CRRT的局部枸橼酸抗凝

1、持续肾脏替代治疗的局部枸橼酸抗凝,北京协和医院 杜斌,ICU中的急性肾脏功能衰竭*: BEST Kidney,患病率 1738/29269 (5.7%, 95%CI 5.5 6.0%) 危险因素 感染性休克(47.5%, 95%CI 45.2 49.5%) 住院病死率 60.3% (95%CI 58.0 62.6%) *少尿( 84 mg/dL,Uchino S, Kellum JA, Bellomo R, et al. Acute renal failure in critically ill patients: a multinational, multicenter study. JAM

2、A 2005; 294: 813-818,急性肾功能衰竭的定义: RIFLE标准,Bellomo R, Ronco C, Kellum JA, et al. Acute renal failure: definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit C

3、are 2004; 8: R204-R212,ICU的急性肾脏损伤(AKI,Ostermann M, Chang RWS. Acute kidney injury in the intensive care unit according to RIFLE. Crit Care Med 2007; 35: 1837-1843,35.8,急性肾功能衰竭的治疗(n = 646,Perez-Valdivieso JR, Bes-Rastrollo M, Monedero P, et al. Prognosis and serum creatinine levels in acute renal fai

4、lure at the time of nephrology consultation: an observational cohort study. BMC Nephrology 2007; 8: 14-22,持续肾脏替代治疗管路寿命,满足治疗要求 降低治疗费用 减少重新安装管路的护理时间,18 30 hr,Holt AW, Bierer P, Glover P, Plummer JL, Bersten AD. Conventional coagulation and thromboelastograph parameters and longevity of continuous rena

5、l replacement circuits. Intensive Care Med 2002; 28: 1649-55. Stefanidis I, Hagel J, Frank D, Maurin N. Hemostatic alterations during continuous venovenous hemofiltration in acute renal failure. Clin Nephrol 1996; 46(3): 199-205. Kox WJ, Rohr U, Waurer H. Practical aspects of renal replacement thera

6、py. Int J Artif Organs 1996; 19: 100-5. Tan HK, Baldwin I, Bellomo R. Continuous veno-venous haemofiltration without anticoagulation in high-risk patients. Intensive Care Med 2000; 26: 1652-7,持续肾脏替代治疗的影响因素,血管通路位置 中心静脉导管: 口径, 管腔设计 血流可靠性 血滤管路设计 透析膜的生物相容性 护理人员的培训及专业技能 抗凝效果,持续肾脏替代的抗凝,血滤滤器与管 路的抗凝作用,全身抗凝

7、有害作用,持续肾脏替代的抗凝选择,基础疾病 现有抗凝措施 临床经验,国内文献报告的抗凝方法,CRRT时的肝素抗凝,肝素抗凝的优缺点,优点 最常用的抗凝方法 临床方案成熟 半衰期短 过量时鱼精蛋白对抗,缺点 出血危险 APTT与滤器寿命无关 肝素诱导血小板缺乏(HIT,枸橼酸抗凝的原理,局部枸橼酸抗凝的原理,凝血过程需要游离钙参与 枸橼酸螯合游离钙, 补充钙离子可以恢复 血库使用枸橼酸保存血液 采用枸橼酸可以在RRT时进行局部抗凝: 血液进入体外循环后即加入枸橼酸 血液进入体内前补充游离钙 体外循环对血液进行抗凝, 体内血液正常 通过测定游离钙监测抗凝,肝素抗凝时的滤器中空纤维,Hofbauer

8、 R, Moser D, Frass M, et al. Effect of anticoagulation on blood membrane interactions during hemodialysis. Kidney Int,低分子肝素抗凝时的滤器中空纤维,Hofbauer R, Moser D, Frass M, et al. Effect of anticoagulation on blood membrane interactions during hemodialysis. Kidney Int,枸橼酸抗凝时的滤器中空纤维,Hofbauer R, Moser D, Frass

9、 M, et al. Effect of anticoagulation on blood membrane interactions during hemodialysis. Kidney Int,血滤终止的原因,Kutsogiannis DJ, Gibney RTN, Stollery D et al. Regional citrate versus systemic heparin anticoagulation for continuous renal replacement in critically ill patients. Kidney Int 2005; 67: 2361-2

10、367,滤器寿命的Cox风险比例模型分析,Kutsogiannis DJ, Gibney RTN, Stollery D et al. Regional citrate versus systemic heparin anticoagulation for continuous renal replacement in critically ill patients. Kidney Int 2005; 67: 2361-2367,出血或输血的比例,Kutsogiannis DJ, Gibney RTN, Stollery D et al. Regional citrate versus sys

