CRRT的局部枸櫞酸抗凝ppt課件

1、CRRT的局部枸櫞酸抗凝的局部枸櫞酸抗凝血透室血透室 方詠梅方詠梅ICU中的急性腎臟功能衰竭中的急性腎臟功能衰竭*: BEST Kidney患病率1738/29269 (5.7%, 95%CI 5.5 6.0%)危險因素感染性休克(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 s

2、tudy. JAMA 2019; 294: 813-818急性腎功能衰竭的定義急性腎功能衰竭的定義: RIFLE標(biāo)準(zhǔn)標(biāo)準(zhǔn)GFR標(biāo)準(zhǔn)UO標(biāo)準(zhǔn)Risk肌酐增加x 1.5或GFR降低 25%UO 50%UO 75%UO 4周ESRD終末期腎病 3月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 Co

3、nsensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care 2019; 8: R204-R212ICU的急性腎臟損傷的急性腎臟損傷(AKI)Ostermann M, Chang RWS. Acute kidney injury in the intensive care unit according to RIFLE. Crit Care Med 2019; 35: 1837-184335.8%急性腎功能衰竭的治療急性腎功能衰竭的治療(n = 646)Perez-Valdivieso J

4、R, Bes-Rastrollo M, Monedero P, et al. Prognosis and serum creatinine levels in acute renal failure at the time of nephrology consultation: an observational cohort study. BMC Nephrology 2019; 8: 14-22持續(xù)腎臟替代治療管路壽命持續(xù)腎臟替代治療管路壽命滿足治療要求降低治療費(fèi)用減少重新安裝管路的護(hù)理時間18 30 hrHolt AW, Bierer P, Glover P, Plummer JL, Be

5、rsten AD. Conventional coagulation and thromboelastograph parameters and longevity of continuous renal replacement circuits. Intensive Care Med 2019; 28: 1649-55.Stefanidis I, Hagel J, Frank D, Maurin N. Hemostatic alterations during continuous venovenous hemofiltration in acute renal failure. Clin

6、Nephrol 2019; 46(3): 199-205.Kox WJ, Rohr U, Waurer H. Practical aspects of renal replacement therapy. Int J Artif Organs 2019; 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.持續(xù)腎臟替代治療的影

7、響因素持續(xù)腎臟替代治療的影響因素血管通路位置中心靜脈導(dǎo)管: 口徑, 管腔設(shè)計(jì)血流可靠性血濾管路設(shè)計(jì)透析膜的生物相容性護(hù)理人員的培訓(xùn)及專業(yè)技能抗凝效果持續(xù)腎臟替代的抗凝持續(xù)腎臟替代的抗凝血濾濾器與管路的抗凝作用全身抗凝有害作用持續(xù)腎臟替代的抗凝選擇持續(xù)腎臟替代的抗凝選擇基礎(chǔ)疾病現(xiàn)有抗凝措施臨床經(jīng)驗(yàn)國內(nèi)文獻(xiàn)報告的抗凝方法國內(nèi)文獻(xiàn)報告的抗凝方法抗凝方法抗凝方法病例數(shù)病例數(shù)(%)單藥抗凝普通肝素844 (37.9)低分子肝素686 (30.8)枸櫞酸26 (1.2)聯(lián)合抗凝普通肝素+低分子肝素483 (21.7)普通肝素+枸櫞酸52 (2.3)無抗凝137 (6.1)CRRT時的肝素抗凝時的肝素抗凝出

8、血危險負(fù)荷劑量IU/kg維持劑量IU/kg/hrAPTTsecACTsec無危險性5010 2060 250危險較小15 255 1045160 180危險較大102.5 530120肝素抗凝的優(yōu)缺點(diǎn)肝素抗凝的優(yōu)缺點(diǎn)優(yōu)點(diǎn)最常用的抗凝方法臨床方案成熟半衰期短過量時魚精蛋白對抗缺陷出血危險APTT與濾器壽命無關(guān)肝素誘導(dǎo)血小板缺乏(HIT)枸櫞酸抗凝的原理枸櫞酸抗凝的原理局部枸櫞酸抗凝的原理局部枸櫞酸抗凝的原理凝血過程需要游離鈣參與枸櫞酸螯合游離鈣, 補(bǔ)充鈣離子可以恢復(fù)血庫使用枸櫞酸保存血液采用枸櫞酸可以在RRT時進(jìn)行局部抗凝:血液進(jìn)入體外循環(huán)后即加入枸櫞酸血液進(jìn)入體內(nèi)前補(bǔ)充游離鈣體外循環(huán)對血液進(jìn)行

