血液凈化原理,模式及治療的選擇課件

1、Tips for improving filter life,Aquarius System,Copyright 2015 NIKKISO Co., LTD. All rights reserved.,PM-0063-11/2015-1,1,PPT學(xué)習(xí)交流,腎臟替代治療“的內(nèi)容,腎臟替代治療的基本內(nèi)容 濾器的選擇 抗凝劑的應(yīng)用,2,PPT學(xué)習(xí)交流,CRRT命名的發(fā)展,CRRT： Continuous renal replacement therapy（連續(xù)腎臟替代治療） ICBP: Intensive care blood purification（重癥血液凈化） CBP： Continuou

2、s Blood purification （連續(xù)血液凈化） MOST：Multi Organ Support Therapy （多臟器支持療法）,3,PPT學(xué)習(xí)交流,CRRT 的特點(diǎn)和優(yōu)越性,CRRT是緩慢、連續(xù)排除水分，模擬尿的排泄方式。更符合生理狀態(tài)，能較好地維護(hù)血流動(dòng)力學(xué)穩(wěn)定；容量波動(dòng)小；溶質(zhì)清除率高；有利于營養(yǎng)改善及能清除細(xì)胞因子，從而改善危重ARF患者的預(yù)后，更好的血液動(dòng)力學(xué)穩(wěn)定性 更好的溶液控制能力和清除多余水分 累積的更好溶質(zhì)清除性 維持尿排泄并保存殘余腎功能 清除炎癥介質(zhì) 改善營養(yǎng)支持,4,PPT學(xué)習(xí)交流,CRRT的分類,SCUF-緩慢連續(xù)超濾 CAVH-連續(xù)動(dòng)靜脈血液濾過 C

3、VVH-連續(xù)靜靜脈血液濾過 HVHF高容量血液濾過 CAVHD-連續(xù)動(dòng)靜脈血液透析 CVVHD-連續(xù)靜靜脈血液透析 CVVHFD連續(xù)靜靜脈高通量透析 CAVHDF-連續(xù)動(dòng)靜靜脈血液透析濾過 CVVHDF-連續(xù)靜靜脈血液透析濾過 MPS- 血漿置換 HP- 血液灌流和免疫吸附 CRRT 以一種更符合機(jī)體生理特性的方式，連續(xù)地清除機(jī)體多余的水分和毒素，調(diào)節(jié)酸堿和電解質(zhì)的平衡，來有效地維持機(jī)體內(nèi)環(huán)境的穩(wěn)定。不單用于急性腎衰，還是救治許多危重病癥的有力輔助手段。,5,PPT學(xué)習(xí)交流,原理與機(jī)制,彌散,對流,吸附,500,5000,50000,6,PPT學(xué)習(xí)交流,Solute Classes by Mo

4、lecular Weight,Daltons,7,PPT學(xué)習(xí)交流,炎癥介質(zhì)的特征,8,PPT學(xué)習(xí)交流,炎癥介質(zhì)的特征,9,PPT學(xué)習(xí)交流,PSHF系列濾器篩選系數(shù)/高截留分子量,10,PPT學(xué)習(xí)交流,如何選擇血濾器 ？,11,PPT學(xué)習(xí)交流,Molecular Weights （分子的重量或分子量的大?。?Copyright 2015 NIKKISO Co., LTD. All rights reserved.,Ashley et all. The Renal Drug Handbook, 2nd Ed. 2004, Medical Press, Abingdon, UK. ISBN: 185

5、7758730,12,PPT學(xué)習(xí)交流,New functional membrane with defined larger pore size,HCO membrane,13,PPT學(xué)習(xí)交流, 0,01 m, 0,02 m, 0,09 m, 0,30 m,: pore diameter,high flux,high cut-off*,protein separation membrane,plasma separation membrane,Variation of membrane pore size,Electron micrographs of inner membrane surfa

6、ce,14,PPT學(xué)習(xí)交流,High Cut-Off Hemofilter,15,PPT學(xué)習(xí)交流,Sieving Coefficient,A sieving coefficient is the measure of how easily a substance passes from the blood compartment to the dialysate compartment in a haemofilter. Thus, a sieving coefficient of 1.0 means the solute is 100% filterable; i.e. in a haemo

7、filter, the solute will equilibrate on both sides of the membrane. So the returning blood and the effluent both have the same concentration (50:50). An example is potassium (sieving coefficient is 1.0) A sieving coefficient of 0 means the solute does not cross the membrane, eg. albumin. Of course, t

