CRRT的局部枸櫞酸抗凝(杜斌)課件

持續(xù)腎臟替代治療的局部枸櫞酸抗凝北京協(xié)和醫(yī)院杜 斌ICU中的急性腎臟功能衰竭*:BESTKidney患病率1738/29269(5.7%,95%CI5.5–6.0%)危險因素感染性休克(47.5%,95%CI45.2–49.5%)住院病死率60.3%(95%CI58.0–62.6%)*少尿(<200ml/12hr)和(或)明顯的氮質(zhì)血癥(BUN>84mg/dL)UchinoS,KellumJA,BellomoR,etal.Acuterenalfailureincriticallyillpatients:amultinational,multicenterstudy.JAMA2005;294:813-818急性腎功能衰竭的定義:RIFLE標準BellomoR,RoncoC,KellumJA,etal.Acuterenalfailure:definition,outcomemeasures,animalmodels,fluidtherapyandinformationtechnologyneeds:theSecondInternationalConsensusConferenceoftheAcuteDialysisQualityInitiative(ADQI)Group.CritCare2004;8:R204-R212ICU的急性腎臟損傷(AKI)OstermannM,ChangRWS.AcutekidneyinjuryintheintensivecareunitaccordingtoRIFLE.CritCareMed2007;35:1837-184335.8%急性腎功能衰竭的治療(n=646)Perez-ValdiviesoJR,Bes-RastrolloM,MonederoP,etal.Prognosisandserumcreatininelevelsinacuterenalfailureatthetimeofnephrologyconsultation:anobservationalcohortstudy.BMCNephrology2007;8:14-22持續(xù)腎臟替代治療管路壽命滿足治療要求降低治療費用減少重新安裝管路的護理時間18–30hrHoltAW,BiererP,GloverP,PlummerJL,BerstenAD.Conventionalcoagulationandthromboelastographparametersandlongevityofcontinuousrenalreplacementcircuits.IntensiveCareMed2002;28:1649-55.StefanidisI,HagelJ,FrankD,MaurinN.Hemostaticalterationsduringcontinuousvenovenous

