肾透析医疗技术基础.ppt

1、Medical and Technical Basics相关医学和技术基础,20/09/2020,肾脏生理,生成尿液，排除代谢终末产物、毒物和药物 调节体内水、电解质、渗透压和酸碱平衡 调节血压 分泌肾素、促红细胞生成素、1,25-(OH)2D3、前列腺素等,20/09/2020,血液透析的作用,清除体内的毒素（弥散、对流、吸附） 纠正酸碱平衡紊乱（弥散） 清除体内过多的水份（超滤） 纠正电解质失衡（弥散）,20/09/2020,Diffusion弥散,Start开始时: DifferentConcentrations 膜两侧浓度有差别,End结束时: EqualConcentrations

2、膜两侧浓度相同,time,弥散是微分子物质随机的运动可导致均匀分布的结果 Diffusion is a consequence of the random movementof all molecules (Brownian Movement).,20/09/2020,Ultrafiltration超滤,Time Pressure,Start:,End:,Exertion of pressure on one side of the membrane produces filtration of water with solutes, as long as they can pass the

3、membrane. 运用压力的作用将水份从膜一侧推到另一侧，膜孔够大时溶质也可以被挤出,20/09/2020,dialysate side透析液侧,blood side血液侧,Adsorption 吸附 after chemical disinfection?,hollow fiver,endotoxins 内毒素 - contact space接触空间,Virus病毒,20/09/2020,HF,B,HD,B,D,B,D,HDF,mmHg,B,B,D,low-flux低通透析器,high-flux高通透析器,high-flux高通透析器,diffusion,convection adsorp

4、tion,diffusion/convection adsorption,Therapy types治疗模式,Hemodialysis血液透析,Hemofiltration血液滤过,Hemodiafiltration血液透析滤过,弥散原理,对流 吸附,弥散 对流 吸附,20/09/2020,Hemodialysis 血液透析 利用血液和透析液中溶质的浓度差别使溶质在弥散作用下通过半透膜随透析液排出Diffusive metabolic transport through semi-permeable membranes with balance of a concentration diffe

5、rence between blood and dialysis fluid. 小分子物质可有效的被清除Small molecular substances will essentially more effective.,diffusive convective adsorptive clearance,Hemodialysis血液透析and Hemofiltration血液透析滤过,Hemofiltration 血液透析滤过 可溶物质随着通过高通透性半透膜的液体流动而被清除（对流）。对流依靠跨膜压和膜的物理性质（面积、密度、质量、孔径）来实现。 Soluble substances are

6、 swept along in a fluid stream through high permeable membranes (convection). The convection depends on the transmembrane pressure and on membrane features like size, density, and quality of the pores (cut-off- value“). 清除高分子量物质（只要是低于膜孔的筛选值的物质）的有效方法High moleculare substances, as long as they are bel

7、ow the cut-off-value“, will be eliminated in a better way.,20/09/2020,HDF Hemodiafiltration血液透析滤过,结合两种治疗模式：血液透析和血液滤过 结合由弥散产生的小分子物质的高清除率 和由对流产生的中大分子物质的高清除率 两种方式的优点。 Combination of two dialysis technics, hemodialysis and hemofiltration: high clearance of conventionel small molecules by diffusion linke

8、d with high clearance of middle molecules by convection.,mmHg,B,B,D,Diffusion + Convection + Adsorption,high-flux高通滤器,20/09/2020,Replacement Solution for HF and HDF置换液,常规离子范围,常用配方,20/09/2020,R,heater,heparin,V,V,PV,PA,UF,BLD,SAD,Postdilution后稀释,Predilution前稀释,HDF-Online在线透析滤过 Medical医学,20/09/2020,Cl

9、earance in HD, HF and HDF各治疗模式的清除率,20/09/2020,Semipermeable Membrane半透膜,Virus病毒,Bacteria细菌,Medium sizedmolecules, e.g.b2-Microglobulin,Water flow iseasily possible 水最容易通过,Erythrocyte,red blood cell红血球,Albumin, asexample of a bigprotein molecule 白蛋白等大蛋白分子,Electrolytes电解质,The semipermeable membrane fu

10、nctions similar to a fine sieve, only molecules that are small enough can pass. 半透膜就是性能良好的筛网，仅有小于筛孔的物质可以通过,20/09/2020,Pressure Drop on Dialyser - Low Flux 透析器内的压力分布示意图,200,250,300,350,400,blood side,pressure drop,dialysate side,pressure drop,filtration = net UF 净超滤,450,PBE,PV,PDA,Ultrafiltration 超滤作

11、用,medium TMP,pressure in the filter,20/09/2020,Advantages of the Dialog Balance Chamber Control Dialog 机器的改良的容量平衡控制系统的优点,permanent monitoring of the membrane position持续监测平衡腔膜片位置continuous control连续控制 no pressure spikes at the dialyser透析器内没有压力尖峰smooth UF and prevention of reverse UF in the switching

