透析器復(fù)用經(jīng)驗交流課件

透析器復(fù)用經(jīng)驗交流Dialyserreuse透析器復(fù)用經(jīng)驗交流提要ContentsⅠ

透析器復(fù)用Reason,disputes,methodsofreuse復(fù)用的原因和爭議及現(xiàn)狀復(fù)用的方法Ⅱ部分B.Braun客戶使用、復(fù)用DiacapPolysulfone的經(jīng)驗experienceofourcustomerⅢ復(fù)用中的可能問題Potentialproblems透析器復(fù)用經(jīng)驗交流透析器復(fù)用1復(fù)用的原因和爭議及現(xiàn)狀Reason,disputesa.復(fù)用的支持和反對意見Prosandconsb.復(fù)用現(xiàn)狀What’son2復(fù)用的方法Methodsa.自動復(fù)用Automaticb.手工復(fù)用Manualc.兩者的比較Comparison透析器復(fù)用經(jīng)驗交流1.復(fù)用的原因和爭議及現(xiàn)狀

Reason,disputes

a復(fù)用的支持意見pros降低使用成本，減輕病人經(jīng)濟負擔(dān)economicalconsiderationCéTS,1991改善生物相容性，減少相應(yīng)的免疫反應(yīng)increasebiocompatibilityDaugirdasandIng,1988;HakimandLowrie,1980

減少透析器首次使用綜合癥reduce1stusesyndromeBoketal,1980有利于環(huán)保environmentalfriendly透析器復(fù)用經(jīng)驗交流

透析器的性能受到的可能影響possibleinfluenceofthedialyserGotch,1986;Cheung,1999;Pizziconi,1990消毒不嚴(yán)格帶來的可能后果malpracticeofdisinfection殘余消毒劑帶來的不利影響adversereactionofdisinfectant血液交叉感染/對濾器處理人員的危險crossinfectiona可能的不利因素cons透析器復(fù)用經(jīng)驗交流NationalKidneyFoundationreportondialyzerreuse.TaskForceonReuseofDialyzers,CouncilonDialysis,NationalKidneyFoundation.AmJKidneyDis.1997

美國腎病基金會報告

TheNationalKidneyFoundationtakesnopositionfororagainstdialyzerreuse.Theprincipalreasonforthepracticeofreuseiseconomical.

經(jīng)濟原因決定復(fù)用Inviewoftheuncertaintiesrelatedtothesafetyandbiologicalimpactofreuseprocedures,thetaskforcerecommendsthatafulldiscussionoftheissueofreuseanditspotentialbeneficialanddetrimentaleffectsbe

undertakenwitheachpatient.復(fù)用的考慮應(yīng)個體化DialyzersshouldnotbereprocessedfrompatientswhohavetestedpositiveforhepatitisBsurfaceantigen.HBV陽性不應(yīng)復(fù)用Giventhesignificantfallindialyzerefficiencyforurearemovalthatcanoccurafterrepeatedusesofadialyzer,dialysisprescriptionsinunitspracticingreuseshouldbedesignedtodeliveraKt/VorURRvaluethatexceedsthedoseusedforpatientstreatedwithsingle-usedialyzerstomakeallowanceforanypossiblereuse-inducedreductionindialyzerefficiency.治療劑量的調(diào)整Theeffectsofreprocessinghigh-fluxdialyzersonbeta2-microglobulinclearancearedependentonthereprocessingtechnique,thenumberofreuses,andthenatureofthedialyzermembraneused.復(fù)用技術(shù)對后續(xù)使用有很大影響透析器復(fù)用經(jīng)驗交流Theeffectofdialyzerreuseondialysisdelivery.

ShermanRA,CodyRP,RogersME,SolanchickJC

ShermanDepartmentofMedicine,UMDNJ-RobertWoodJohnsonMedicalSchool,NewBrunswickAmJKidneyDis.1994Dec;24(6):924-6.