8、his all depends on the membrane, and sieving coefficients will vary depending on the pore size. DEFINITION:The cut-off point of a solute for any membrane is a sieving coefficient of 0.1 . This means that 10% of the molecules will pass and 90% will not pass .,Copyright 2015 NIKKISO Co., LTD. All righ

9、ts reserved.,16,PPT學(xué)習(xí)交流,Molecular Weight Da,Standard HighFlux,High Cut-Off,HF, UF=1L/h, t=2h,Median, 25th-75th percentiles),ICM (2002) 28:651-655,HCO Membrane with increased permeability for inflammatory mediators,membrane characteristics,17,PPT學(xué)習(xí)交流,Molecular weight,Ashley et all. The Renal Drug Han

10、dbook, 2nd Ed. 2004, Medical Press, Abingdon, UK. ISBN: 1857758730 Copyright 2015 NIKKISO Co., LTD. All rights reserved.,HF1200 Haemofilter Cut-Off 55 000 daltons,18,PPT學(xué)習(xí)交流,Comparison of Interleukin-6 Removal Properties among Hemofilters Consisting of Varying Membrane Materials and Surface Areas,Re

11、cent Studies in Membrane,19,PPT學(xué)習(xí)交流,全身抗凝,局部抗凝,無肝素抗凝 肝素 低分子肝素鈣,魚精蛋白 枸櫞酸,抗凝的選擇,Copyright 2015 NIKKISO Co., LTD. All rights reserved.,20,PPT學(xué)習(xí)交流,積極主動(dòng)預(yù)防管路的凝血,利用重新預(yù)沖和循環(huán)模式清除管路及濾器中的氣泡 仔細(xì)觀察預(yù)沖后管路的通暢. 保持靜脈壺的血液水平在二分之一以上， 減少氣血接觸防止靜脈小壺的凝血，靜脈 小壺的凝血影響了血液的流速 壓力降,Copyright 2015 NIKKISO Co., LTD. All rights reserved.

12、,21,PPT學(xué)習(xí)交流,預(yù)防濾器內(nèi)的凝血(Filtration Ratio%),保持超濾比率在 25 %一下.超濾比率是衡量濾器中 血液濃度 (血流速率與濾出是百分比）. 是多少血夜 進(jìn)入濾器和多少液體排除的比較。 目標(biāo)血流速度的目的制定達(dá)到低的超濾比率， 從而達(dá)到更長的濾器使用壽命. 高的血流速度可以達(dá)到低的超濾比率 如果臨床需求允許可以提高血流速10 15% 當(dāng)連接病人時(shí)，可以延長治療直到血流速度達(dá)到要求 盡可能的在病人開始治療時(shí)防止血液的濃縮,Copyright 2015 NIKKISO Co., LTD. All rights reserved.,22,PPT學(xué)習(xí)交流,預(yù)防濾器內(nèi)的凝血

13、(Recirculation),重復(fù)循環(huán)模式：連接病人之前重復(fù)循環(huán) 20 - 40 /min ， 重復(fù)循環(huán)可以侵泡濾器的纖維，同時(shí)排空纖維中的 空氣 . 濾器的纖維經(jīng)過侵泡更加的飽滿，改善血流通過 纖維的流量，排除極小的氣泡防止早期的凝血. 一個(gè)循環(huán)時(shí)間在20 20/ minutes . 濾器和管路基本可以 72 小時(shí)使用, 但這包括重復(fù)使用的時(shí)間.,Copyright 2015 NIKKISO Co., LTD. All rights reserved.,23,PPT學(xué)習(xí)交流,Filtration Fraction（濾過分?jǐn)?shù)）,Filtration Fraction 濾過分?jǐn)?shù)是 總液體通過

14、濾器的量與超濾量的相比 濾過分?jǐn)?shù)通常是盡可能的低，理想是25% Filtration Fraction 濾過分?jǐn)?shù)是 不會(huì)受到前 稀釋泵的影響 Filtration Fraction 濾過分?jǐn)?shù)是會(huì)受到血流速 的影響 .,Copyright 2015 NIKKISO Co., LTD. All rights reserved.,24,PPT學(xué)習(xí)交流,超濾比率 Filtration Ratio,Copyright 2015 NIKKISO Co., LTD. All rights reserved.,Filtration Ratio是表示濾器中血液濃度增加 . 理想的超濾比率在低于 25%. Fil

15、tration Ratio 是受到前稀釋泵的影響 . Filtration Ratio 是受到血流速的影響.,25,PPT學(xué)習(xí)交流,Filtration Ratio and blood pump speed,Postdilution (l/h) Blood Pump Speed (mls/min) 60 (mins) = Filtration Ratio /1000 3l/h Exchange 3 1 100mls/min x 60 mins = 6 = 2 = 50% Filtration Ratio /1000 3l/h Exchange 3 1 200mls/min x 60 mins