12、moment超滤平稳并且避免了液流切换时产生反超 continuous dialysate flow even in the switching moment 透析液持续不断（包括液流切换时刻） better therapy results (K*t/V) by maintaining the diffussion pressure维持住弥散压力可带来更好的治疗效果(K*t/V值) protection of the membrane material, valves and pumps 对膜片、阀门和泵都有保护作用。extended life time延长配件寿命,competitor,20

13、/09/2020,The Access Points - on Patient 病人血管通路,Cimino Fistula,V. jugularis interna,V. subclavia,V. cubitalis,V. femoralis,The blood flow in the fistula must be at least the doubled from the required blood flow at therapy to minimize the recirculation.,20/09/2020,The Sieving Coefficient of the Dialys

14、er 透析器的筛选系数,Albumine 69000 Da,Urea 60 Da,Creatinin 113 Da,Phosphat 96 Da,Vitamin B12 1355 Da,Inulin 5200 Da 2-Microglobuline,Membrane pores 0,003 m,Erythozyt 8,5 * 2 m,20/09/2020,UF Factor Substance Transport Factor超滤系数,Diacap HE 1400 - factor 7,4 7,4ml/h per mmHg Pressure difference 300mmHg * 7,4 m

15、l/h/mmHg = 2220ml / h,200mmHg,-100mmHg,TMP 300mmHg,factor 7,4,Cuprophan CE2000 factor 8,6 transport UF 1500 per hour venous pressure 220 mmHg TMP = PDA =,1500 : 8,6 = 174,4 mmHg,TMP - PV = - 45,6 mmHg,venous pressure,PDA,calculation of UF removal,pressure calculation,memorize: the factor of the filt

16、er can even in one charged up to 15% changed.,20/09/2020,Dialyser Types透析器类型,Synthetic membrane Cellulose membrane modified cellulose regenerated cellulose,Polysulfone (PSU) Polyamide (PA) Polycarbonate (PC) Ethyl-vinyl-alcohol copolymer (EVAL) Polyacrylonitrile (PAN) Polymethyl methacrylate (PMMA),

17、High-flux and Low-flux Low-flux,Synthetic modified cellulose (SMC) Cellulose acetate (CA) Cellulose diacetate (CDA) Cellulose triacetate (CTA) Hemophan (HE),Cuprophan (CU) Cuprammonium,20/09/2020,Dialyser Types,high biocompatible but more heparin necessary,high clearance at middle molecular substanc

18、es,more effective on small molecular substances,membrane with high adsorption effect,Diacap Polysulfone,Diacap SMC Synthetic modified Cellulose,excellent balanced biocompatible profile,20/09/2020,10,10,104,105,106,107,108,Exotoxic fragments,Exotoxics,Muramylpeptid,Peptidoglykane,Endotoxic fragments,

19、Lipid A,Endotoxics,Virus,Bacteria,verification,CIS,CIS,CIS,CIS,CIS,LAL,LAL,Cut-Off Point of Dialyser,Molecular weight/Dalton,low flux high flux,20/09/2020,Microbiologic Request微生物要求,AAMI = American Association for the Advancement of Medical Instrumentation Ph. Eur. = Europische Pharmacopoeia CFU = C

20、olony Forming Units EU = Endotoxin Units,20/09/2020,Quality of Water and Dialysate反渗水和透析液水质,The user must ensure that the water quality is continuous monitored. The following requirements must be fulfilled: The incoming water must be free from Mg+ and Ca+. pH value of between 5 and 7 Water and dialy

21、sate must comply with the country specific standards, i.e.: ISO 13959:2002 Water for hemodialysis and related therapies DIN VDE 0753-4, issue: 1986-09 Application regulations for hemodialysis machines ANSI/AAMI RD5-03 Hemodialysis systems ANSI/AAMI RD61:2001 Concentrates for hemodialysis ANSI/AAMI R

22、D62:2001 Water treatment equipment for hemodialysis applications,20/09/2020,Quality of Water and Dialysate Fluid反渗水和透析液水质,20/09/2020,Context pH Value, HCO3- and pCO2,Normal value on blood pH 7,36 7,45 pCO2 33 45 mmHg HCO3- 21 26 mmol/L Increasing or drop the pH value in the blood, over or under a cr

23、itical value is non physological. Consequences like headaches, cramps, hypotension, hypertension or a total collapse of the blood circuit are possible. pH value 7.45 alkaloses pH value 7.36 acidosis The normal value for pCO2 is between 33 - 45mmHg, i.e., the pCO2 increase (alkaloses) - automatically

24、 the patient starts a hyper vitalisation. The patient starts CO2 dismantle as a contra reaction.,20/09/2020,Context pH Value, HCO3- and pCO2,H+ + HCO3- H2CO3 H2O + CO2 hydrogen bicarbonate carbon dioxide - buffer system,pCO2 (mmHg),HCO3- (mmol/L,pH 7,4,50 40 35 30 24 20 16 12 10 9 8 7,12 14 16 20 25