9、抗凝, 體內(nèi)血液正常通過測定游離鈣監(jiān)測抗凝肝素抗凝時的濾器中空纖維肝素抗凝時的濾器中空纖維Hofbauer R, Moser D, Frass M, et al. Effect of anticoagulation on blood membrane interactions during hemodialysis. Kidney Int低分子肝素抗凝時的濾器中空纖維低分子肝素抗凝時的濾器中空纖維Hofbauer R, Moser D, Frass M, et al. Effect of anticoagulation on blood membrane interactions during

10、 hemodialysis. Kidney Int枸櫞酸抗凝時的濾器中空纖維枸櫞酸抗凝時的濾器中空纖維Hofbauer R, Moser D, Frass M, et al. Effect of anticoagulation on blood membrane interactions during hemodialysis. Kidney Int血濾終止的原因血濾終止的原因枸櫞酸(n = 36)肝素(n = 43)管路凝血6 (16.7%)23 (53.5%)改為IHD1 (2.8%)0血管通路問題2 (5.6%)0管路斷裂或滲漏1 (2.8%)0管路打折1 (2.8%)0轉(zhuǎn)運(yùn)至放射科或手

11、術(shù)室8 (22.2%)8 (18.6%)濾器壓力高1 (2.8%)2 (4.7%)其他原因16 (44.4%)10 (23.3%)Kutsogiannis DJ, Gibney RTN, Stollery D et al. Regional citrate versus systemic heparin anticoagulation for continuous renal replacement in critically ill patients. Kidney Int 2019; 67: 2361-2367濾器壽命的濾器壽命的Cox風(fēng)險比例模型分析風(fēng)險比例模型分析HR95%CIP值枸櫞

12、酸0.3710.197 0.6990.002LOD評分1.2671.138 1.411 0.001女性0.5240.314 0.8740.01AT-III水平0.2140.065 0.7120.01Kutsogiannis DJ, Gibney RTN, Stollery D et al. Regional citrate versus systemic heparin anticoagulation for continuous renal replacement in critically ill patients. Kidney Int 2019; 67: 2361-2367出血或輸血的

13、比例出血或輸血的比例枸櫞酸肝素相對危險度P值明確或隱性出血0.01 (0 0.04)0.13 (0.04 0.23)0.17 (0.03 1.04)0.06輸注RBC0.17 (0.10 0.25)0.33 (0.18 0.49)0.53 (0.24 1.20)0.13輸注FFP0.40 (0.29 0.52)0.08 (0.01 0.16)4.95 (0.47 52.3)0.18Kutsogiannis DJ, Gibney RTN, Stollery D et al. Regional citrate versus systemic heparin anticoagulation for

14、continuous renal replacement in critically ill patients. Kidney Int 2019; 67: 2361-2367CRRT時出血的多因素時出血的多因素Poisson回歸回歸RR95%CIP值截距0.0010.00001 0.1740.008枸櫞酸0.1370.020 0.9590.05LOD評分0.9240.571 1.4940.75AT-III水平6.6470.789 56.0030.08Kutsogiannis DJ, Gibney RTN, Stollery D et al. Regional citrate versus sy

15、stemic heparin anticoagulation for continuous renal replacement in critically ill patients. Kidney Int 2019; 67: 2361-2367不同抗凝方法的濾器壽命不同抗凝方法的濾器壽命Kutsogiannis DJ, Gibney RTN, Stollery D et al. Regional citrate versus systemic heparin anticoagulation for continuous renal replacement in critically ill p

