血液透析并发症

血液透析并发症Hemodialysis

ComplicationsObjective

课程目标UnderstandthedifferentHDrelatedcomplicationsandtheiroutcomes了解各种血透相关并发症以及预后Hemodialysis-relatedComplications

血透相关并发症Commoncomplications

常见并发症Hypotension

低血压 backpain

后背疼痛Cramping

肌肉痉挛Itching

皮肤瘙痒nauseaandvomiting

恶心呕吐feverandchills

发热寒颤Headache

头痛mildchestpain

轻微胸痛Seriouscomplications(emergency!)

严重并发症Seizure癫痫Severedialyserreactions严重的透析器反应Hemolysis

溶血Exsanguination

失血Airembolism空气栓塞Severecardiacproblems严重心脏问题Hemodialysis-relatedcomplications

血液透析相关并发症Hypotension低血压Causesrelatedtoexcessiveortoorapiddecreaseinthebloodvolume

failuretouseaninstrumentwithanultrafiltrationcontroller

patienthadlargeinterdialyticweightgain

patienthadtooshortoftreatmenttosafelyremoveweightneeded

excessiveultrafiltrationbelowthepatient’s“dryweight”

useoftoolowsodiumdialysate

relatedtolackofvasoconstriction

acetatedialysateused(aknownvasodilator)

useofnormaltemperaturedialysate(37-38C.)

foodingestion

tissueischemiacausesfurthervasodilatation

autonomicneuropathy

anti-hypertensivemedications

relatedtocardiacfactors

leftventricularhypertrophyanddiastolicdysfunction

heartrateandcontractility

couldbeasignofamoreseriousevent

associatedwithdialyzermembrane“reactions”

原因过多或过快地减少血容量未使用具超滤控制装置的设备患者在透析间期体重增长过多治疗时间过短，过快达到“干体重”达到“干体重”后的过度超滤低钠透析缩血管因素缺乏醋酸盐透析（已知具血管扩张作用）常温透析液(37-38C.)进食组织缺血导致更多的血管扩张自主神经功能障碍抗高血压药物与心脏因素有关左心室肥大以及心脏舒张功能障碍心率及收缩功能异常可能为其它更严重事件的预示与透析器膜反应相关(continued)（继续）Signsandsymptoms

Dizzy

light-headed

hot,flushedfeeling

nauseated,sometimesvomiting

maybeassociatedwithcramps

maybeasymptomatic

Management

Trendelenburgposition(feetup,headdown)Trendelenburg

100ml.,ormoreofnormalsalinealternativestonormalsaline

glucose,mannitol,albumin,hypertonicsaline

reduceultrafiltrationrate

slowbloodflowrate

症状和体征眩晕头重脚轻发热、颜面潮红恶心，有时呕吐可伴有肌肉痉挛可以无症状处理调整体位（头低脚高位）100ml以上生理盐水快速补充生理盐水的替代物如：葡萄糖、甘露醇、白蛋白、高渗盐水等降低超滤率调低血流速(continued)（继续）Preventionuseinstrumentwithultrafiltrationcontroller

patientshouldlimitweightgainto<1-1.5Kg/day

donotultrafilterpatientbelowdryweight

dialysatesodiumequaltoorgreaterthanpatient’sserumlevel

patientshouldtakebloodpressuremedicationsaftertreatment

patient’shematocritshouldbe25-30%pre-treatment

donotgivefoodorglucoseduringtreatmenttohypotensivepatients

usebicarbonatedialysate

dialysatetemperatureat34-36C.