16、= 12 = 4 = 25% Filtration Ratio 3l/hr Exchange 3 1 300mls/min x 60 mins = 18 = 6 = 17% Filtration Ratio,Copyright 2015 NIKKISO Co., LTD. All rights reserved.,26,PPT學(xué)習(xí)交流,肝素是如何工作的?,Heparin肝素抑制導(dǎo)致血液凝固和纖維蛋白凝塊形成的反應(yīng). 肝素在抗凝系統(tǒng)中是多部位的作用. 小劑量的肝素，與抗凝血酶III結(jié)合， 可以抑制凝血酶塊的形成通過消除 Factor X因子. 減少了凝血素轉(zhuǎn)化成凝血酶 治療劑量的肝素有利于血濾器

17、的壽命.,5Ronco et al. Effects of different doses in continuous veno-venous haemofiltration on outcomes of acute renal failure: a prospective randomised trial. Lancet. 2000 Jul 1;356(9223):26-30,Copyright 2015 NIKKISO Co., LTD. All rights reserved.,27,PPT學(xué)習(xí)交流,肝素; 優(yōu)勢和劣勢,優(yōu)勢: 容易管理和監(jiān)控 ICU非常熟悉肝素抗凝. 便宜. 短的半衰期

18、. 肝素可以中和. 缺點(diǎn): 增加出血的風(fēng)險(xiǎn). 血小板減少. 增加肝素的劑量. 抗凝血酶元水平下降會(huì)影響肝素的作用.,Copyright 2015 NIKKISO Co., LTD. All rights reserved.,28,PPT學(xué)習(xí)交流,枸櫞酸是如何工作的?,枸櫞酸螯合了血循中的鈣.抑制了凝血,ACD-A (Citrate Solution),What,citrate binds to calcium which inhibits coagulation,Copyright 2015 NIKKISO Co., LTD. All rights reserved.,29,PPT學(xué)習(xí)交流,合

19、適的枸櫞酸劑量,圖表顯示鈣在血漿中的分布情況.,枸櫞酸劑量考慮是 Total Calcium (typically 2.2-2.6 mmol/l) and Total Magnesium (typically 1.1 1.4 mmol/l). 影響到選擇枸櫞酸的量 Citrate dosing between 3.3 4.0 mmol/l.,Copyright 2015 NIKKISO Co., LTD. All rights reserved.,30,PPT學(xué)習(xí)交流,What does the body do with Citrate?,Copyright 2015 NIKKISO Co.,

20、 LTD. All rights reserved.,31,PPT學(xué)習(xí)交流,Therapy monitoring,The selection and adjustment of therapy parameters, replacement fluids and anticoagulant fluids remains a prescription at the physicians discretion. A change in an individual prescription will require physician review or be clearly defined in

21、a locally approved document. To monitor and adjust the therapy, the following typical parameters may be considered in the individualized prescribers local protocol : Ionised Calcium (after hemofilter) typically 0.25 - 0.35 mmol/l Ionised Calcium (from patient) typically 1.05 - 1.3 mmol/l Total Citra

22、te (from patient) typically less than 2.5 mmol/l Calcium Ratio (a comparison of Calcium distribution) typically less than 2.3 Acid/base monitoring Electrolytes monitoring Fluid balance monitoring,Copyright 2015 NIKKISO Co., LTD. All rights reserved.,32,PPT學(xué)習(xí)交流,Aquarius Regional Citrate Anticoagulati

23、on Protocol,John R Prowle MD FRCP FFICM Adult Critical Care Unit Royal London Hospital,33,PPT學(xué)習(xí)交流,Eligibility for RCA,Requiring RRT within the ICU (either new or on-going treatment) for conventional Renal indications Considered by the treating Physician to have a contraindication to heparin anticoag

24、ulation or unable to achieve adequate filter lifespan (12h) using heparin Appropriately trained nursing staff available,34,PPT學(xué)習(xí)交流,Contra-indications to RCA in pilot,Requirement for systemic anticoagulant (other than prophylaxis) Chronic Liver Disease - Childs B or C Acute Liver Injury with INR 2 or

25、 Lactate 4mol/L Post-hepatic resection Severe shock: Noradrenaline 0.5mcg/kg/min and/or Lactate 4mol/L Arterial Blood Ionized Calcium 7.5 or HCO3- 40mmol/L at commencement of RCA Serum Sodium 160 at commencement of RCA Uncontrolled hyperglycaemia 6U/h Insulin IBW 90kg,35,PPT學(xué)習(xí)交流,35ml/kg/h CVVH RCA P