濾器復(fù)用對治療的效應(yīng)Prospective436-patient,34-centerstudy.Allpatientsunderwentformalureakineticmodelingmonthly,usuallyfor3sequentialmonths.Dialyzerswerereprocessedandreusedintheusualmannerforeachunit.Kt/Vureaforthetreatmentusingthedialyzerwiththemostreuses(mean,13.8)wascomparedwiththatwiththetreatmentusingthedialyzerwiththefewestreuses(mean,3.8).ThemeanKt/Vdeliveredforhighreusetreatmentswassignificantlylowerthanthatforlowreusetreatments(1.05v1.10,P=0.002).復(fù)用對清除產(chǎn)生明顯負面的影響Ofthe23centersusingformalin-basedreprocessing,anaveragedifferenceof>or=0.12(mean,0.17)inKt/Vbetweenhighandlowreusetreatmentswasseenin10centers.Dialyzerreprocessingsignificantlyimpairsdialysisdelivery,aneffectthatmayberelatedtothemethodsandproceduresinindividualdialysiscenters.復(fù)用過程對治療效果有極大影響透析器復(fù)用經(jīng)驗交流b.復(fù)用現(xiàn)狀what’son

USReuseofdialyzersandclinicaloutcomes:factorfiction.AgodoaL,WolfeRA,PortFKAmJKidneyDis6:S88-S92,1998SinceitsintroductionintheUnitedStatesmorethantwodecadesago,thepracticeofdialyzerreusehascontinuedtogrow.Inrecentyears,itappearstohavebeenbasedmainlyoneconomic,ratherthanmedical,considerations.demographic,comorbidity,laboratory,treatment,socioeconomic,andinsurancedataonalargerandomsampleofapproximately20,000oftheUSdialysispatientpopulationovera3-yearperiod,usingthedialysisrecords.Datawerecollected20,000個病人納入研究TheresultsshowthattherehasbeenasignificantincreaseinthepracticeofdialyzerreuseintheUnitedStates.濾器復(fù)用在增加Largeregionaldifferencesexist,andreuseisgreatestinfreestandingfor-profit(FSFP)units(87%)andfreestandingnonprofit(FSNP)units(77%)andleastinhospitalunits(49%).復(fù)用的分布情況與醫(yī)療機構(gòu)性質(zhì)有關(guān)透析器復(fù)用經(jīng)驗交流b.復(fù)用現(xiàn)狀what’son

HEMODIALYZERREUSE:CONSIDERATIONSOFSAFETYANDCOSTS.Montreal:CéTS,1991.65復(fù)用的使用及經(jīng)濟學(xué)分析Sincedialyserreusewasfirstdescribedin1969,ithasbeenemployedwithincreasingfrequencyintheUnitedStatesofAmericawherethepercentageofpatientswhoreusetheirhemodialysershasincreasedfrom18%in1976to72%in1988.InEurope,thegenerallevelofreuseislower{average10%in1988}.DifferencesbetweenEuropeancountriesarehowever,considerable,forexample;Belgium19%,UnitedKingdom16%,Denmark12%,France8%,Sweden,Norway,HollandandIrelandallbelow1%.InCanada,in1987,13%ofdialysiscentrespractisedreutilization.歐洲的情況EconomicconsequencesofreutilisationinQuebecTogainsomeideaofthepossiblesavingswhichmightbeachievedinQuebec,astudywasmadeofthedifferenceindirectcostbetweensingleuseandmultiplereuse{6to11times}ofhemodialysers.Itwasestimatedthat5reusesmightgenerateeconomiesofapproximately$3,245dollarsperpatientperyear{$2,700to$3,800}.Thesavingassociatedwith10reutilisationswouldbeoftheorderof$3,500peryear.十次復(fù)用可達的每年經(jīng)濟效應(yīng)Furtherestimationscanbemadeontheassumptionthatonlyinunitsinexcessof30patientswoulditbeeconomicallyfeasibletopurchaseautomatedreconditioningequipment.Ifallsuchunitspractised10reutilisationsforeachpatientinwhomtherewerenocontraindications,thetotalsavingwouldbebetween2and2.7milliondollarsperyear.復(fù)用規(guī)模效應(yīng)IntheU.S.A.,companiesareavailabletocollect,reconditionandre-distributehemodialysersatacostofapproximatelyof$6peruse.專業(yè)化經(jīng)營

