinanticoagulationAppropriatelytrainednursingstaffavailable 8PalssonR NilesJL RegionalcitrateanticoagulationincontinuousvenovenoushemofiltrationincriticallyillpatientswithahighriskofbleedingKidneyInt1999 55 1991 1997 9FlaniganMetal Reducingthehemorrhagiccomplicationsofhemodialysis Acontrolledcomparisonoflow doseheparinandcitrateanticoagulation AmJKidneyDis1987 2 147 153 Copyright 2015NIKKISOCo LTD Allrightsreserved Contraindications ChronicLiverDisease ChildsBorCAcuteLiverInjurywithINR 2orLactate 4 mol LPost hepaticresectionSevereshock Noradrenaline 0 5mcg kg minand orLactate 4 mol LArterialBloodIonizedCalcium7 5orHCO3 40mmol LatcommencementofRCAReductionofrequirementsforsystemicanticoagulant otherthanprophylaxis SerumSodium160atcommencementofRCAUncontrolledhyperglycaemia 6U hInsulinIBW 90kgCitrateintoleranceClinicalsituationwherecitratemetabolismbecomesuncertain Copyright 2015NIKKISOCo LTD Allrightsreserved 10Prowleetal ServiceDevelopmentPlanandProtocolforRegionalCitrateAnticoagulation TheRoyalLondonHospital Therapymonitoring IonisedCalcium Ionizedcalciumisameasureoffreecalcium Afterhemofiltertypically0 25 0 35mmol lFrompatienttypically1 05 1 3mmol lTotalCalcium Totalcalciumincludesbothprotein boundandfreecalcium TotalCalcium frompatient typicallylessthan2 5mmol lAcid basemonitoring SystemicpHwillbemonitored3 6hrly Glucosemonitoring Bloodglucosemonitoredforhyperglycaemia3 6hrlyElectrolytemonitoring Levelstobemonitored3 6hrly Fluidbalancemonitoring Anyotherclinicalsigns Copyright 2015NIKKISOCo LTD Allrightsreserved 49 OptimizeVascularAccess Considerusingahighflowsiliconevascularaccesscatheterthatdoesnothave kinkmemory andwithanappropriatelengthforthechosensite AvoidattachingtheAquariustoacatheterwithpoorflow Forexample beingabletowithdraw20mlofbloodin6secondsor10mlofbloodin3secondswithouthesitancyorinterruptionmayhelpacatheterassessment Considerrotatingthehubofthecatheter90 sothattheholesontheaccesslumenarefacingtheflowofblood notagainstthevesselwall youmayneedtomomentarilystopthebloodpumptodothis Considerthepatientsintravascularvolume Eventhoughthepatientmaybefluidoverloaded iftheirintravascularspaceisdehydrated theremaybepoorflowthroughthecatheterwhichwillencourageclotting Copyright 2015NIKKISOCo LTD Allrightsreserved 50 OptimizeAnticoagulation Highreturnpressureisonesignofunderanti coagulation Thebloodpumpwantstopushthebloodthroughthereturnchamberwherepartiallyformedbloodclotsmayincreaseinsize makingitdifficultforthebloodtosqueezethrough Aroutineofregularobservation followedbyacheckofthepatientclotting andadjustmentofanticoagulantwhereindicated maypreventearlyreturnchamberclotting Considerincreasingtheproportionofpre dilutionifanticoagulationadjustmentisnotindicated Forexample alteringthepre dilutionto90 andreducingpost dilutionto10 maythinthebloodpassingthroughthefilterandreducetheeffectsofhaemoconcentration Againinlifespanmaybeoffsetbyasmalllossinclearance easilyadjustedbyusingtheRenalDosedisplay Copyright 2015NIKKISOCo LTD Allrightsreserved 51 Theeffectofbloodpumpspeed Copyright 2015NIKKISOCo LTD Allrightsreserved Filtrateremovedisapercentageoftotalflowthroughthefilterfibres Whyisthetotalbloodflowimportant Withafasterbloodpumpspeed thetotalflowisincreasedandeffectsofhaemoconcentrationarereduced Increasingbloodflowgivesareducedfiltrationratiowhichmayslowfiltercloggingandextendfilterlifespan 52 TheeffectofPre dilution Copyright 2015NIKKISOCo LTD Allrightsreserved Filtrateremovedisapercentageoftotalflowthroughthefilterfibres Theproportionofpredilutionflowmaybeadjustedtooptimisetreatment Withagreaterproportionofpredilution thefiltrationfractionandeffectsofhaemoconcentrationarereduced Animprovedfiltrationfractionmayslowfiltercloggingandextendfilterlifespan 53 Considerations Copyright 2015NIKKISOCo LTD Allrightsreserved Diameter lengthandtypesofcatheters II Type MaterialfeaturesSiliconeelastomercathetershavelowerthrombogenicityandbetterflexibility BiocompatibleandkinkresistanceConformtovesselanatomy thereforereduceriskoftraumaDiameterandbloodflow 11French 250 300ml minBloodFlow13 5French 450 500ml minBloodFlowRecirculation upto20 Especiallyiffemoralaccessislessthan20cmAvoidreverseAVconnection 54 PatientPreparation Copyright 2015NIKKISOCo LTD Allrightsreserved PatientbodystatusCoagulationandIntravascularfillingMobilityinfluencesPresenceofothercentrallinesInfluencesoncatheterchoiceClinicianchoiceAvailabilityofultrasoundguidanceAssessmentofcatheterpatencyConnectiontechniquesSpecialcircumstances 55 CatheterCharacteristics Copyright 2015NIKKISOCo LTD Allrightsreserved Easeofinsertion toavoidvesseltraumaGoodflowcharacteristics tooptimisebloodflowKinkresistant toavoidaccesspressureproblemsBiocompatible toreducecomplicationrisksAmenabilitytoguidewirechange tooptimisetherapy 56 Side by SidePolyurethaneCatheters Copyright 2015NIKKISOCo LTD Allrightsreserved 57 CoaxialPolyurethaneCatheters Copyright 2015NIKKISOCo LTD Allrightsreserved 58 TriplelumenCatheters Copyright 2015NIKKISOCo LTD Allrightsreserved 59 SiliconeCatheters Copyright 2015NIKKISOCo LTD Allrightsreserved 60 ReversingtheLines Copyright 2015NIKKISOCo LTD Allrightsreserved 1LewingtonA KanagasundaramS AcuteKidneyInjury RenalAssociationguidelines