26、rotocol,All patients will start at 35ml/kg/h unless directed by physician Dose includes citrate volume pre-filter Filtration Ratio is 20% Pre-filter citrate concentration will be 2.8mmol/L,Protocol 1,36,PPT學(xué)習(xí)交流,Calcium Replacement,Accusol replacement solution contains 1.75mmol/L Calcium which will p

27、rovide most or all of the Calcium replacement A 10mmol/L Calcium Chloride solution will be used for additional Calcium replacement if required: 1x10ml ampule of Calcium Chloride (10mmol) in 990ml Normal Saline given via integrated Calcium Pump on Aquarius-Citrate device only Infusion rate 0-175ml/h,

28、37,PPT學(xué)習(xí)交流,Initial Calcium Rate,Then check arterial Cai in 1h,38,PPT學(xué)習(xí)交流,Adjusting Calcium Infusion,* Likely to change to check in 6h in final protocol,39,PPT學(xué)習(xí)交流,* Likely to change to check in 6h in final protocol,40,PPT學(xué)習(xí)交流,Metabolic Alkalosis Monitor pH and Bicarbonate 3 hly*,* Likely to change t

29、o check in 6h in final protocol,41,PPT學(xué)習(xí)交流,Step 2: if pH7.5 or HCO3- 40mmol/L on Protocol 2 change settings to Protocol 3 (25ml/kg/h with increased filtration ratio) below and monitor every 3h*,Step 3: if still pH40mmol/L DISCONTINUE RCA,Step 1: if pH7.5 or HCO3- 40mmol/L on Protocol 1 Change the se

30、ttings to Protocol 2 (25ml/kg/h) below and continue to monitor every 3h*. (Protocol 2 may also be selected for dose reduction),Protocol 2,Protocol 3,* Likely to change to check in 6h in final protocol,42,PPT學(xué)習(xí)交流,How it works,43,PPT學(xué)習(xí)交流,44,PPT學(xué)習(xí)交流,THANKS!,45,PPT學(xué)習(xí)交流,Indications for Citrate Anticoagul

31、ation,Requiring RRT within the ICU (either new or on-going treatment) for conventional Renal indications Considered by the treating Physician to have a contraindication to heparin anticoagulation Appropriately trained nursing staff available,8Palsson R ,Niles JL, Regional citrate anticoagulation in

32、continuous venovenous hemofiltration in critically ill patients with a high risk of bleeding Kidney Int 1999, 55: 1991-1997. 9Flanigan M et al. Reducing the hemorrhagic complications of hemodialysis: A controlled comparison of low-dose heparin and citrate anticoagulation. Am J Kidney Dis 1987; 2: 14

33、7-153,Copyright 2015 NIKKISO Co., LTD. All rights reserved.,46,PPT學(xué)習(xí)交流,Contraindications,Chronic Liver Disease - Childs B or C Acute Liver Injury with INR 2 or Lactate 4mol/L Post-hepatic resection Severe shock: Noradrenaline 0.5mcg/kg/min and/or Lactate 4mol/L Arterial Blood Ionized Calcium 7.5 or

34、HCO3- 40mmol/L at commencement of RCA Reduction of requirements for systemic anticoagulant (other than prophylaxis) Serum Sodium 160 at commencement of RCA Uncontrolled hyperglycaemia 6U/h Insulin IBW 90kg Citrate intolerance Clinical situation where citrate metabolism becomes uncertain.,Copyright 2

35、015 NIKKISO Co., LTD. All rights reserved.,10Prowle et al. Service Development Plan and Protocol for Regional Citrate Anticoagulation , The Royal London Hospital,47,PPT學(xué)習(xí)交流,Therapy monitoring,Ionised Calcium: Ionized calcium is a measure of free calcium. After hemofilter typically 0.25 - 0.35 mmol/l

36、 From patient typically 1.05 - 1.3 mmol/l Total Calcium: Total calcium includes both protein-bound and free calcium. Total Calcium (from patient) typically less than 2.5 mmol/l Acid/base monitoring: Systemic pH will be monitored 3-6hrly. Glucose monitoring: Blood glucose monitored for hyperglycaemia

37、 3-6hrly Electrolyte monitoring: Levels to be monitored 3-6hrly. Fluid balance monitoring. Any other clinical signs?,Copyright 2015 NIKKISO Co., LTD. All rights reserved.,48,PPT學(xué)習(xí)交流,Optimize Vascular Access,Consider using a high flow silicone vascular access catheter that does not have “kink memory”

