腎透析醫(yī)療技術基礎課件

腎透析醫(yī)療技術基礎MedicalandTechnicalBasics

相關醫(yī)學和技術基礎29/09/2024腎透析醫(yī)療技術基礎腎臟生理生成尿液，排除代謝終末產物、毒物和藥物調節(jié)體內水、電解質、滲透壓和酸堿平衡調節(jié)血壓分泌腎素、促紅細胞生成素、1,25-(OH)2D3、前列腺素等29/09/2024腎透析醫(yī)療技術基礎血液透析的作用清除體內的毒素（彌散、對流、吸附）糾正酸堿平衡紊亂（彌散）清除體內過多的水份（超濾）糾正電解質失衡（彌散）29/09/2024腎透析醫(yī)療技術基礎

Diffusion彌散Start開始時:Different

Concentrations膜兩側濃度有差別End結束時:Equal

Concentrations膜兩側濃度相同time彌散是微分子物質隨機的運動可導致均勻分布的結果

Diffusionisaconsequenceoftherandommovement

ofallmolecules(BrownianMovement).29/09/2024腎透析醫(yī)療技術基礎Ultrafiltration超濾TimePressureStart:End:Exertionofpressureononesideofthemembraneproducesfiltrationofwaterwithsolutes,aslongastheycanpassthemembrane.運用壓力的作用將水份從膜一側推到另一側，膜孔夠大時溶質也可以被擠出29/09/2024腎透析醫(yī)療技術基礎dialysateside透析液側bloodside血液側Adsorption

吸附afterchemicaldisinfection?hollowfiverendotoxins內毒素-contactspace接觸空間Virus病毒29/09/2024腎透析醫(yī)療技術基礎H2OwatersolublemoleculesHFFmmHgmmHgBBHDBDBDHDFmmHgBmmHgDBDlow-flux低通透析器high-flux高通透析器high-flux高通透析器diffusionconvectionadsorptiondiffusion/convectionadsorptionTherapytypes治療模式Hemodialysis血液透析Hemofiltration血液濾過Hemodiafiltration血液透析濾過彌散原理對流吸附彌散對流吸附29/09/2024腎透析醫(yī)療技術基礎Hemodialysis血液透析利用血液和透析液中溶質的濃度差別使溶質在彌散作用下通過半透膜隨透析液排出Diffusivemetabolictransportthroughsemi-permeablemembraneswithbalanceofaconcentrationdifferencebetweenbloodanddialysisfluid.

小分子物質可有效的被清除Smallmolecularsubstanceswillessentiallymoreeffective.diffusiveconvectiveadsorptiveclearanceBmmHgDBDhigh-fluxHemodialysis血液透析andHemofiltration血液透析濾過Hemofiltration血液透析濾過可溶物質隨著通過高通透性半透膜的液體流動而被清除（對流）。對流依靠跨膜壓和膜的物理性質（面積、密度、質量、孔徑）來實現(xiàn)。

Solublesubstancesaresweptalonginafluidstreamthroughhighpermeablemembranes(convection).Theconvectiondependsonthetransmembranepressureandonmembranefeatureslikesize,density,andqualityofthepores(?cut-off-value“).清除高分子量物質（只要是低于膜孔的篩選值的物質）的有效方法Highmolecularesubstances,aslongastheyarebelowthe?cut-off-value“,willbeeliminatedinabetterway.

29/09/2024腎透析醫(yī)療技術基礎HDF–Hemodiafiltration血液透析濾過結合兩種治療模式：血液透析和血液濾過結合由彌散產生的小分子物質的高清除率和由對流產生的中大分子物質的高清除率兩種方式的優(yōu)點。Combinationoftwodialysistechnics,hemodialysisandhemofiltration:highclearanceofconventionelsmallmoleculesbydiffusionlinkedwithhighclearanceofmiddlemoleculesbyconvection.mmHgBmmHgDBDDiffusion+Convection+Adsorptionhigh-flux高通濾器29/09/2024腎透析醫(yī)療技術基礎ReplacementSolutionforHFandHDF置換液常規(guī)離子范圍常用配方29/09/2024腎透析醫(yī)療技術基礎RheaterheparinVVPVPAUFBLDSADPostdilution后稀釋Predilution前稀釋HDF-Online在線透析濾過–Medical醫(yī)學29/09/2024腎透析醫(yī)療技術基礎Clearance

inHD,HFandHDF各治療模式的清除率0408012010102103104105Urea尿素氮Creatinine肌酐Vit.B12?2-Microglob.AlbumineClearance清除率ml/minMGDalton道爾頓（質量單位）HFHDHDFKidney腎臟29/09/2024腎透析醫(yī)療技術基礎SemipermeableMembrane半透膜Virus病毒Bacteria細菌Mediumsized

molecules,e.g.

