血液净化原理-模式及治疗的选择-PPT.pptx

血液净化原理,模式及治疗的选择肾脏替代治疗“的内容1.肾脏替代治疗的基本内容2.滤器的选择3.抗凝剂的应用3CRRT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）4CRRT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5CRRT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。6原理与机制弥散对流吸附500 500050000大家有疑问的，可以询问和交流大家有疑问的，可以询问和交流可以互相讨论下，但要小声点可以互相讨论下，但要小声点可以互相讨论下，但要小声点可以互相讨论下，但要小声点SoluteClassesbyMolecularWeightDaltonsInflammatory Mediators(1,200-50,000)“small”“middle”“large”Jean-MichelLannoyNikkisoABPDirector9炎症介质的特征 介介质分子量分子量C3a2500C5a2800TNF-a17500 x3C5a2800IL-62125000IL-1Ra14000IL-89000LPS100000FactorD2300023000Jean-MichelLannoyNikkisoABPDirector10炎症介质的特征 介介质蛋白蛋白结合合分子量分子量C3ano2500C5ano2800TNF-a部分17500 x3STNRFIyes55000STNRFIIyes75000IL-621yes25000IL-1Rano14000IL-lano89000PAF部分450FactorDyes230005/1/202411PSHF系列滤器筛选系数系列滤器筛选系数/高截留分子量高截留分子量如如何选择血滤器何选择血滤器？Jean-MichelLannoyNikkisoABPDirector12MolecularWeights（分子的重量或分子量的大小）13Copyright2015NIKKISOCo.,LTD.Allrightsreserved.Ashleyetall.TheRenalDrugHandbook,2ndEd.2004,MedicalPress,Abingdon,UK.ISBN:1857758730NewfunctionalmembranewithdefinedlargerporesizeHCO membrane 0,01 m 12h)usingheparinAppropriatelytrainednursingstaffavailable35ml/kg/hCVVHRCAProtocolAll patients will start at 35ml/kg/h unless directed by physicianDose includes citrate volume pre-filterFiltration Ratio is 20%Pre-filter citrate concentration will be 2.8mmol/LIBW kgPost dilutionmL/hBlood PumpmL/minACD-A(Citrate)mL/h802700230350Protocol 1CalciumReplacementAccusolreplacementsolutioncontains1.75mmol/LCalciumwhichwillprovidemost or alloftheCalciumreplacementA10mmol/LCalciumChloridesolutionwillbeusedforadditionalCalciumreplacementifrequired:1x10ml ampule of Calcium Chloride(10mmol)in 990ml Normal Saline given via integrated Calcium Pump on Aquarius-Citrate device onlyInfusion rate 0-175ml/hInitialCalciumRateThen check arterial Cai in 1hSystemic iCaInitial rate of CaCl solution1.00mL/h(0mmol/h)Use this table only when first starting RCAAdjustingCalciumInfusioniCaCaCl infusion adjustment(MAXIMUM RATE=175mL/hr):Recheck1.31.DecreaseCaClinfusionby25ml/h2.IfCaClinfusionoffthenchecksystemiciCain3hours3.InformDoctorifiCarisesto1.53h*Likely to change to check in 6h in final protocolMonitoringBaseline ABG for iCa2+&HCO3-Lab Bloods within12hforU&EMg2+TotalCa2+After the one hour:ABGforiCa2+&HCO3-Thereafter every 3h*:ABGforiCa2+&HCO3-monitoring(unlessearliercheckrequiredafteradjustmentofCalciuminfusion)Around every 12 hours:LabBloods:U&E;TotalCa2+;Mg2+(Aim Mg 1mmol/L)PostFilteriCa2+(Takefromreturn-linesampleport)Record all Results on RCA Pro-forma*Likelytochangetocheckin6hinfinalprotocolStart35ml/kg/hCVVHIfpH7.5orHCO3-40Reduceto25ml/kg/hIfpH7.5orHCO3-40Use25ml/kg/hwith25%FRIfpH7.5orHCO3-40StopRCAMetabolic AlkalosisMonitorpHandBicarbonate3hly*Likely to change to check in 6h in final protocolIBW kgPost dilutionmL/hBlood PumpmL/minACD-A(Citrate)mL/h801900160240IBW kgPost dilutionmL/hBlood PumpmL/minACD-A(Citrate)mL/h801900130200Step 2:ifpH7.5orHCO3-40mmol/LonProtocol 2changesettingstoProtocol 3(25ml/kg/hwithincreasedfiltrationratio)belowandmonitorevery3h*Step 3:ifstillpH40mmol/LDISCONTINUE RCAStep 1:ifpH7.5orHCO3-40mmol/LonProtocol 1ChangethesettingstoProtocol 2(25ml/kg/h)belowandcontinuetomonitorevery3h*.