透析器復(fù)用經(jīng)驗交流BACKGROUNDANDAIM:DialyserreusetreatmentsinKoreawerefirstpractisedatafacilityin1985.Until1999,therewasonlyonefacilitypractisingdialyserreusetreatments,butthereusepracticehasgraduallyincreasedsince1999.Thepurposeofthisstudywastogatherandanalysethecurrent(April2002)dialyserreusetreatmentdatainKorea.METHODANDRESULTS:Datawascollectedviaaquestionnairesenttotheeachhospitalthatreusesthedialyser,andwereceivedaresponsefrom26outof29facilities(89.7%).Twenty-ninefacilitiescomprised7.7%(29of376)ofthetotalnationwidehaemodialysisfacilitiesinKorea.Thepercentageofpatientsondialyserreusetreatmentswas6.2%(1234of20,010).Allfacilitiesusedanautomatedreuseprocessingtechniquefordialyserreuseand22facilitiesusedaperaceticacidmixture(PAM)withouthypochlorite.Therewasonefacilitythatusedtheheatedcitricacidmethod.Eightypercentoffacilitiesusedonlyhighfluxmembranes(Kuf>or=20mL/hpermmHg)and12%ofthefacilitiesusedbothhighandlowfluxmembranes.

Theaveragenumberofthereusetreatmentswas15-fold(range10-22)andtheaverageofthemaximumnumberofreusetreatmentswas20-fold(range10-50).CONCLUSION:AlthoughdialyserreusetreatmentsarenotacommonpracticeinKorea,thereuseprogramsaresteadilyincreasing.StrictqualitycontrolandfurtherregulationsregardingthereuseprogramshouldbepromptlyenactedtoprovideabetterqualityofhaemodialysistreatmentforpatientsinKorea.

復(fù)用率不高；復(fù)用次數(shù)大于中國；尚無嚴(yán)格法規(guī)StatusofdialyserreuseinKorea.

ChoHKChoHK,ShinGT,KimH

Nephrology(Carlton).2004Aug;9(4):212-6.

DepartmentofNephrology,AjouUniversitySchoolofMedicine,Suwon,Korea.

韓國的復(fù)用

透析器復(fù)用經(jīng)驗交流中國China中國大陸范圍約七成為復(fù)用市場70%reuse經(jīng)濟原因?qū)?fù)用有直接關(guān)系，有一些地方有強制非復(fù)用規(guī)定economicalreasonisthemotivation自動，手工復(fù)用同時存在，以后者為主；復(fù)用質(zhì)量有待提高bothmanualandautomatic透析器復(fù)用經(jīng)驗交流2.復(fù)用方法methodsa.自動復(fù)用automaticreuse標(biāo)記labeling自動沖洗rinse自動安全測試safetytest自動消毒液灌注disinfection科學(xué)化管理（條碼識別）management透析器復(fù)用經(jīng)驗交流b.手工復(fù)用過程概述manualmethod標(biāo)記labeling下機后沖洗cleaningafteruse安全檢測safetycheck消毒和保存disinfectionandstore使用前沖洗rinsing