b2-MicroglobulinWaterflowis

easilypossible水最容易通過Erythrocyte,

redbloodcell紅血球Albumin,as

exampleofabig

proteinmolecule白蛋白等大蛋白分子Electrolytes電解質Thesemipermeablemembranefunctionssimilartoafinesieve,

onlymoleculesthataresmallenoughcanpass.半透膜就是性能良好的篩網(wǎng)，僅有小于篩孔的物質可以通過29/09/2024腎透析醫(yī)療技術基礎PressureDroponDialyser-LowFlux透析器內的壓力分布示意圖200250300350400bloodsidepressuredropdialysatesidepressuredropfiltration=netUF凈超濾450PBEPVPDAUltrafiltration超濾作用mediumTMPpressureinthefilter29/09/2024腎透析醫(yī)療技術基礎AdvantagesoftheDialogBalanceChamberControlDialog機器的改良的容量平衡控制系統(tǒng)的優(yōu)點permanentmonitoringofthemembraneposition持續(xù)監(jiān)測平衡腔膜片位置

continuouscontrol連續(xù)控制nopressurespikesatthedialyser透析器內沒有壓力尖峰

smoothUFandpreventionofreverseUFintheswitching moment超濾平穩(wěn)并且避免了液流切換時產生反超continuousdialysateflowevenintheswitchingmoment

透析液持續(xù)不斷（包括液流切換時刻）

bettertherapyresults(K*t/V)bymaintainingthediffussion pressure維持住彌散壓力可帶來更好的治療效果(K*t/V值)protectionofthemembranematerial,valvesandpumps

對膜片、閥門和泵都有保護作用。

extendedlifetime延長配件壽命Dialog+competitor29/09/2024腎透析醫(yī)療技術基礎

TheAccessPoints-onPatient

病人血管通路CiminoFistulaV.jugularisinternaV.subclaviaV.cubitalisV.femoralisThebloodflowinthefistulamustbeatleastthedoubledfromtherequiredbloodflowattherapytominimizetherecirculation.29/09/2024腎透析醫(yī)療技術基礎TheSievingCoefficientoftheDialyser透析器的篩選系數(shù)Albumine69000DaUrea60DaCreatinin113DaPhosphat96DaVitaminB121355DaInulin5200Da

?2-Microglobuline

Membranepores

0,003μmErythozyt8,5*2μm29/09/2024腎透析醫(yī)療技術基礎UFFactor–SubstanceTransportFactor超濾系數(shù)

Diacap?HE1400-factor7,47,4ml/hpermmHgPressuredifference300mmHg*7,4ml/h/mmHg=2220ml/h200mmHg-100mmHgTMP300mmHgfactor7,4Cuprophan?CE2000factor8,6transportUF1500perhourvenouspressure220mmHgTMP=PDA=1500:8,6=174,4mmHgTMP-PV=-45,6mmHgvenouspressurePDAcalculationofUFremovalpressurecalculationmemorize:thefactorofthefiltercaneveninonechargedupto±15%changed.29/09/2024腎透析醫(yī)療技術基礎DialyserTypes透析器類型Syntheticmembrane

Cellulosemembrane

modifiedcelluloseregeneratedcellulose

Polysulfone(PSU)Polyamide(PA)Polycarbonate(PC)

Ethyl-vinyl-alcoholcopolymer(EVAL)

Polyacrylonitrile(PAN)

Polymethylmethacrylate(PMMA)High-fluxandLow-flux Low-fluxSyntheticmodifiedcellulose(SMC)Celluloseacetate(CA)Cellulosediacetate(CDA)

Cellulosetriacetate(CTA)Hemophan(HE)Cuprophan(CU)Cuprammonium29/09/2024腎透析醫(yī)療技術基礎DialyserTypeshighbiocompatiblebutmoreheparinnecessaryhighclearanceatmiddlemolecularsubstancesmoreeffectiveon

smallmolecularsubstancesmembranewithhighadsorptioneffectDiacap?PolysulfoneDiacap?