预防使用具有超滤控制装置的透析机患者透析间期应限制体重增加<

1-1.5公斤/天达到干体重后不应继续超滤透析液钠浓度等于或略高于病人血清钠浓度，避免低钠透析透析后服用降血压药透析前血球压积应达到25-30%低血压患者透析期间不应进食或输注葡萄糖使用碳酸盐透析液透析液温度34-36C。Headache头痛Causes

mostlyunknown

maybeasubtlemanifestationofDisequilibriumSyndrome

useofacetatedialysate

caffeine“withdrawal”

Management

Tylenol™(acetaminophen)Tylenol™

Prevention

changetobicarb

dialysate

similartohypotensionprevention

原因多数原因未知可能是失衡综合症的表现使用醋酸盐透析液咖啡因“戒断”处理Tylenol™（泰诺）预防转为碳酸盐透析与低血压预防相似MuscleCramps肌肉痉挛Causesmostlyunknown

predisposingfactors

Hypotension

patientbelowdryweight

crampswilloccurmanyhoursaftertreatment

usinglowsodiumdialysate

causesvesselconstrictioninthemuscleManagement

reduceultrafiltrationrate

givehypertonicsalineorhypertonicglucose,orcanuseSodiumButtononArenainstrument

sometimeswarmcompresseshelp

原因多数原因未知诱因低血压体重低于干体重（过度超滤）痉挛可在透析后数小时发生使用低钠透析引起肌肉内的血管挛缩处理降低超滤率使用高渗盐水或高渗葡萄糖；可使用机器上的钠按钮等辅助装置有时需要局部热敷(continued)（继续）Preventionpreventionofhypotension

increasedialysatesodiumto>145mEq/L

useavariablesodiumprograminconjunctionwithadecreasingultrafiltrationrate

giveCarnitinesupplement

giveoralQuinineSulfate2hoursbeforedialysis(unknownmechanism)

stretchingexercises

预防预防低血压透析液钠增加到>145mEq/L使用可调钠程序，超滤率将在透析过程中逐步降低补充肉碱类药物透析前2小时内口服硫酸奎宁（机理未知）加强锻炼NauseaandVomiting恶心和呕吐Causes

Multifactorial

usuallyrelatedtohypotension

earlymanifestationofDisequilibriumSyndrome

Management

1st:treatanyhypotension

maygiveantiemeticmedicationifpersists

Prevention

avoidhypotension

bicarbonatedialysate

原因多种原因（常为伴随症状）常与低血压有关失衡综合症的早期表现处理首先治疗低血压症状持续可使用止呕药预防防治低血压碳酸盐透析Non-specificDialyzerReaction

非特异性透析器反应Description

firstusesyndrome

groupofadversereactionsofunknownreason

twotypes

anaphylactictype(adialysisemergency;willdiscussinnexttopic)

non-specificdialyzerreaction

Causes

Unknown

complementactivated

Signsandsymptoms

sometimeswillexhibitchestpain

mayormaynotbeaccompaniedbybackpain

symptomsmayoccurwithinseveralminutesofinitiationandupto1hourorso

描述首次使用综合症不明原因的副反应症候群类型过敏类型（属于透析紧急反应，将在后面讨论）非特定的透析器反应原因未知补体激活症状和体征有时表现为胸痛可伴有背痛症状可发生在开始透析后的几分钟到1小时左右(continued)（继续）ManagementSupportiveO2treatmentcancontinueassymptomswillusuallysubsideafterthefirsthour

Prevention

?Reuse

usedialyzerswithmorebiocompatiblemembranes

处理

支持性治疗

给氧

透析多可以继续，症状通常在1小时后消失

预防透析器必须复用（？）使用生物相容性好的透析器SevereDialyzerReaction严重透析器反应Description

severefirstusesyndromereaction

groupofeventsthatincludesanaphylacticshockofunknownreason

Causesofanaphylactictypereaction

“allergy”toETOusedtosterilizedialyzers对associationofusingapolyacrylonitrilemembranedialyzerandtakingACEinhibitormedications

contaminateddialysate

reuse(?contaminatedwater)

Heparin

complementrelease(bioincompatiblemembranes)