目的是為沖去殘余消毒劑，避免不良反應(yīng)的發(fā)生。預(yù)充及循環(huán)管路rinsing,circulation

循環(huán)管路是為了最大限度降低濾器中消毒劑濃度，防止透析中不良反應(yīng)的發(fā)生，也有觀點認(rèn)為循環(huán)管路時加做超濾會有益于抗凝。透析器復(fù)用經(jīng)驗交流c.兩者的比較comparison自動復(fù)用automatic對沖洗水壓，水流控制更好，更穩(wěn)定；避免了不良反應(yīng)的發(fā)生stablecontrol,lesscomplication避免了處理時的個體差異universalinpractice節(jié)約了人力和時間用于病員護理savingofmanpower保證復(fù)用質(zhì)量betterQC手工復(fù)用manual節(jié)約成本，機動靈活costeffectiveforsmallscalepractice,flexible透析器復(fù)用經(jīng)驗交流B.Braun客戶使用Polysulfone的經(jīng)驗1上海華山醫(yī)院血透中心2上海浦東新區(qū)人民醫(yī)院腎臟科3上海南匯區(qū)人民醫(yī)院腎臟科4四川大學(xué)華西醫(yī)院血透中心5中山大學(xué)附屬一院6深圳紅會醫(yī)院血透中心7馬來西亞用戶經(jīng)驗透析器復(fù)用經(jīng)驗交流上海華山醫(yī)院血透中心目前有血透機40臺貝朗機器12臺，其中Advance6臺，HDFonline機4臺，Dialog+2臺固定透析病員數(shù)約150人透析器復(fù)用經(jīng)驗交流1.下機后沖洗rinsing使用反滲水沖洗,水壓一般介于0.1-0.2Mpa/cm2間。在氣溫較低時，用溫水沖洗，低溫水會促使血液凝結(jié)，使凝塊更難沖洗。沖洗時逆血流方向進行，即濾器內(nèi)由靜脈端向動脈端沖，還應(yīng)包括正向（超濾）及反向（反超濾）沖洗。如血凝塊存在，使用0.2%過氧乙酸浸泡，直至目測洗出液變清。將過氧乙酸注入透析液室及血室，依靠彌散來發(fā)生作用。（低濃度溶液使血塊溶解，高濃度溶液使血塊凝結(jié)。）應(yīng)對所用消毒劑的濃度進行檢查，明確是否使用了適當(dāng)?shù)臐舛?。再次沖洗直至洗出液清亮透析器復(fù)用經(jīng)驗交流2.安全檢測safetytest血室容積試驗，血室容積不小于原值80%(TCVtest)血室容積下降反映透析室內(nèi)有可能的微小血塊或蛋白殘留，將對下次的透析產(chǎn)生影響破膜試驗(MembraneRuptureTest)將血路一端堵死，使用250-270mmHg的壓力在另一端進行檢測，沒有泄漏為準(zhǔn)不能通過兩項試驗者應(yīng)棄去。(Discardforthosecannotpassthetest)透析器復(fù)用經(jīng)驗交流3.消毒和保存disinfectionandstorage灌入消毒劑之前應(yīng)確定水分已完全排除，避免消毒劑被水份稀釋，無法達成消毒效果。灌入相當(dāng)三倍血室容積的消毒劑使用0.4%過氧乙酸溶液進行封管消毒，持續(xù)至少12小時后備用，有效7天。將血室及透析液室均灌滿消毒劑后，封口，置于冷藏室中透析器復(fù)用經(jīng)驗交流4.使用前沖洗rinsing首先將透析器內(nèi)消毒劑放空使用至少1000ml0.9%生理鹽水沖洗，將此水放空而不應(yīng)同時用于循環(huán)管路。透析器復(fù)用經(jīng)驗交流5.預(yù)充及循環(huán)管路primingandcirculation預(yù)充血泵速度為150ml/min。過快的預(yù)充速度會在管路中導(dǎo)致湍流，產(chǎn)生小氣泡，對以后的凝血起重要的促進作用。預(yù)充時仔細檢查，確認(rèn)管路中沒有氣泡的殘留。0.9%NS500ml循環(huán)管路,血泵速300ml/min，循環(huán)20min,循環(huán)末期回路中加入20mg左右的肝素循環(huán)，使管路及濾器上可以吸附部分肝素。透析器復(fù)用經(jīng)驗交流6.抗凝劑的使用anticoagulation首劑0.4mg/kg,維持量0.08~0.16mg/kg/h;使用單次追加法的時候首劑量較持續(xù)推注維持法時可能要大。首劑肝素5~10min后開始引血，低分子肝素使用，常規(guī)情況在開始前使用一劑可滿足治療需要?，F(xiàn)常用以下種類，于血透開始前動脈端注入：

速避凝(Fraxiparine)0.4ml吉派林5000μ法安明(Fragmin)5000μ透析器復(fù)用經(jīng)驗交流上海浦東新區(qū)人民醫(yī)院腎臟科

People’sHospital,PuDongNewArea,Shanghai血透機20臺Dialogadvance單泵6臺，雙泵2臺，plus4臺，Secura2臺透析病員數(shù)約85人透析器復(fù)用經(jīng)驗交流反滲水沖洗，正向反向共10min，水壓0.1Mpa，直至洗出液清晰3.5%Renalin灌注消毒一晚備用二次使用前，管路連接完畢后用500ml鹽水沖洗管路；500ml循環(huán)管路加用超濾900ml/h，其中并加入肝素30mg；首劑肝素量30mg,引血前7~10min加入，追加5mg/h,低分子肝素一劑給完（復(fù)用血路管，同樣用Renalin消毒）復(fù)用至三次為止透析器復(fù)用經(jīng)驗交流下機后反滲水沖洗，正向反向，水壓0.1Mpa，直至洗出液清晰除蛋白：2%次氯酸鈉浸泡一晚（已廢除）消毒處理：3.5%Renalin灌注，可放置21天上機前先沖去消毒劑；血泵速300ml/min,循環(huán)15min加入20mgHeparin

