血液净化原理,模式及治疗的选择课件

血液净化原理,模式及治疗的选择,Tipsforimprovingfilterlife,AquariusSystem,Copyright2015NIKKISOCo.,LTD.Allrightsreserved.,PM-0063-11/2015-1,血液净化原理,模式及治疗的选择,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,血液净化原理,模式及治疗的选择,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）,血液净化原理,模式及治疗的选择,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,血液净化原理,模式及治疗的选择,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。,血液净化原理,模式及治疗的选择,6,原理与机制,弥散,对流,吸附,500,5000,50000,血液净化原理,模式及治疗的选择,SoluteClassesbyMolecularWeight,Daltons,血液净化原理,模式及治疗的选择,8,炎症介质的特征,血液净化原理,模式及治疗的选择,9,炎症介质的特征,血液净化原理,模式及治疗的选择,10,PSHF系列滤器筛选系数/高截留分子量,血液净化原理,模式及治疗的选择,11,如何选择血滤器？,血液净化原理,模式及治疗的选择,12,MolecularWeights（分子的重量或分子量的大小）,Copyright2015NIKKISOCo.,LTD.Allrightsreserved.,Ashleyetall.TheRenalDrugHandbook,2ndEd.2004,MedicalPress,Abingdon,UK.ISBN:1857758730,血液净化原理,模式及治疗的选择,Newfunctionalmembranewithdefinedlargerporesize,HCOmembrane,血液净化原理,模式及治疗的选择,2orLactate4mol/LPost-hepaticresectionSevereshock:Noradrenaline0.5mcg/kg/minand/orLactate4mol/LArterialBloodIonizedCalcium7.5orHCO3-40mmol/LatcommencementofRCASerumSodium160atcommencementofRCAUncontrolledhyperglycaemia6U/hInsulinIBW90kg,血液净化原理,模式及治疗的选择,35ml/kg/hCVVHRCAProtocol,Allpatientswillstartat35ml/kg/hunlessdirectedbyphysicianDoseincludescitratevolumepre-filterFiltrationRatiois20%Pre-filtercitrateconcentrationwillbe2.8mmol/L,Protocol1,血液净化原理,模式及治疗的选择,CalciumReplacement,Accusolreplacementsolutioncontains1.75mmol/LCalciumwhichwillprovidemostoralloftheCalciumreplacementA10mmol/LCalciumChloridesolutionwillbeusedforadditionalCalciumreplacementifrequired:1x10mlampuleofCalciumChloride(10mmol)in990mlNormalSalinegivenviaintegratedCalciumPumponAquarius-CitratedeviceonlyInfusionrate0-175ml/h,血液净化原理,模式及治疗的选择,InitialCalciumRate,ThencheckarterialCaiin1h,血液净化原理,模式及治疗的选择,AdjustingCalciumInfusion,*Likelytochangetocheckin6hinfinalprotocol,血液净化原理,模式及治疗的选择,*Likelytochangetocheckin6hinfinalprotocol,血液净化原理,模式及治疗的选择,MetabolicAlkalosisMonitorpHandBicarbonate3hly*,*Likelytochangetocheckin6hinfinalprotocol,血液净化原理,模式及治疗的选择,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,血液净化原理,模式及治疗的选择,Howitworks,血液净化原理,模式及治疗的选择,44,血液净化原理,模式及治疗的选择,45,THANKS!,血液净化原理,模式及治疗的选择,IndicationsforCitrateAnticoagulation,RequiringRRTwithintheICU(eitherneworon-goingtreatment)forconventionalRenalindicationsConsideredbythetreatingPhysiciantohaveacontraindicationtoheparinanticoagulationAppropriatelytrainednursingstaffavailable,8PalssonR,NilesJL,RegionalcitrateanticoagulationincontinuousvenovenoushemofiltrationincriticallyillpatientswithahighriskofbleedingKidneyInt1999,55:1991-1997.9FlaniganMetal.Reducingthehemorrhagiccomplicationsofhemodialysis:Acontrolledcomparisonoflow-doseheparinandcitrateanticoagulation.AmJKidneyDis1987;2:147-153,Copyright2015NIKKISOCo.,LTD.Allrightsreserved.,血液净化原理,模式及治疗的选择,Contraindications,ChronicLiverDisease-ChildsBorCAcuteLiverInjurywithINR2orLactate4mol/LPost-hepaticresectionSevereshock:Noradrenaline0.5mcg/kg/minand/orLactate4mol/LArterialBloodIonizedCalcium7.5orHCO3-40mmol/LatcommencementofRCAReductionofrequirementsforsystemicanticoagulant(otherthanprophylaxis)SerumSodium160atcommencementofRCAUncontrolledhyperglycaemia6U/hInsulinIBW90kgCitrateintoleranceClinicalsituationwherecitratemetabolismbecomesuncertain.,Copyright2015NIKKISOCo.,LTD.Allrightsreserved.,10Prowleetal.ServiceDevelopmentPlanandProtocolforRegionalCitrateAnticoagulation,TheRoyalLondonHospital,血液净化原理,模式及治疗的选择,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.,血液净化原理,模式及治疗的选择,49,OptimizeVascularAccess,Considerusingahighflowsiliconevascularaccesscatheterthatdoesnothave“kinkmemory”,andwithanappropriatelengthforthechosensite.AvoidattachingtheAquariustoacatheterwithpoorflow.Forexample,beingabletowithdraw20mlofbloodin6secondsor10mlofbloodin3secondswithouthesitancyorinterruptionmayhelpacatheterassessment.Considerrotatingthehubofthecatheter90sothattheholesontheaccesslumenarefacingtheflowofblood,notagainstthevesselwall(youmayneedtomomentarilystopthebloodpumptodothis).Considerthepatientsintravascularvolume.Eventhoughthepatientmaybefluidoverloaded,iftheirintravascularspaceisdehydrated,theremaybepoorflowthroughthecatheterwhichwillencourageclotting.,Copyright2015NIKKISOCo.,LTD.Allrightsreserved.,血液净化原理,模式及治疗的选择,50,OptimizeAnticoagulation,Highreturnpressureisonesignofunderanti-coagulation.Thebloodpumpwantstopushthebloodthroughthereturnchamberwherepartiallyformedbloodclotsmayincreaseinsize,makingitdifficultforthebloodtosqueezethrough.Aroutineofregularobservation,followedbyacheckofthepatientclotting,andadjustmentofanticoagulantwhereindicated,maypreventearlyreturnchamberclotting.Considerincreasingtheproportionofpre-dilutionifanticoagulationadjustmentisnotindicated.Forexample:alteringthepre-dilutionto90%andreducingpost-dilutionto10%maythinthebloodpassingthroughthefilterandreducetheeffectsofhaemoconcentration.Againinlifespanmaybeoffsetbyasmalllossinclearance,easilyadjustedbyusingtheRenalDosedisplay.,Copyright2015NIKKISOCo.,LTD.Allrightsreserved.,血液净化原理,模式及治疗的选择,51,Theeffectofbloodpumpspeed,Copyright2015NIKKISOCo.,LTD.Allrightsreserved.,Filtrateremovedisapercentageoftotalflowthroughthefilterfibres.Whyisthetotalbloodflowimportant?Withafasterbloodpumpspeed,thetotalflowisincreasedandeffectsofhaemoconcentrationarereduced.Increasingbloodflowgivesareducedfiltrationratiowhichmayslowfiltercloggingandextendfilterlifespan.,血液净化原理,模式及治疗的选择,52,TheeffectofPre-dilution,Copyright2015NIKKISOCo.,LTD.Allrightsreserved.,Filtrateremovedisapercentageoftotalflowthroughthefilterfibres.Theproportionofpredilutionflowmaybeadjustedtooptimisetreatment.Withagreaterproportionofpredilution,thefiltrationfractionandeffectsofhaemoconcentrationarereduced.Animprovedfiltrationfractionmayslowfiltercloggingandextendfilterlifespan.,血液净化原理,模式及治疗的选择,53,Considerations,Copyright2015NIKKISOCo.,LTD.Allrightsreserved.,Diameter,lengthandtypesofcatheters(II)Type:MaterialfeaturesSiliconeelastomercathetershavelowerthrombogenicityandbetterflexibility.BiocompatibleandkinkresistanceConformtovesselanatomy,thereforereduceriskoftraumaDiameterandbloodflow:11French:250-300ml/minBloodFlow13.5French:450-500ml/minBloodFlowRecirculation-upto20%Especiallyiffemoralaccessislessthan20cmAvoidreverseAVconnection,血液净化原理,模式及治疗的选择,54,PatientPreparation,Copyright2015NIKKISOCo.,LTD.Allrightsreserved.,PatientbodystatusCoagulationandIntravascularfillingMobilityinfluencesPresenceofothercentrallinesInfluencesoncatheterchoiceClinicianchoiceAvailabilityofultrasoundguidanceAssessmentofcatheterpatencyConnectiontechniquesSpecialcircumstances,血液净化原理,模式及治疗的选择,55,CatheterCharacteristics,Copyright2015NIKKISOCo.,LTD.Allrightsreserved.,Easeofinsertion:toavoidvesseltraumaGoodflowcharacteristics:tooptimisebloodflowKinkresistant:toavoidaccesspressureproblemsBiocompatible:toreducecomplicationrisksAmenabilitytoguidewirechange:tooptimisetherapy,血液净化原理,模式及治疗的选择,56,Side-by-SidePolyurethaneCatheters,Copyright2015NIKKISOCo.,LTD.Allrightsreserved.,血液净化原理,模式及治疗的选择,57,CoaxialPolyurethaneCatheters,Copyright2015NIKKISOCo.,LTD.Allrightsreserved.,血液净化原理,模式及治疗的选择,58,TriplelumenCatheters,Copyright2015NIKKISOCo.,LTD.Allrightsreserved.,血液净化原理,模式及治疗的选择,59,SiliconeCatheters,Copyright2015NIKKISOCo.,LTD.Allrightsreserved.,血液净化原理,模式及治疗的选择,60,ReversingtheLines,Copyright2015NIKKISOCo.,LTD.Allrightsreserved.,1LewingtonA,KanagasundaramS.AcuteKidneyInjury.RenalAssociationguidelines:Guideline8.1AKI:VascularaccessforRRT.Guideline8.2,Page45of59,Para3Rationalefor8.1-8.9lines7-9,血液净化原理,模式及治疗的选择,61,VascularAccess,Copyright2015NIKKISOCo.,LTD.Allrightsreserved.,VascularAccessiscontinuouslytestedduringCRRTtreatmentPracticalunderstandingaboutvascularaccessisnecessaryforoptimaltreatmentCathetersite,size,typeandpatientpreparationmaybeconsideredInadequaciesinvascularaccessmaylimitdeliveredtherapyTroubleshootingchoices,血液净化原理,模式及治疗的选择,62,VascularAccessT