血液净化原理,模式及治疗的选择

Tipsforimprovingfilterlife,AquariusSystem,Copyright2015NIKKISOCo.,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,5/12/2020,10,PSHF系列滤器筛选系数/高截留分子量,如何选择血滤器？,Jean-MichelLannoyNikkisoABPDirector,11,MolecularWeights（分子的重量或分子量的大小）,12,Copyright2015NIKKISOCo.,LTD.Allrightsreserved.,Ashleyetall.TheRenalDrugHandbook,2ndEd.2004,MedicalPress,Abingdon,UK.ISBN:1857758730,Newfunctionalmembranewithdefinedlargerporesize,HCOmembrane,2orLactate4mol/LPost-hepaticresectionSevereshock:Noradrenaline0.5mcg/kg/minand/orLactate4mol/LArterialBloodIonizedCalcium7.5orHCO3-40mmol/LatcommencementofRCASerumSodium160atcommencementofRCAUncontrolledhyperglycaemia6U/hInsulinIBW90kg,35ml/kg/hCVVHRCAProtocol,Allpatientswillstartat35ml/kg/hunlessdirectedbyphysicianDoseincludescitratevolumepre-filterFiltrationRatiois20%Pre-filtercitrateconcentrationwillbe2.8mmol/L,Protocol1,CalciumReplacement,Accusolreplacementsolutioncontains1.75mmol/LCalciumwhichwillprovidemostoralloftheCalciumreplacementA10mmol/LCalciumChloridesolutionwillbeusedforadditionalCalciumreplacementifrequired:1x10mlampuleofCalciumChloride(10mmol)in990mlNormalSalinegivenviaintegratedCalciumPumponAquarius-CitratedeviceonlyInfusionrate0-175ml/h,InitialCalciumRate,ThencheckarterialCaiin1h,AdjustingCalciumInfusion,*Likelytochangetocheckin6hinfinalprotocol,*Likelytochangetocheckin6hinfinalprotocol,MetabolicAlkalosisMonitorpHandBicarbonate3hly*,*Likelytochangetocheckin6hinfinalprotocol,Step2:ifpH7.5orHCO3-40mmol/LonProtocol2changesettingstoProtocol3(25ml/kg/hwithincreasedfiltrationratio)belowandmonitorevery3h*,Step3:ifstillpH40mmol/LDISCONTINUERCA,Step1:ifpH7.5orHCO3-40mmol/LonProtocol1ChangethesettingstoProtocol2(25ml/kg/h)belowandcontinuetomonitorevery3h*.(Protocol2mayalsobeselectedfordosereduction),Protocol2,Protocol3,*Likelytochangetocheckin6hinfinalprotocol,Howitworks,Jean-MichelLannoyNikkisoABPDirector,44,THANKS!,5/12/2020,45,IndicationsforCitrateAnticoagulation,RequiringRRTwithintheICU(eitherneworon-goingtreatment)forconventionalRenalindicationsConsideredbythetreatingPhysiciantohaveacontraindicationtoheparinanticoagulationAppropriatelytrainednursingstaffavailable,8PalssonR,NilesJL,RegionalcitrateanticoagulationincontinuousvenovenoushemofiltrationincriticallyillpatientswithahighriskofbleedingKidneyInt1999,55:1991-1997.9FlaniganMetal.Reducingthehemorrhagiccomplicationsofhemodialysis:Acontrolledcomparisonoflow-doseheparinandcitrateanticoagulation.AmJKidneyDis1987;2:147-153,Copyright2015NIKKISOCo.,LTD.Allrightsreserved.,Contraindications,ChronicLiverDisease-ChildsBorCAcuteLiverInjurywithINR2orLactate4mol/LPost-hepaticresectionSevereshock:Noradrenaline0.5mcg/kg/minand/orLactate4mol/LArterialBloodIonizedCalcium7.5orHCO3-40mmol/LatcommencementofRCAReductionofrequirementsforsystemicanticoagulant(otherthanprophylaxis)SerumSodium160atcommencementofRCAUncontrolledhyperglycaemia6U/hInsulinIBW90kgCitrateintoleranceClinicalsituationwherecitratemetabolismbecomesuncertain.,Copyright2015NIKKISOCo.,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?,Copyright2015NIKKISOCo.,LTD.Allrightsreserved.,OptimizeVascularAccess,Considerusingahighflowsiliconevascularaccesscatheterthatdoesnothave“kinkmemory”,andwithanappropriatelengthforthechosensite.AvoidattachingtheAquariustoacatheterwithpoorflow.Forexample,beingabletowithdraw20mlofbloodin6secondsor10mlofbloodin3secondswithouthesitancyorinterruptionmayhelpacatheterassessment.Considerrotatingthehubofthecatheter90sothattheholesontheaccesslumenarefacingtheflowofblood,notagainstthevesselwall(youmayneedtomomentarilystopthebloodpumptodothis).Considerthepatientsintravascularvolume.Eventhoughthepatientmaybefluidoverloaded,iftheirintravascularspaceisdehydrated,theremaybepoorflowthroughthecatheterwhichwillencourageclotting.,49,Copyright2015NIKKISOCo.,LTD.Allrightsreserved.,OptimizeAnticoagulation,Highreturnpressureisonesignofunderanti-coagulation.Thebloodpumpwantstopushthebloodthroughthereturnchamberwherepartiallyformedbloodclotsmayincreaseinsize,makingitdifficultforthebloodtosqueezethrough.Aroutineofregularobservation,followedbyacheckofthepatientclotting,andadjustmentofanticoagulantwhereindicated,maypreventearlyreturnchamberclotting.Considerincreasingtheproportionofpre-dilutionifanticoagulationadjustmentisnotindicated.Forexample:alteringthepre-dilutionto90%andreducingpost-dilutionto10%maythinthebloodpassingthroughthefilterandreducetheeffectsofhaemoconcentration.Againinlifespanmaybeoffsetbyasmalllossinclearance,easilyadjustedbyusingtheRenalDosedisplay.,50,Copyright2015NIKKISOCo.,LTD.Allrightsreserved.,Theeffectofbloodpumpspeed,51,Copyright2015NIKKISOCo.,LTD.Allrightsreserved.,Filtrateremovedisapercentageoftotalflowthroughthefilterfibres.Whyisthetotalbloodflowimportant?Withafasterbloodpumpspeed,thetotalflowisincreasedandeffectsofhaemoconcentrationarereduced.Increasingbloodflowgivesareducedfiltrationratiowhichmayslowfiltercloggingandextendfilterlifespan.,TheeffectofPre-dilution,52,Copyright2015NIKKISOCo.,LTD.Allrightsreserved.,Filtrateremovedisapercentageoftotalflowthroughthefilterfibres.Theproportionofpredilutionflowmaybeadjustedtooptimisetreatment.Withagreaterproportionofpredilution,thefiltrationfractionandeffectsofhaemoconcentrationarereduced.Animprovedfiltrationfractionmayslowfiltercloggingandextendfilterlifespan.,Considerations,53,Copyright2015NIKKISOCo.,LTD.Allrightsreserved.,Diameter,lengthandtypesofcatheters(II)Type:MaterialfeaturesSiliconeelastomercathetershavelowerthrombogenicityandbetterflexibility.BiocompatibleandkinkresistanceConformtovesselanatomy,thereforereduceriskoftraumaDiameterandbloodflow:11French:250-300ml/minBloodFlow13.5French:450-500ml/minBloodFlowRecirculation-upto20%Especiallyiffemoralaccessislessthan20cmAvoidreverseAVconnection,PatientPreparation,54,Copyright2015NIKKISOCo.,LTD.Allrightsreserved.,PatientbodystatusCoagulationandIntravascularfillingMobilityinfluencesPresenceofothercentrallinesInfluencesoncatheterchoiceClinicianchoiceAvailabilityofultrasoundguidanceAssessmentofcatheterpatencyConnectiontechniquesSpecialcircumstances,CatheterCharacteristics,55,Copyright2015NIKKISOCo.,LTD.Allrightsreserved.,Easeofinsertion:toavoidvesseltraumaGoodflowcharacteristics:tooptimisebloodflowKinkresistant:toavoidaccesspressureproblemsBiocompatible:toreducecomplicationrisksAmenabilitytoguidewirechange:tooptimisetherapy,Side-by-SidePolyurethaneCatheters,56,Copyright2015NIKKISOCo.,LTD.Allrightsreserved.,CoaxialPolyurethaneCatheters,57,Copyright2015NIKKISOCo.,LTD.Allrightsreserved.,TriplelumenCatheters,58,Copyright2015NIKKISOCo.,LTD.Allrightsreserved.,SiliconeCatheters,59,Copyright2015NIKKISOCo.,LTD.Allrightsreserved.,ReversingtheLines,60,Copyright2015NIKKISOCo.,LTD.Allrightsreserved.,1LewingtonA,KanagasundaramS.AcuteKidneyInjury.RenalAssociationguidelines:Guideline8.1AKI:VascularaccessforRRT.Guideline8.2,Page45of59,Para3Rationalefor8.1-8.9lines7-9/Clinical/GuidelinesSection/AcuteKidneyInjury.aspx,VascularAccess,61,Copyright2015NIKKISOCo.,LTD.Allrightsreserved.,VascularAccessiscontinuouslytestedduringCRRTtreatmentPracticalunderstandingaboutvascularaccessisnecessaryforoptimaltreatmentCathetersite,size,typeandpatientpreparationmaybeconsideredInadequaciesinvascularaccessmaylimitdeliveredtherapyTroubleshootingchoices,VascularAccessTroubleshooting,62,Co