描述严重的首次使用综合症包括未知原因的过敏性休克等不良事件过敏反应的原因对环氧乙烷消毒的透析器“过敏”与使用聚丙烯腈膜透析器/ACE抑制剂药物有关透析液污染复用（使用受污染的水？）肝素补体释放（生物相容性差的膜）(continued)（继续）Signsandsymptomsofanaphylactictypereaction

usuallyduringfirstfewminutesofdialysis

onsetmaybedelayedupto30min.ormore

difficultybreathing(dyspnea)

senseofimpendingdoom

warmflushedfeelingthroughoutbody

cardiacarrest

Death

Management

stoptreatmentimmediately

clampbloodlinesanddonotreturnblood

cardiorespiratorysupportmaybenecessary

antihistamines,steroidsandepinephrinecanbegiven

Prevention

properrinsingofdialyzerstogetridofETO

avoidusingETOsterilizeddialyzersinthosepatientswithknownallergies

givepre-treatmentantihistamines

症状和体征通常发生在透析的前几分钟可延迟到30分钟或更长呼吸困难濒死感全身发热心脏骤停死亡处理立即停止治疗夹住血液管路，暂停回血可能需要给予心肺支持使用抗组胺剂、类固醇和肾上腺素预防正确冲洗透析器以祛除环氧乙烷对环氧乙烷过敏的病人避免使用此类透析器在透析前使用抗组胺药物PyrogenReaction热原反应Causes

Infection

introductionofpyrogensorendotoxinsviadialysateorwater

inadequatelyreprocesseddialyzers

Signsandsymptoms

patientfeelscold

involuntaryshakingchills

Fever

Hypotension

原因感染通过浓缩液或透析用水进入的致热原或内毒素复用透析器处理不当症状和体征畏寒难以控制的寒颤发热低血压(continued)（继续）Management

checkforsourcesandsignsofinfection

obtainbloodcultures,butusuallynegative

collectdialysateandwatercultures

administerantipyretics

administerantibiotics

Prevention

properwatertreatment

preparedialyzernomorethan2hourspre-treatment

appropriatecareofbicarbonateconcentrate

cleaninganddisinfectingofwatertreatmentsystem

cleaninganddisinfectingbicarbonateconcentratecontainers

处理寻查感染源和感染征兆血培养（但通常为阴性）透析用水进行培养检验使用退热剂使用抗生素预防正确的水处理使用预处理不超过2小时的透析器正确使用碳酸氢盐浓缩液进行水处理系统的清洁和消毒清洁和消毒配置碳酸盐透析液容器DES-DisequilibriumSyndrome

失衡综合症Causes

toorapidremovalofureacauseswatertoenterthebrainandswellingofbraintissue过rapidpHchangesandelectrolyte

occursmoreofteninacuterenalfailurethanchronicrenalfailurewherepre-treatmentureamaybe>150mg/dl

muchlargerproblem10-20years

Signsandsymptoms

Headache

nausea,vomiting

Restlessness

Hypertension

increasedpulsepressure

decreasedsensorium

convulsions,coma,death

原因过快地清除尿素等废物，脑脊液与血液之间出现浓度差渗透压差水分进入脑组织脑水肿（血脑屏障）pH值和电解质浓度变化过快在急性肾衰发生频率比慢性肾衰高是10-20年前血透的主要常见问题症状和体征头痛恶心、呕吐烦躁不安高血压脉压差增大中枢神经反应迟钝抽搐、昏迷、死亡(continued)（继续）Management

treatmentformildsymptomssuchasheadache,nauseaandvomiting

mayhelptodecreasedbloodflowratetodecreaseurearemoval

forsevereDES,discontinuethetreatmentearly

hypertonicsalineorglucose

IVMannitol

Prevention

inanacutesetting

donotdialyzeaggressively

ureareductionshouldbelimitedtoonly30%

donotuselowsodiumdialysateinachronicsetting

usedialysatewithsodiumlevelofatleast140mEq/L.andglucoselevelof200mg/dL

usevariablesodiumlevels

处理处理头痛、恶心和呕吐等症状（可应用糖皮质激素降低血流量减慢尿素的清除速度出现严重DES者，应尽早结束该次透析静脉输入甘露醇－降低颅内压预防急性透析不要过度透析（首次透析<3小时）尿素清除应不超过30%不使用低钠透析慢性透析使用钠水平>140mEq/L的透析液，葡萄糖的水平为200mg/dL。使用可调钠浓度透析CardiacProblems心脏疾患1，Dysrhythmias