(Protocol2mayalsobeselectedfordosereduction)Protocol 2Protocol 3*Likely to change to check in 6h in final protocolHowitworksJean-MichelLannoyNikkisoABPDirector455/1/202446IndicationsforCitrateAnticoagulationRequiringRRTwithintheICU(eitherneworon-goingtreatment)forconventionalRenalindicationsConsideredbythetreatingPhysiciantohaveacontraindicationtoheparinanticoagulationAppropriatelytrainednursingstaffavailable8PalssonR,NilesJL,Regional citrate anticoagulation in continuous venovenous hemofiltration in critically ill patients with a high risk of bleeding KidneyInt1999,55:1991-1997.9FlaniganMetal.Reducing the hemorrhagic complications of hemodialysis:A controlled comparison of low-dose heparin and citrate anticoagulation.AmJKidneyDis1987;2:147-153Copyright2015NIKKISOCo.,LTD.Allrightsreserved.ContraindicationsChronicLiverDisease-ChildsBorCAcuteLiverInjurywithINR2orLactate4mol/LPost-hepaticresectionSevereshock:Noradrenaline0.5mcg/kg/minand/orLactate4mol/LArterialBloodIonizedCalcium7.5orHCO3-40mmol/LatcommencementofRCAReductionofrequirementsforsystemicanticoagulant(otherthanprophylaxis)SerumSodium160atcommencementofRCAUncontrolledhyperglycaemia6U/hInsulinIBW90kgCitrateintoleranceClinicalsituationwherecitratemetabolismbecomesuncertain.Copyright2015NIKKISOCo.,LTD.Allrightsreserved.10Prowleetal.Service Development Plan and Protocol for Regional Citrate Anticoagulation,TheRoyalLondonHospitalTherapymonitoringIonisedCalcium:Ionizedcalciumisameasureoffreecalcium.Afterhemofiltertypically0.25-0.35mmol/l Frompatienttypically1.05-1.3mmol/lTotalCalcium:Totalcalciumincludesbothprotein-boundandfreecalcium.TotalCalcium(frompatient)typicallylessthan2.5mmol/lAcid/basemonitoring:SystemicpHwillbemonitored3-6hrly.Glucosemonitoring:Bloodglucosemonitoredforhyperglycaemia3-6hrlyElectrolytemonitoring:Levelstobemonitored3-6hrly.Fluidbalancemonitoring.Anyotherclinicalsigns?Copyright2015NIKKISOCo.,LTD.Allrightsreserved.OptimizeVascularAccessConsider using a high flow silicone vascular access catheter thatdoesnothave“kinkmemory”,andwithanappropriatelengthforthechosensite.Avoid attaching the Aquarius to a catheter with poor flow.Forexample,beingabletowithdraw20mlofbloodin6secondsor10mlofbloodin3secondswithouthesitancyorinterruptionmayhelpacatheterassessment.Consider rotating the hub of the catheter 90 sothattheholesontheaccesslumenarefacingtheflowofblood,notagainstthevesselwall(youmayneedtomomentarilystopthebloodpumptodothis).Consider the patients intravascular volume.Eventhoughthepatientmaybefluidoverloaded,iftheirintravascularspaceisdehydrated,theremaybepoorflowthroughthecatheterwhichwillencourageclotting.50Copyright2015NIKKISOCo.,LTD.Allrightsreserved.OptimizeAnticoagulationHigh return pressure is one sign of under anti-coagulation.Thebloodpumpwantstopushthebloodthroughthereturnchamberwherepartiallyformedbloodclotsmayincreaseinsize,makingitdifficultforthebloodtosqueezethrough.A routine of regular observation,followedbyacheckofthepatientclotting,andadjustmentofanticoagulantwhereindicated,maypreventearlyreturnchamberclotting.Consider increasing the proportion of pre-dilution