血液净化原理,模式及治疗的选择PPT课件

1、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,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： 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 purificati

2、on （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

3、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,.,8,炎症介质的特征,.,9,炎症介质的特征,10,PS

4、HF系列滤器筛选系数/高截留分子量,.,11,如何选择血滤器 ？,12,Molecular Weights （分子的重量或分子量的大小）,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, 0,01 m, 0

5、,02 m, 0,09 m, 0,30 m,: pore diameter,high flux,high cut-off*,protein separation membrane,plasma separation membrane,Variation of membrane pore size,Electron micrographs of inner membrane surface,High Cut-Off Hemofilter,16,Sieving Coefficient,A sieving coefficient is the measure of how easily a subs

6、tance passes from the blood compartment to the dialysate compartment in a haemofilter. Thus, a sieving coefficient of 1.0 means the solute is 100% filterable; i.e. in a haemofilter, the solute will equilibrate on both sides of the membrane. So the returning blood and the effluent both have the same

7、concentration (50:50). An example is potassium (sieving coefficient is 1.0) A sieving coefficient of 0 means the solute does not cross the membrane, eg. albumin. Of course, this all depends on the membrane, and sieving coefficients will vary depending on the pore size. DEFINITION:The cut-off point o

8、f a solute for any membrane is a sieving coefficient of 0.1 . This means that 10% of the molecules will pass and 90% will not pass .,Copyright 2015 NIKKISO Co., LTD. All rights reserved.,Molecular Weight Da,Standard HighFlux,High Cut-Off,HF, UF=1L/h, t=2h,Median, 25th-75th percentiles),ICM (2002) 28

9、:651-655,HCO Membrane with increased permeability for inflammatory mediators,membrane characteristics,18,Molecular weight,Ashley et all. The Renal Drug Handbook, 2nd Ed. 2004, Medical Press, Abingdon, UK. ISBN: 1857758730 Copyright 2015 NIKKISO Co., LTD. All rights reserved.,HF1200 Haemofilter Cut-O

10、ff 55 000 daltons,19,Comparison of Interleukin-6 Removal Properties among Hemofilters Consisting of Varying Membrane Materials and Surface Areas,Recent Studies in Membrane,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 2015 NIKKISO Co., LTD. All rights reserved.,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

11、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 2015 NIKKISO Co., LTD. All rights reserved.,22,预防滤器内的凝血(Filtration Ratio%),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1

12、0 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 2015 NIKKISO Co., LTD. All rights reserved.,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.,Copyrigh

13、t 2015 NIKKISO Co., LTD. All rights reserved.,24,Filtration Fraction（滤过分数）,Filtration Fraction 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% Filtration Fraction 滤过分数是 不会受到前 稀释泵的影响 Filtration Fraction 滤过分数是会受到血流速 的影响 .,Copyright 2015 NIKKISO Co., LTD. All rights reserved.,25,超滤比率 Filtration Ratio,Copyr

14、ight 2015 NIKKISO Co., LTD. All rights reserved.,Filtration Ratio是表示滤器中血液浓度增加 . 理想的超滤比率在低于 25%. Filtration Ratio 是受到前稀释泵的影响 . Filtration Ratio 是受到血流速的影响.,26,Filtration Ratio and blood pump speed,Postdilution (l/h) Blood Pump Speed (mls/min) 60 (mins) = Filtration Ratio /1000 3l/h Exchange 3 1 100mls

15、/min x 60 mins = 6 = 2 = 50% Filtration Ratio /1000 3l/h Exchange 3 1 200mls/min x 60 mins = 12 = 4 = 25% Filtration Ratio 3l/hr Exchange 3 1 300mls/min x 60 mins = 18 = 6 = 17% Filtration Ratio,Copyright 2015 NIKKISO Co., LTD. All rights reserved.,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

16、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 Factor X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.,5Ronco et al. Effects of different doses in continuous veno-venous haemofiltration on outcomes of acute renal failure: a prospective randomised trial. Lancet. 2000 Jul 1;356(9223):26-30,Copyright 2015 NIKKISO Co., L

17、TD. All rights reserved.,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 2015 NIKKISO Co., LTD. All rights reserved.,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 (Citrate Solution),What,citrate binds to calcium which inhibits coagulation,Copyrigh