16、atients. Kidney Int 2019; 67: 2361-2367枸櫞酸局部抗凝方案枸櫞酸局部抗凝方案枸櫞酸局部抗凝圖示枸櫞酸局部抗凝圖示RheaterACD-AVVPVPAUFBLDSAD葡萄糖酸鈣枸櫞酸局部抗凝方案說明枸櫞酸局部抗凝方案說明血濾機(jī)常規(guī)預(yù)沖肝素鹽水根據(jù)患者病情選擇適當(dāng)治療模式CVVHCVVHDCVVHDF枸櫞酸局部抗凝方案枸櫞酸局部抗凝方案準(zhǔn)備枸櫞酸抗凝液血液保存液(I) 600 ml/袋廣州華南醫(yī)療用品有限公司成分成分分子量分子量含量含量(g)mmol枸櫞酸三鈉(二水)294.122.075枸櫞酸(一水)210.148.038葡萄糖(一水)198.1724.51

17、20加注射用水至1000 mlRheaterACD-AVVPVPAUFBLDSAD葡萄糖酸鈣枸櫞酸局部抗凝方案枸櫞酸局部抗凝方案準(zhǔn)備輸液泵將輸液管路與血濾管路的動脈端相連接最接近患者處(血泵前)根據(jù)患者病情, 設(shè)置血濾機(jī)的常規(guī)參數(shù)RheaterACD-AVVPVPAUFBLDSAD葡萄糖酸鈣枸櫞酸局部抗凝方案枸櫞酸局部抗凝方案ACD-A初始泵速為血液流速(BFR)的2.0 2.5%泵速(ml/hr) = 1.2 1.5 x BFR (ml/min)例如BFR = 120 ml/minACD-A泵速 = 144 180 ml/hrRheaterACD-AVVPVPAUFBLDSAD葡萄糖酸鈣枸櫞

18、酸局部抗凝方案枸櫞酸局部抗凝方案常規(guī)情況下選擇前稀釋方式RheaterACD-AVVPVPAUFBLDSAD葡萄糖酸鈣枸櫞酸局部抗凝方案枸櫞酸局部抗凝方案置換液中不含鈣RheaterACD-AVVPVPAUFBLDSAD葡萄糖酸鈣常規(guī)置換液配方常規(guī)置換液配方0.9% NS2000 ml注射用水500 ml5% NaHCO3125 ml25% MgSO43 ml10% CaGlu20 ml15% KCl5 ml50% GS總量枸櫞酸局部抗凝方案枸櫞酸局部抗凝方案準(zhǔn)備10%葡萄糖酸鈣溶液及注射器泵將輸液管路連接至血濾管路靜脈端葡萄糖酸鈣溶液初始泵速為8.8 11.0 ml/hr (ACD-A泵速的

19、6.1%)RheaterACD-AVVPVPAUFBLDSAD葡萄糖酸鈣枸櫞酸局部抗凝方案枸櫞酸局部抗凝方案: 抗凝監(jiān)測抗凝監(jiān)測Q2h x 4Q4h x 4Day 1Day 2Q 6 8 h枸櫞酸局部抗凝方案枸櫞酸局部抗凝方案: 抗凝監(jiān)測抗凝監(jiān)測RheaterACD-AVVPVPAUFBLDSAD枸櫞酸鈣動脈標(biāo)本動脈標(biāo)本外周靜脈或動脈外周靜脈或動脈游離鈣游離鈣1.00 1.20 mmol/L靜脈標(biāo)本靜脈標(biāo)本濾器后血濾管路濾器后血濾管路游離鈣游離鈣0.20 0.40 mmol/L枸櫞酸局部抗凝方案枸櫞酸局部抗凝方案: 抗凝監(jiān)測抗凝監(jiān)測靜脈標(biāo)本游離鈣靜脈標(biāo)本游離鈣從濾器后靜脈取血部位取血從濾器后靜脈取血部位取血ACD-A輸注速度調(diào)整輸注速度調(diào)整 0.50 mmol/L增加10 ml/hr枸櫞酸局部抗凝方案枸櫞酸局部抗凝方案: 抗凝監(jiān)測抗凝監(jiān)測動脈標(biāo)本游離鈣動脈標(biāo)本游離鈣從外周靜脈或動脈取血從外周靜脈或動脈取血10