SMCSyntheticmodifiedCelluloseexcellentbalancedbiocompatibleprofile

29/09/2024腎透析醫(yī)療技術基礎102103104105106107108ExotoxicfragmentsExotoxicsMuramylpeptidPeptidoglykaneEndotoxicfragmentsLipidAEndotoxicsVirusBacteriaverificationCISCISCISCISCISLALLALCut-OffPointofDialyserMolecularweight/Daltonlowfluxhighflux29/09/2024腎透析醫(yī)療技術基礎MicrobiologicRequest微生物要求AAMI=AmericanAssociationfortheAdvancementofMedicalInstrumentationPh.Eur.=Europ?ischePharmacopoeiaCFU=ColonyFormingUnitsEU=EndotoxinUnits29/09/2024腎透析醫(yī)療技術基礎QualityofWaterandDialysate反滲水和透析液水質Theusermustensurethatthewaterqualityiscontinuousmonitored.Thefollowingrequirementsmustbefulfilled:?TheincomingwatermustbefreefromMg++andCa++.?pHvalueofbetween5and7Wateranddialysatemustcomplywiththecountryspecificstandards,i.e.:?ISO13959:2002Waterforhemodialysisandrelatedtherapies?DINVDE0753-4,issue:1986-09Applicationregulationsforhemodialysismachines?ANSI/AAMIRD5-03Hemodialysissystems?ANSI/AAMIRD61:2001Concentratesforhemodialysis?ANSI/AAMIRD62:2001Watertreatmentequipmentforhemodialysisapplications29/09/2024腎透析醫(yī)療技術基礎QualityofWaterandDialysateFluid反滲水和透析液水質29/09/2024腎透析醫(yī)療技術基礎ContextpHValue,HCO3-andpCO2Normalvalueonblood pH 7,36–7,45 pCO2 33–45mmHg HCO3- 21–26mmol/LIncreasingordropthepHvalueintheblood,overorunderacriticalvalueisnonphysological.Consequenceslikeheadaches,cramps,hypotension,hypertensionoratotalcollapseofthebloodcircuitarepossible.pHvalue>7.45alkalosespHvalue<7.36acidosisThenormalvalueforpCO2isbetween33-45mmHg,i.e.,thepCO2increase(alkaloses)-automaticallythepatientstartsahypervitalisation.ThepatientstartsCO2

dismantleasacontrareaction.29/09/2024腎透析醫(yī)療技術基礎ContextpHValue,HCO3-andpCO2H++HCO3-?H2CO3?H2O+CO2hydrogen–bicarbonate–carbondioxide-buffersystempCO2(mmHg)HCO3-(mmol/LpH7,450403530242016121098712141620253040506070pH7,3AzidosepH7,5Alkalosestandardrange

H+=24________pCO2

HCO3-

29/09/2024腎透析醫(yī)療技術基礎BicarbonateTherapy碳酸鹽治療–Technical技術方面

ImportantforthefactorspecificationorrechecktackthesamplecarefullyonlyonthebluecouplingwithasyringeasecurespecificationonlywithtitrationpossiblePHvaluerecheckmeasurementinstrumentondialysatemodus.SchalterSendeelektrodenVerst?rkerGleichrichterTiefpa?+5VoltRef.4kHzLFSignalEmpfangselktrodeconductivitycell29/09/2024腎透析醫(yī)療技術基礎BicarbonateTherapy–CalcificationNormalvalueinblood24mmol/L(attheendoftherapy26-28mmol/L).Thedirectmeasurementofthebicarbonateisnotpossible,wemeasureonlythesodiumonthebiccell.Normallytheproportionis1:1.Thegrainsofthepowder(2Na+HCO3-)inthecartridgearecoatedwithcarbonate.Thiscoatingisdissolvedfirst,thepHincreasesandtheunitcangetcalcified.Followup:proportionisnotmore1:1strongercalcification(frompH>7,5critical)pHmovementondialysate,bloodandbuddyfluidblockofdialysatefiltercoatingonconductivitycells(ratioalarm,sodiumnotcorrect)bloodleakalarm29/09/2024腎透析醫(yī)療技術基礎BicarbonateTherapy–MedicalAcetatemustbemetabolizedintheliverandkidneyfirsttobicarbonate,sothattheacid/basebalance(pHvalue)iscorrected.Duetothedelayintheconversionthepatientcanbecomeacidotic.Thiscanleadtocramps,hypotensionandvomitingofthepatient.Thisisevenworseifthepatienthasaliverdysfunction.Todayismostlyonlybicarbonateused.WiththattreatmentthepHvalueismorestable.Thepatientfeelsbetterandhisbodyisnotsoheavilyused.Thefluidtransportandexchangeofionsstartdirectlyafterthestartofthetherapy.Normalvalueinblood:24-28mmol/L29/09/2024腎透析醫(yī)療技術基礎AtomsBasicnucleus