Causes

toorapiddecreaseofelectrolytes(potassium)andpHunderlyingheartdisease

removalofantiarrhythmicdrugsduringtreatment

managementandprevention

usehigherK+indialysate

1，心律不齐原因电解质（钾）和pH值的降低过快潜在的心脏疾患透析中抗心律失常药物被清除治疗和预防提高透析液钾浓度CardiacProblems心脏疾患2，AnginaCauses

Anemia

coronaryatherosclerosis

coronaryarteryspasm

severevascularvolumedepletion

Management

decreaseultrafiltrationrate

O2asnecessary

treatvolumedepletion

Prevention

bloodtransfusionormaintainhematocritatasymptomaticlevel

Nitroglycerin

chooseappropriateultrafiltrationtarget

2，心绞痛原因贫血冠状动脉硬化冠状动脉痉挛严重血容量不足处理降低超滤率根据需要给氧纠正血容量不足预防输血或维持血球压积硝酸甘油适当的超滤目标Seizure

癫痫Cause

children,patientswithhighpre-dialysisurealevels,andpatientswith

canbealatermanifestationofDisequilibriumSyndrome

severeelectrolyteimbalances

severeoruntreatedhypotension

dialysatecompositionerrors

Management

useosmoticagentsduringpatient’sfirsttreatment(Mannitol)

frequentmonitoringofbloodpressureandcorrecthypotensiveepisodes

Prevention

avoidlargedropsinurea

counteracttherapiddropwithanosmoticagent(Mannitol)

maintainbloodpressure

原因儿童、透析前尿素水平高（BUN>540mmol/L）的患者和严重高血压患者最常见癫痫发作可以是失衡综合症的后期表现严重的电解质失调严重的低血压透析液成份错误处理首次治疗时使用渗透剂（甘露醇）严密监视血压，及时纠正低血压预防避免尿素的过快清除使用渗透剂（甘露醇）缓解渗透压的快速下降维持血压Hemolysis

溶血“Bursting”ofRBCs

Causes

dialysatecontaminatedwithformaldehyde,bleach,chloramine,copperandnitrites

akinkinthebloodline,usuallyatthearterialendofthedialyzer

Signsandsymptoms

backpain

headache,malaise

tightnessinthechest

shortnessofbreath,coughing

darkerbloodcolorinthe“from“dialysateline

红细胞破裂原因透析液被甲醛、次氯酸、氯胺、铜和亚硝酸盐污染（消毒剂残留）透析液配置错误：低渗透析液血液管路扭结，通常在透析器的动脉端（机械性破坏）症状和体征腰背部痛头痛胸部压迫感呼吸短促、咳嗽透析液引出管路见到深的“血色”

(continued)（继续）Management

stopbloodpumpandclampbloodlines;doNOTreturnpatient’sblood(riskofhyperkalemia!)

Prevention

propermanagementofwateranddialysatemixingsystems(multipleptscanbeaffectedatthesametime)

observe/preventkinkinginbloodlines

处理停止血泵，夹住血液管路；不要回血（有引起高血钾的危险）住院观察预防透析液混合系统的管理（如果是透析液混合系统问题，则在同一时间可见多个病人出现症状体征）防止血液管路扭结Exsanguination