hemofiltrationinacuterenalfailure.Clin

Nephrol1996;46(3):199-205.KoxWJ,RohrU,WaurerH.Practicalaspectsofrenalreplacementtherapy.IntJArtifOrgans1996;19:100-5.TanHK,BaldwinI,BellomoR.Continuousveno-venoushaemofiltrationwithoutanticoagulationinhigh-riskpatients.IntensiveCareMed2000;26:1652-7.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)驗國內(nèi)文獻報告的抗凝方法CRRT時的肝素抗凝肝素抗凝的優(yōu)缺點優(yōu)點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點出血危險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時進行局部抗凝:血液進入體外循環(huán)后即加入枸櫞酸血液進入體內(nèi)前補充游離鈣體外循環(huán)對血液進行抗凝,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HofbauerR,MoserD,FrassM,etal.Effectofanticoagulationonbloodmembraneinteractionsduringhemodialysis.KidneyInt低分子肝素抗凝時的濾器中空纖維HofbauerR,MoserD,FrassM,etal.Effectofanticoagulationonbloodmembraneinteractionsduringhemodialysis.KidneyInt枸櫞酸抗凝時的濾器中空纖維HofbauerR,MoserD,FrassM,etal.Effectofanticoagulationonbloodmembraneinteractionsduringhemodialysis.KidneyInt血濾終止的原因KutsogiannisDJ,GibneyRTN,StolleryDetal.Regionalcitrateversussystemicheparinanticoagulationforcontinuousrenalreplacementincriticallyillpatients.KidneyInt2005;67:2361-2367濾器壽命的Cox風(fēng)險比例模型分析KutsogiannisDJ,GibneyRTN,StolleryDetal.Regionalcitrateversussystemicheparinanticoagulationforcontinuousrenalreplacementincriticallyillpatients.KidneyInt2005;67:2361-2367出血或輸血的比例KutsogiannisDJ,GibneyRTN,StolleryDetal.Regionalcitrateversussystemicheparinanticoagulationforcontinuousrenalreplacementincriticallyillpatients.KidneyInt2005;67:2361-2367CRRT時出血的多因素Poisson回歸KutsogiannisDJ,GibneyRTN,StolleryDetal.Regionalcitrateversussystemicheparinanticoagulationforcontinuousrenalreplacementincriticallyillpatients.KidneyInt2005;67:2361-2367不同抗凝方法的濾器壽命KutsogiannisDJ,GibneyRTN,StolleryDetal.Regionalcitrateversussystemicheparinanticoagulationforcontinuousrenalreplacementincriticallyillpatients.KidneyInt2005;67:2361-2367枸櫞酸局部抗凝方案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血濾機常規(guī)預(yù)沖肝素鹽水根據(jù)患者病情選擇適當治療模式CVVHCVVHDCVVHDF枸櫞酸局部抗凝方案準備枸櫞酸抗凝液血液保存液(I)600ml/袋廣州華南醫(yī)療用品有限公司RheaterACD-AVVPVPAUFBLDSAD葡萄糖酸鈣枸櫞酸局部抗凝方案準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)置血濾機的常規(guī)參數(shù)RheaterACD-AVVPVPAUFBLDSAD葡萄糖酸鈣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)xBFR(ml/min)例如BFR=120ml/minACD-A泵速=144–180ml/hrRheaterACD-AVVPVPAUFBLDSAD葡萄糖酸鈣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置換液中不含鈣RheaterACD-AVVPVPAUFBLDSAD葡萄糖酸鈣枸櫞酸局部抗凝方案準備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8.8–11.0ml/hr(ACD-A泵速的6.1%)RheaterACD-AVVPVPAUFBLDSAD葡萄糖酸鈣枸櫞酸局部抗凝方案:抗凝監(jiān)測Q2hx4Q4hx4Day1Day2Q6–8h枸櫞酸局部抗凝方案:抗凝監(jiān)測RheaterACD-AVVPVPAUFBLDSAD枸櫞酸鈣動脈標本外周靜脈或動脈游離鈣1.00–1.20mmol/L靜脈標本濾器后血濾管路游離鈣0.20–0.40mmol/L枸櫞酸局部抗凝方案:抗凝監(jiān)測枸櫞酸局部抗凝方案:抗凝監(jiān)測枸櫞酸局部抗凝方案:抗凝監(jiān)測每次更換輸液部位或管路后1–2小時內(nèi)應(yīng)監(jiān)測離子鈣若血泵停止數(shù)分鐘以上必須關(guān)閉ACD-A泵(防止枸櫞酸進入患者體內(nèi))必須關(guān)閉葡萄糖酸鈣泵(防止過量鈣進入患者體內(nèi))若因病情需要停止血濾(如診斷,更換導(dǎo)管,手術(shù),凝血或更換管路),應(yīng)在重新開始血濾時按照停止前的速度設(shè)置ACD-A及葡萄糖酸鈣泵速枸櫞酸局部抗凝方案:抗凝監(jiān)測若HCO3增加>10mEq/L需要確認ACD-A輸注部位正確,未直接進入患者體內(nèi)降低ACD-A泵速25%2–4小時后測定HCO3若測定結(jié)果仍不正常再次降低ACD-A泵速25%枸櫞酸局部抗凝方案:抗凝監(jiān)測若患者血Na上升10mEq/L或>155mEq/L需要確認ACD-A輸注部位正確,未直接進入患者體內(nèi)降低ACD-A泵速25%2–4小時后測定血Na若測定結(jié)果仍不正常輸注5%GS枸櫞酸抗凝的并發(fā)癥:代謝性堿中毒主要原因枸櫞酸轉(zhuǎn)化為HCO3(1mmol枸櫞酸能夠產(chǎn)生3mmol的HCO3)