protonelectronelectronelectronnucleus

proton/neutronhydrogenhelium29/09/2024腎透析醫(yī)療技術基礎ElectrolytesandIonsH2

O

Na+Cl-

Na+Cl-dissolvertDefinition Electrolytesaresubstanceswheretheelectricalcurrent isguidedviaions

Definition

Ionsareatomswithelectronabsence(cations)

orelectronexcess(anions)

Forinstance NaCldissociateinwater inNa+cationsandCl-anions29/09/2024腎透析醫(yī)療技術基礎Conductivity電導率Theconductivityisbasedonelectrolytesandtemperature.ThephysicalunitismS/cm(milleSiemenspercm).

ThisisanAmericannotationfortheelectricalresistanceandthisisareciprocalvaluetoEuropewithOhm(

).

Cl-

Na+currentquellcurrentmeasurementmS/cmMinuspole負極Pluspole正極29/09/2024腎透析醫(yī)療技術基礎CellconstantsoftheConductivityCell電導度傳感器的傳感器系數(shù)Thecellconstantsarechangingdifferencewiththecoating傳感器敏感系數(shù)會隨附著層增加而變化82,5=3,2165,5=2,9183=2,666166=2,666cellconstants傳感器系數(shù)

Distance距離diameter直徑distanceholderflowdirection透析液流向referenceelectrodetransmitter-electrodereceiver-electrodemeasurementcell2measurementcell10,5mmcoatingtransmitter-electrode=29/09/2024腎透析醫(yī)療技術基礎QualityofWaterandDialysateFluid

水質與透析液0,5mmcoating附著層MagnesiumCarbonate碳酸鎂CalciumCarbonate

碳酸鈣Thecellconstantsarechangingdifferencewiththecoating傳感器敏感系數(shù)會隨附著層增加而變化Damagetothemachineduetocalciumdepositionsduringbicarbonatedialysis!鈣質沉淀物將會損壞機器！Decalcifythemachineaftereachbicarbonatedialysis.每次碳酸鹽透析治療后都需要脫鈣Warning29/09/2024腎透析醫(yī)療技術基礎ReasonsforCalcification生成沉淀的原因2Na+HCO-3

Na2CO3+H2O+CO2bicarbonatesoda+water+carbondioxideNa2CO3+MgCl2MgCO3+2NaClmagnesiumcarbonateNa2CO3+CaCl2CaCO3+2NaClandcalciumcarbonate-frequently(often,chemicalresolvable)2Na2CO3+CaCl2+MgCl2CaMg(CO3)2+4NaClmarble(seldom,andnoteasydissolvable)Thecalciumandmagnesiumoftheacidconcentratereactchemicallywiththecarbonateandprecipitatestonon-dissolvableMgCO3+CACO3.沉淀物質是A液中的鈣鎂離子和B液中的碳酸根離子產生的碳酸鈣和碳酸鎂29/09/2024腎透析醫(yī)療技術基礎AccommodationSystemfortwoMachinesmainsupplycentralacidconnectorsinletconnectoroutletconnectorwithfreefallgrounding29/09/2024腎透析醫(yī)療技術基礎IonExchanger-Softener離子交換罐—軟化29/09/2024腎透析醫(yī)療技術基礎microbiologicdebitofthepermeatecircuitwaternetreverseosmo