失血“Bleedingout”ofthepatientwhichcancausedeathifundetected

Causes

separationofbloodlines

needledislodgedfromvessel

ruptureoffistulaaneurysmoranastomosis

separationofcapfromcatheter

Signsandsymptoms

sourceisusuallyobvious

lossofconsciousness,shock,convulsions

Death

患者不断失血，在未发觉的情况下可导致严重后果甚至死亡

原因

血液管路分离

内瘘针脱落

内瘘管动脉瘤或吻合口裂

导管上的帽脱落

症状和体征

明显的出血

意识丧失、休克、抽搐

死亡(continued)（继续）Management

turnoffbloodpumpandplaceclamponbothsidesofseparatedbloodlineorcatheter

applypressuretoanybleedingsite

evaluatesuitabilityofreturningbloodtopatientfromruptureddialyzer

giveO2ifbloodlossissignificant

givevolumeexpanderifhypotensive

Prevention

secureallbloodlinesandconnections

tapeneedles

allowforvisualizationofcircuitandaccess

capandsecurecatheters

properseatingofbloodlinesinbloodpump

properlyfunctioningbloodleakdetector

处理

关闭血泵

对患者出血部位加压止血

评估是否将破膜透析器中的血引回患者

失血较多时给氧

对出现低血压者及时补充血容量

预防

血液管路牢固连接

固定内瘘针

透析过程中应可看到血液循环回路和内瘘针穿刺部位

导管上的盖子应盖紧

正确安装血液管路

保持漏血探测器正常工作AirEmbolism

空气栓塞Apotentialcatastrophethatcanleadtodeathunlessquicklydetectedandtreated

Causes

anypossiblesiteinthebloodcircuitthatmayallowairtoenterthesystem(mostoftenwithCVC)

defectiveair/foamdetectors

emptyair-ventedIVbottles

Signsandsymptoms,dependsonpatient’sposition

dyspnea,coughing

slightcyanosis

chesttightness

lossofconsciousness

Convulsions

Death

foamorbubbleswillbeseeninthevenousbloodlineofthecircuit

“churning”soundheardintheheart

威胁生命，未及时发现和妥当治疗可导致死亡

原因血液循环中任何一个空气可能进入的环节（大多在深静脉插管处）空气/泡沫探测器失灵可进入空气的静脉输液容器空气回血除气环路失效症状和体征（根据患者体位有所不同）呼吸困难、咳嗽面色苍白胸部压迫感意识丧失抽搐死亡在静脉血液环路中发现泡沫或气泡心脏有明显杂音(continued)（继续）Managementstopbloodpump,clamp

placepatientonleftsidewithheaddowntokeepairinrightventricle

giveO2

mayhaveairaspiratedfromventricleofheartwithneedle(ONLYphysiciantodo!)

doNOTdocardiacmassageunlessairremovedfromventriclePrevention

verifyfunctioningfoam/airdetector

verifypatencyofbloodcircuit

returnpatient’sbloodwithsaline,NOTair,atendoftreatment

usebagsofsolutioninsteadofglassbottles

infusionsshouldbegivenPREfoam/airdetector

处理停止血泵，夹住静脉管路（不给患者回血）让患者左侧卧位使空气停留在右心室给氧医师做心脏穿刺将空气吸出空气从心室排出前不可进行心脏按压预防确定泡沫/气泡监测器正常在整个透析过程中可以看到血液环路透析结束时用盐水回血，不要用空气回血使用软袋装而不是瓶装盐水在泡沫/气泡监测器前输入液体SevereCardiacProblems

严重的心脏疾患1.PericarditisandTamponade inflammationofthepericardialsacsurroundingtheheart

fluid/bloodcollectsinthepericardialsac toomuchfluidwillpressontheheartcausinga“tamponade”

Causesinadequatedialysis,orusuallyseenpriortothepatientbeginningdialysis(preESRD)

volumeoverload,hyperuricemia,malnutrition

signsandsymptoms

“frictionrub”heard

chestpain,achingbetweentheshoulderblades

frequenthypotensionduringtreatment

1.心包炎和心包填塞心包炎心包腔大量聚集体液或血液可导致“心包填塞”

原因 透析不充分；也经常出现在病人开始透析治疗之前（终末期肾衰前期）

液体过多，尿酸过多，营养不良

症