38、 , and with an appropriate length for the chosen site. Avoid attaching the Aquarius to a catheter with poor flow. For example, being able to withdraw 20ml of blood in 6 seconds or 10ml of blood in 3 seconds without hesitancy or interruption may help a catheter assessment. Consider rotating the hub o

39、f the catheter 90 so that the holes on the access lumen are facing the flow of blood, not against the vessel wall (you may need to momentarily stop the blood pump to do this). Consider the patients intravascular volume. Even though the patient may be fluid overloaded, if their intravascular space is

40、 dehydrated, there may be poor flow through the catheter which will encourage clotting.,Copyright 2015 NIKKISO Co., LTD. All rights reserved.,49,PPT學(xué)習(xí)交流,Optimize Anticoagulation,High return pressure is one sign of under anti-coagulation. The blood pump wants to push the blood through the return cham

41、ber where partially formed blood clots may increase in size, making it difficult for the blood to squeeze through. A routine of regular observation, followed by a check of the patient clotting, and adjustment of anticoagulant where indicated, may prevent early return chamber clotting. Consider incre

42、asing the proportion of pre-dilution if anticoagulation adjustment is not indicated. For example: altering the pre-dilution to 90 % and reducing post-dilution to 10 % may thin the blood passing through the filter and reduce the effects of haemoconcentration. A gain in lifespan may be offset by a sma

43、ll loss in clearance, easily adjusted by using the Renal Dose display.,Copyright 2015 NIKKISO Co., LTD. All rights reserved.,50,PPT學(xué)習(xí)交流,The effect of blood pump speed,Copyright 2015 NIKKISO Co., LTD. All rights reserved.,Filtrate removed is a percentage of total flow through the filter fibres. Why i

44、s the total blood flow important? With a faster blood pump speed, the total flow is increased and effects of haemoconcentration are reduced. Increasing blood flow gives a reduced filtration ratio which may slow filter clogging and extend filter lifespan.,51,PPT學(xué)習(xí)交流,The effect of Pre-dilution,Copyrig

45、ht 2015 NIKKISO Co., LTD. All rights reserved.,Filtrate removed is a percentage of total flow through the filter fibres. The proportion of predilution flow may be adjusted to optimise treatment. With a greater proportion of predilution, the filtration fraction and effects of haemoconcentration are r

46、educed. An improved filtration fraction may slow filter clogging and extend filter lifespan.,52,PPT學(xué)習(xí)交流,Considerations,Copyright 2015 NIKKISO Co., LTD. All rights reserved.,Diameter, length and types of catheters (II) Type: Material features Silicone elastomer catheters have lower thrombogenicity an

47、d better flexibility. Biocompatible and kink resistance Conform to vessel anatomy, therefore reduce risk of trauma Diameter and blood flow: 11 French : 250-300 ml/min Blood Flow 13.5 French : 450-500 ml/min Blood Flow Recirculation- up to 20% Especially if femoral access is less than 20 cm Avoid rev

48、erse AV connection,53,PPT學(xué)習(xí)交流,Patient Preparation,Copyright 2015 NIKKISO Co., LTD. All rights reserved.,Patient body status Coagulation and Intravascular filling Mobility influences Presence of other central lines Influences on catheter choice Clinician choice Availability of ultrasound guidance Ass

49、essment of catheter patency Connection techniques Special circumstances,54,PPT學(xué)習(xí)交流,Catheter Characteristics,Copyright 2015 NIKKISO Co., LTD. All rights reserved.,Ease of insertion: to avoid vessel trauma Good flow characteristics: to optimise blood flow Kink resistant: to avoid access pressure probl

50、ems Biocompatible: to reduce complication risks Amenability to guide wire change: to optimise therapy,55,PPT學(xué)習(xí)交流,Side-by-Side Polyurethane Catheters,Copyright 2015 NIKKISO Co., LTD. All rights reserved.,56,PPT學(xué)習(xí)交流,Coaxial Polyurethane Catheters,Copyright 2015 NIKKISO Co., LTD. All rights reserved.,57,PPT學(xué)習(xí)交流,Triple lumen Catheters,Copyright 2015 NIKKISO Co., LTD. All rights reserved.,58,PPT學(xué)習(xí)交流,Silicone Catheters,Copyright 2015 NIKKISO Co., LTD. All rights reserved.,59,PPT學(xué)習(xí)交流,Reversing the Lines,Copyright 2015 NIKKISO Co., LTD. All rights reserved.,1 Lewing