肝素：首劑20~25mg,追加8~10mg/h，按公斤體重調(diào)整復(fù)用五次上海南匯區(qū)人民醫(yī)院腎臟科

People’sHospital,NanHuiDistrict,Shanghai透析器復(fù)用經(jīng)驗交流38臺透析機28臺B.Braun機器90個病人四川大學(xué)華西醫(yī)院血透中心

WesternChinaHospital,SichuanUniversity透析器復(fù)用經(jīng)驗交流四川大學(xué)華西醫(yī)院血透中心

WesternChinaHospital,SichuanUniversity反滲水沖洗至目測洗出液清晰1%次氯酸鈉透析器膜內(nèi)短時灌注兩次，除蛋白，去除沉積物過氧乙酸浸泡消毒，濃度至少0.5%以上,0.8%兩小時可復(fù)用透析器復(fù)用經(jīng)驗交流四川大學(xué)華西醫(yī)院血透中心

WesternChinaHospital,SichuanUniversity0.9%NS1000ml沖洗殘余消毒液肝素20mg加入鹽水500ml循環(huán)管路，約10~20min首劑肝素25~30mg,8~10mg/h追加高低通復(fù)用方法一致，復(fù)用八次透析器復(fù)用經(jīng)驗交流中山大學(xué)附屬一院

No.1AffiliatedHospital,

ZhongShanUniversity60余血透機器固定透析病人200余人透析器復(fù)用3~5次透析器復(fù)用經(jīng)驗交流兩袋鹽水(每袋1000ml)預(yù)沖管路,在預(yù)沖第二袋開始循管,循管量為500ml在循管加肝素,劑量為18-22mg,加用超濾病人治療前體內(nèi)肝素化,劑量為18mg左右,治療中維持量為6-10mg/h

中山大學(xué)附屬一院

No.1AffiliatedHospital,

ZhongShanUniversity

透析器復(fù)用經(jīng)驗交流深圳紅會醫(yī)院血透中心

HongHuiHospital,Shengzhen血透機12臺貝朗機器9臺透析病員數(shù)約60人透析器復(fù)用經(jīng)驗交流深圳紅會醫(yī)院血透中心

HongHuiHospital,Shengzhen反滲水沖洗,直至洗出液清晰1%次氯酸鈉浸泡，膜內(nèi)膜外保持15min3~4%甲醛封管消毒四瓶鹽水(每瓶500ml)預(yù)沖,在預(yù)沖完1000ml(兩瓶)后,第三瓶循管,并開始加肝素,一般劑量為16-22mg，在此階段將機器設(shè)置到循管超濾模式病人在治療前體內(nèi)肝素化,加入劑量為12-16mg。治療開紿后,肝素維持劑量為6-8mg/h。透析器復(fù)用經(jīng)驗交流馬來西亞用戶使用方法

MalaysianExperience40%人工復(fù)用,60%自動復(fù)用

反滲水(RO)沖洗，水壓<2大氣壓,直至洗出液清晰人工復(fù)用用<2%過氧乙酸/3.5~4.5%福爾馬林消毒；自動復(fù)用用3.5%Renalin消毒1L鹽水用于使用前沖洗沖洗完成后使用試紙檢測殘余Renalin濃度肝素:2000IU首劑,1000IU追加/3hrs可隨病人體重調(diào)整

透析器復(fù)用經(jīng)驗交流復(fù)用中的可能問題potentialproblems1復(fù)用次數(shù)不夠fewerreusetimes2復(fù)用后破膜membranerupture3殘余消毒液反應(yīng)disinfectantreaction4感染反應(yīng)infection透析器復(fù)用經(jīng)驗交流不適當(dāng)?shù)氖褂孟緞?dǎo)致透析膜的損傷，在膜上形成毛糙面，有利于蛋白及血細胞的沉積，并進而導(dǎo)致凝血。Improperuseofdisinfectants推薦使用3.5%Renalin，在美國被50%以上的透析中心使用，證明了它的有效和安全性；次氯酸鈉及雙氧水的強大氧化作用對膜可能產(chǎn)生巨大的傷害。Theeffectofbleach透析器復(fù)用經(jīng)驗交流Dialyzer-dependentchangesinsoluteandwaterpermeabilitywithbleachreprocessing.

ScottMK,MuellerBA,SowinskiKM,ClarkWR

AmJKidneyDis.1999Jan;33(1):87-96.

（漂白劑對復(fù)用濾器清除率影響）Wecomparedtheeffectsofautomatedbleach/formaldehydereprocessingonsoluteandhydraulicpermeabilityfor