18、t 2015 NIKKISO Co., LTD. All rights reserved.,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 Total Calcium (typically 2.2-2.6 mmol/l) and Total Magnesium (typically 1.1 1.4 mmol/l). 影响到选择枸橼酸的量 Citrate dosing between 3.3 4.0 mmol/l.,Copyright 2015 NIKKISO Co., LTD. All rights reserved.,What does the body do wi

19、th Citrate?,Copyright 2015 NIKKISO Co., LTD. All rights reserved.,32,Therapy monitoring,The selection and adjustment of therapy parameters, replacement fluids and anticoagulant fluids remains a prescription at the physicians discretion. A change in an individual prescription will require physician r

20、eview or be clearly defined in a locally approved document. To monitor and adjust the therapy, the following typical parameters may be considered in the individualized prescribers local protocol : Ionised Calcium (after hemofilter) typically 0.25 - 0.35 mmol/l Ionised Calcium (from patient) typicall

21、y 1.05 - 1.3 mmol/l Total Citrate (from patient) typically less than 2.5 mmol/l Calcium Ratio (a comparison of Calcium distribution) typically less than 2.3 Acid/base monitoring Electrolytes monitoring Fluid balance monitoring,Copyright 2015 NIKKISO Co., LTD. All rights reserved.,Aquarius Regional C

22、itrate Anticoagulation Protocol,John R Prowle MD FRCP FFICM Adult Critical Care Unit Royal London Hospital,Eligibility for RCA,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

23、 anticoagulation or unable to achieve adequate filter lifespan (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 L

24、actate 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 p

25、atients 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,Protocol 1,Calcium Replacement,Accusol replacement solution contains 1.75mmol/L Calcium which will provide most or all of th

26、e 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,The

27、n check arterial Cai in 1h,Adjusting Calcium Infusion,* Likely to change to check in 6h in final protocol,* Likely to change to check in 6h in final protocol,Metabolic Alkalosis Monitor pH and Bicarbonate 3 hly*,* Likely to change to check in 6h in final protocol,Step 2: if pH7.5 or HCO3- 40mmol/L o

28、n 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*. (Prot

29、ocol 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,.,44,45,THANKS!,Indications for Citrate Anticoagulation,Requiring RRT within the ICU (either new or on-going treatment) for conventional Renal indications Considered

30、 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: 1

31、991-1997. 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

32、 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 Sodi

33、um 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 Anticoag

34、ulation , 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

35、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 NIKKI

36、SO Co., LTD. All rights reserved.,49,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 with

37、draw 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 st

38、op 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.,Copyright 2015 NIKKISO Co., LTD. All rights reserved.,50,

39、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, foll

40、owed 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-dil

41、ution 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.,Copyright 2015 NIKKISO Co., LTD. All rights reserved.,51,The effect of blood pump

42、speed,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 flo

43、w gives a reduced filtration ratio which may slow filter clogging and extend filter lifespan.,52,The effect of Pre-dilution,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 adjust

44、ed 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.,53,Considerations,Copyright 2015 NIKKISO Co., LTD. All rights reserved.,Diam

45、eter, 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

46、 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,54,Patient Preparation,Copyright 2015 NIKKISO Co., LTD. All rights reserved.,Patient body status Coagulation and Intravascular filling Mobility influences Pre

47、sence of other central lines Influences on catheter choice Clinician choice Availability of ultrasound guidance Assessment of catheter patency Connection techniques Special circumstances,55,Catheter Characteristics,Copyright 2015 NIKKISO Co., LTD. All rights reserved.,Ease of insertion: to avoid ves

48、sel 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,56,Side-by-Side Polyurethane Catheters,Copyright 2015 NIKKISO Co., LTD. All rights reserved

49、.,57,Coaxial Polyurethane Catheters,Copyright 2015 NIKKISO Co., LTD. All rights reserved.,58,Triple lumen Catheters,Copyright 2015 NIKKISO Co., LTD. All rights reserved.,59,Silicone Catheters,Copyright 2015 NIKKISO Co., LTD. All rights reserved.,60,Reversing the Lines,Copyright 2015 NIKKISO Co., LTD. All rights reserved.,1 Lewington A, Kanagasundaram S. Acute Kidney Injury. Renal Association guide