ifanticoagulationadjustmentisnotindicated.Forexample:alteringthepre-dilutionto90%andreducingpost-dilutionto10%maythinthebloodpassingthroughthefilterandreducetheeffectsofhaemoconcentration.Againinlifespanmaybeoffsetbyasmalllossinclearance,easilyadjustedbyusingtheRenalDosedisplay.51Copyright2015NIKKISOCo.,LTD.Allrightsreserved.Theeffectofbloodpumpspeed52Copyright2015NIKKISOCo.,LTD.Allrightsreserved.Filtrateremovedisapercentageoftotalflowthroughthefilterfibres.Whyisthetotalbloodflowimportant?Withafasterbloodpumpspeed,thetotalflowisincreasedandeffectsofhaemoconcentrationarereduced.Increasingbloodflowgivesareducedfiltrationratiowhichmayslowfiltercloggingandextendfilterlifespan.TheeffectofPre-dilution53Copyright2015NIKKISOCo.,LTD.Allrightsreserved.Filtrateremovedisapercentageoftotalflowthroughthefilterfibres.Theproportionofpredilutionflowmaybeadjustedtooptimisetreatment.Withagreaterproportionofpredilution,thefiltrationfractionandeffectsofhaemoconcentrationarereduced.Animprovedfiltrationfractionmayslowfiltercloggingandextendfilterlifespan.Considerations54Copyright2015NIKKISOCo.,LTD.Allrightsreserved.Diameter,lengthandtypesofcatheters(II)Type:MaterialfeaturesSiliconeelastomercathetershavelowerthrombogenicityandbetterflexibility.BiocompatibleandkinkresistanceConformtovesselanatomy,thereforereduceriskoftraumaDiameterandbloodflow:11French:250-300ml/minBloodFlow13.5French:450-500ml/minBloodFlowRecirculation-upto20%Especiallyiffemoralaccessislessthan20cmAvoidreverseAVconnectionPatientPreparation55Copyright2015NIKKISOCo.,LTD.Allrightsreserved.PatientbodystatusCoagulationandIntravascularfillingMobilityinfluencesPresenceofothercentrallinesInfluencesoncatheterchoiceClinicianchoiceAvailabilityofultrasoundguidanceAssessmentofcatheterpatencyConnectiontechniquesSpecialcircumstancesCatheterCharacteristics56Copyright2015NIKKISOCo.,LTD.Allrightsreserved.Easeofinsertion:toavoidvesseltraumaGoodflowcharacteristics:tooptimisebloodflowKinkresistant:toavoidaccesspressureproblemsBiocompatible:toreducecomplicationrisksAmenabilitytoguidewirechange:tooptimisetherapySide-by-SidePolyurethaneCatheters57Copyright2015NIKKISOCo.,LTD.Allrightsreserved.CoaxialPolyurethaneCatheters58Copyright2015NIKKISOCo.,LTD.Allrightsreserved.TriplelumenCatheters59Copyright2015NIKKISOCo.,LTD.Allrightsreserved.SiliconeCatheters60Copyright2015NIKKISOCo.,LTD.Allrightsreserved.ReversingtheLines61Copyright2015NIKKISOCo.,LTD.Allrightsreserved.1 Lewington A,Kanagasundaram S.Acute Kidney Injury.Renal Association guidelines:Guideline 8.1 AKI:Vascular access for RRT.Guideline 8.2,Page 45 of 59,Para 3 Rationale for 8.1-8.9 lines 7-9 VascularAccess62Copyright2015NIKKISOCo.,LTD.Allrightsreserved.VascularAccessiscontinuouslytestedduringCRRTtreatmentPracticalunderstandingaboutvascularaccessisnecessaryforoptimaltreatmentCathetersite,size,typeandpatientpreparationmaybeconsideredInadequaciesinvascularaccessmaylimitdeliveredtherapyTroubleshootingchoicesVascularAccessTroubleshooting63Copyright2015NIKKISOCo.,LTD.Allrightsreserved.StartingbloodflowGradualincreaseOptimisingbloodflowratesStartingtreatmentUsingAquariusHistoryUsingRecirculationTroubleshootingchoicesAccessIsKINGVascularAccessiscontinuouslytestedduringCRRTtreatment.Cathetersite,size,typeandpatientpreparationshouldbeconsidered.Practicalunderstandingaboutvascularaccessisnecessaryforoptimaltreatment.Inadequacies in vascular access may limit delivered therapy.64Copyright2015NIKKISOCo.,LTD.Allrightsreserved.SummaryofClassificationsofAKIKristensenetal(2014)ESC/ESAGuidelinesonnon-cardiacsurgery:cardiovascularassessmentandmanagementTheJointTaskForceonnon-cardiacsurgery:cardiovascularassessmentandmanagementoftheEuropeanSocietyofCardiology(ESC)andtheEuropeanSocietyofAnaesthesiology(ESA).European Heart Journal 35(35)23832431Copyright2015NIKKISOCo.,LTD.Allrightsreserved.Jean-MichelLannoyNikkisoABPDirector66