25、 30 40 50 60 70,pH 7,3 Azidose,pH 7,5 Alkalose,standard range,H+ = 24 _,pCO2 HCO3-,20/09/2020,Bicarbonate Therapy碳酸盐治疗 Technical技术方面,Important for the factor specification or recheck tack the sample carefully only on the blue coupling with a syringe a secure specification only with titration possibl

26、e PH value recheck measurement instrument on dialysate modus.,Schalter,Sendeelektroden,Verstrker,Gleichrichter,Tiefpa,+5 Volt Ref.,4 kHz,LF Signal,Empfangselktrode,conductivity cell,20/09/2020,Bicarbonate Therapy Calcification,Normal value in blood 24 mmol/L (at the end of therapy 26-28 mmol/L). The

27、 direct measurement of the bicarbonate is not possible, we measure only the sodium on the bic cell. Normally the proportion is 1:1. The grains of the powder (2Na+HCO-) in the cartridge are coated with carbonate. This coating is dissolved first, the pH increases and the unit can get calcified. Follow

28、 up: proportion is not more 1:1 stronger calcification (from pH 7,5 critical) pH movement on dialysate, blood and buddy fluid block of dialysate filter coating on conductivity cells (ratio alarm, sodium not correct) blood leak alarm,20/09/2020,Bicarbonate Therapy Medical,Acetate must be metabolized

29、in the liver and kidney first to bicarbonate, so that the acid / base balance (pH value) is corrected. Due to the delay in the conversion the patient can become acidotic. This can lead to cramps, hypotension and vomiting of the patient. This is even worse if the patient has a liver dysfunction.,Toda

30、y is mostly only bicarbonate used. With that treatment the pH value is more stable. The patient feels better and his body is not so heavily used. The fluid transport and exchange of ions start directly after the start of the therapy.,Normal value in blood: 24 - 28 mmol/L,20/09/2020,Atoms Basic,nucle

31、usproton,electron,electron,electron,nucleusproton/neutron,hydrogen,helium,20/09/2020,Electrolytes and Ions,H2 O,Na+ Cl-,Na+ Cl- dissolvert,DefinitionElectrolytes are substances where the electrical current is guided via ions DefinitionIons are atoms with electron absence (cations) or electron excess

32、 (anions) For instanceNaCl dissociate in water in Na+ cations and Cl- anions,20/09/2020,Conductivity电导率,The conductivity is based on electrolytes and temperature. The physical unit is mS/cm (mille Siemens per cm). This is an American notation for the electrical resistance and this is a reciprocal va

33、lue to Europe with Ohm ().,Cl-,Na+,current quell,current measurement mS/cm,Minus pole 负极,Plus pole 正极,20/09/2020,Cell constants of the Conductivity Cell 电导度传感器的传感器系数,The cell constants are changing difference with the coating 传感器敏感系数会随附着层增加而变化,distance holder,flow direction 透析液流向,reference electrode

34、,transmitter-electrode,receiver- electrode,measurement cell 2,measurement cell 1,transmitter-electrode,=,20/09/2020,Quality of Water and Dialysate Fluid水质与透析液,Magnesium Carbonate碳酸镁 Calcium Carbonate 碳酸钙,The cell constants are changing difference with the coating 传感器敏感系数会随附着层增加而变化,Damage to the mach

35、ine due to calcium depositions during bicarbonate dialysis!钙质沉淀物将会损坏机器！ Decalcify the machine after each bicarbonate dialysis. 每次碳酸盐透析治疗后都需要脱钙,Warning,20/09/2020,Reasons for Calcification 生成沉淀的原因,2Na+HCO-3 Na2CO3 + H2O + CO2,bicarbonate soda + water + carbon dioxide,Na2CO3 + CaCl2 CaCO3 + 2NaCl,and,

36、calciumcarbonate - frequently (often, chemical resolvable),2Na2CO3 + CaCl2 + MgCl2 CaMg(CO3)2 + 4NaCl,marble (seldom, and not easy dissolvable),The calcium and magnesium of the acid concentrate react chemically with the carbonate and precipitates to non-dissolvable MgCO3 + CACO3. 沉淀物质是A液中的钙镁离子和B液中的碳

37、酸根离子产生的碳酸钙和碳酸镁,20/09/2020,Accommodation System for two Machines,main supply,central acid connectors,inlet connector,outlet connector with free fall,grounding,20/09/2020,Ion Exchanger - Softener 离子交换罐软化,20/09/2020,microbiologic debit of the permeate circuit,water net,reverse osmosis,permeate circuit,connection dialysis machine,dialysis machine,Bacteria细菌 / Endotoxins 内毒素,perme