11、temic heparin anticoagulation for continuous renal replacement in critically ill patients. Kidney Int 2005; 67: 2361-2367,CRRT时出血的多因素Poisson回归,Kutsogiannis DJ, Gibney RTN, Stollery D et al. Regional citrate versus systemic heparin anticoagulation for continuous renal replacement in critically ill pa

12、tients. Kidney Int 2005; 67: 2361-2367,不同抗凝方法的滤器寿命,Kutsogiannis DJ, Gibney RTN, Stollery D et al. Regional citrate versus systemic heparin anticoagulation for continuous renal replacement in critically ill patients. Kidney Int 2005; 67: 2361-2367,枸橼酸局部抗凝方案,枸橼酸局部抗凝图示,R,heater,ACD-A,V,V,PV,PA,UF,BLD,S

13、AD,葡萄糖 酸钙,枸橼酸局部抗凝方案说明,血滤机常规预冲 肝素盐水 根据患者病情选择适当治疗模式 CVVH CVVHD CVVHDF,枸橼酸局部抗凝方案,准备枸橼酸抗凝液 血液保存液(I) 600 ml/袋 广州华南医疗用品有限公司,R,heater,ACD-A,V,V,PV,PA,UF,BLD,SAD,葡萄 糖酸 钙,枸橼酸局部抗凝方案,准备输液泵 将输液管路与血滤管路的动脉端相连接 最接近患者处 (血泵前) 根据患者病情, 设置血滤机的常规参数,R,heater,ACD-A,V,V,PV,PA,UF,BLD,SAD,葡萄 糖酸 钙,枸橼酸局部抗凝方案,ACD-A初始泵速为血液流速(BFR

14、)的2.0 2.5% 泵速(ml/hr) = 1.2 1.5 x BFR (ml/min) 例如 BFR = 120 ml/min ACD-A泵速 = 144 180 ml/hr,R,heater,ACD-A,V,V,PV,PA,UF,BLD,SAD,葡萄 糖酸 钙,枸橼酸局部抗凝方案,常规情况下选择前稀释方式,R,heater,ACD-A,V,V,PV,PA,UF,BLD,SAD,葡萄 糖酸 钙,枸橼酸局部抗凝方案,置换液中不含钙,R,heater,ACD-A,V,V,PV,PA,UF,BLD,SAD,葡萄 糖酸 钙,枸橼酸局部抗凝方案,准备10%葡萄糖酸钙溶液及注射器泵 将输液管路连接至血

15、滤管路静脉端 葡萄糖酸钙溶液初始泵速为8.8 11.0 ml/hr (ACD-A泵速的6.1,R,heater,ACD-A,V,V,PV,PA,UF,BLD,SAD,葡萄 糖酸 钙,枸橼酸局部抗凝方案: 抗凝监测,Q2h x 4,Q4h x 4,Day 1,Day 2 Q 6 8 h,枸橼酸局部抗凝方案: 抗凝监测,R,heater,ACD-A,V,V,PV,PA,UF,BLD,SAD,枸橼 酸钙,动脉标本 外周静脉或动脉 游离钙1.00 1.20 mmol/L,静脉标本 滤器后血滤管路 游离钙0.20 0.40 mmol/L,枸橼酸局部抗凝方案: 抗凝监测,枸橼酸局部抗凝方案: 抗凝监测,枸

16、橼酸局部抗凝方案: 抗凝监测,每次更换输液部位或管路后1 2小时内应监测离子钙 若血泵停止数分钟以上 必须关闭ACD-A泵(防止枸橼酸进入患者体内) 必须关闭葡萄糖酸钙泵(防止过量钙进入患者体内) 若因病情需要停止血滤(如诊断, 更换导管, 手术, 凝血或更换管路), 应在重新开始血滤时按照停止前的速度设置ACD-A及葡萄糖酸钙泵速,枸橼酸局部抗凝方案: 抗凝监测,若HCO3增加 10 mEq/L 需要确认 ACD-A输注部位正确, 未直接进入患者体内 降低ACD-A泵速25% 2 4小时后测定HCO3 若测定结果仍不正常 再次降低ACD-A泵速25,枸橼酸局部抗凝方案: 抗凝监测,若患者血Na上升10 mEq/L或 155 mEq/L 需要确认 ACD-A输注部位正确, 未直接进入患者体内 降低ACD-A泵速25% 2 4小时后测定血Na 若测定结果仍不正常 输注5%GS,枸橼酸抗凝的并发症: 代谢性碱中毒,主要原因 枸橼酸转化为HCO3 (1 mmol枸橼酸能够产生3 mmol的HC