血液凈化原理,模式及治療的選擇ppt精選課件

Tipsforimprovingfilterlife,AquariusSystem,Copyright2015NIKKISOCo.,LTD.Allrightsreserved.,PM-0063-11/2015-1,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,3,CRRT命名的發(fā)展,CRRT：Continuousrenalreplacementtherapy（連續(xù)腎臟替代治療）ICBP:Intensivecarebloodpurification（重癥血液凈化）CBP：ContinuousBloodpurification（連續(xù)血液凈化）MOST：MultiOrganSupportTherapy（多臟器支持療法）,4,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(yíng)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(yíng)養(yǎng)支持,5,CRRT的分類,SCUF-緩慢連續(xù)超濾CAVH-連續(xù)動(dòng)靜脈血液濾過(guò)CVVH-連續(xù)靜靜脈血液濾過(guò)HVHF高容量血液濾過(guò)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(guò)CVVHDF-連續(xù)靜靜脈血液透析濾過(guò)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(lái)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。,6,原理與機(jī)制,彌散,對(duì)流,吸附,500,5000,50000,SoluteClassesbyMolecularWeight,Daltons,.,8,炎癥介質(zhì)的特征,.,9,炎癥介質(zhì)的特征,10,PSHF系列濾器篩選系數(shù)/高截留分子量,.,11,如何選擇血濾器？,12,MolecularWeights（分子的重量或分子量的大?。?Copyright2015NIKKISOCo.,LTD.Allrightsreserved.,Ashleyetall.TheRenalDrugHandbook,2ndEd.2004,MedicalPress,Abingdon,UK.ISBN:1857758730,Newfunctionalmembranewithdefinedlargerporesize,HCOmembrane,2orLactate4mol/LPost-hepaticresectionSevereshock:Noradrenaline0.5mcg/kg/minand/orLactate4mol/LArterialBloodIonizedCalcium7.5orHCO3-40mmol/LatcommencementofRCASerumSodium160atcommencementofRCAUncontrolledhyperglycaemia6U/hInsulinIBW90kg,35ml/kg/hCVVHRCAProtocol,Allpatientswillstartat35ml/kg/hunlessdirectedbyphysicianDoseincludescitratevolumepre-filterFiltrationRatiois20%Pre-filtercitrateconcentrationwillbe2.8mmol/L,Protocol1,CalciumReplacement,Accusolreplacementsolutioncontains1.75mmol/LCalciumwhichwillprovidemostoralloftheCalciumreplacementA10mmol/LCalciumChloridesolutionwillbeusedforadditionalCalciumreplacementifrequired:1x10mlampuleofCalciumChloride(10mmol)in990mlNormalSalinegivenviaintegratedCalciumPumponAquarius-CitratedeviceonlyInfusionrate0-175ml/h,InitialCalciumRate,ThencheckarterialCaiin1h,AdjustingCalciumInfusion,*Likelytochangetocheckin6hinfinalprotocol,*Likelytochangetocheckin6hinfinalprotocol,MetabolicAlkalosisMonitorpHandBicarbonate3hly*,*Likelytochangetocheckin6hinfinalprotocol,Step2:ifpH7.5orHCO3-40mmol/LonProtocol2changesettingstoProtocol3(25ml/kg/hwithincreasedfiltrationratio)belowandmonitorevery3h*,Step3:ifstillpH40mmol/LDISCONTINUERCA,Step1:ifpH7.5orHCO3-40mmol/LonProtocol1ChangethesettingstoProtocol2(25ml/kg/h)belowandcontinuetomonitorevery3h*.(Protocol2mayalsobeselectedfordosereduction),Protocol2,Protocol3,*Likelytochangetocheckin6hinfinalprotocol,Howitworks,.,44,45,THANKS!,IndicationsforCitrateAnticoagulation,RequiringRRTwithintheICU(eitherneworon-goingtreatment)forconventionalRenalindicationsConsideredbythetreatingPhysiciantohaveacontraindicationtoheparinanticoagulationAppropriatelytrainednursingstaffavailable,8PalssonR,NilesJL,RegionalcitrateanticoagulationincontinuousvenovenoushemofiltrationincriticallyillpatientswithahighriskofbleedingKidneyInt1999,55:1991-1997.9FlaniganMetal.Reducingthehemorrhagiccomplicationsofhemodialysis:Acontrolledcomparisonoflow-doseheparinandcitrateanticoagulation.AmJKidneyDis1987;2:147-153,Copyright2015NIKKISOCo.,LTD.Allrightsreserved.,Contraindications,ChronicLiverDisease-ChildsBorCAcuteLiverInjurywithINR2orLactate4mol/LPost-hepaticresectionSevereshock:Noradrenaline0.5mcg/kg/minand/orLactate4mol/LArterialBloodIonizedCalcium7.5orHCO3-40mmol/LatcommencementofRCAReductionofrequirementsforsystemicanticoagulant(otherthanprophylaxis)SerumSodium160atcommencementofRCAUncontrolledhyperglycaemia6U/hInsulinIBW90kgCitrateintoleranceClinicalsituationwherecitratemetabolismbecomesuncertain.,Copyright2015NIKKISOCo.,LTD.Allrightsreserved.,10Prowleetal.ServiceDevelopmentPlanandProtocolforRegionalCitrateAnticoagulation,TheRoyalLondonHospital,Therapymonitoring,IonisedCalcium:Ionizedcalciumisameasureoffreecalcium.Afterhemofiltertypically0.25-0.35mmol/lFrompatienttypically1.05-1.3mmol/lTotalCalcium:Totalcalciumincludesbothprotein-boundandfreecalcium.TotalCalcium(frompatient)typicallylessthan2.5mmol/lAcid/basemonitoring:SystemicpHwillbemonitored3-6hrly.Glucosemonitoring:Bloodglucosemonitoredforhyperglycaemia3-6hrlyElectrolytemonitoring:Levelstobemonitored3-6hrly.Fluidbalancemonitoring.Anyotherclinicalsigns?,Copyright2015NIKKISOCo.,LTD.Allrightsreserved.,49,OptimizeVascularAccess,Considerusingahighflowsiliconevascularaccesscatheterthatdoesnothave“kinkmemory”,andwithanappropriatelengthforthechosensite.AvoidattachingtheAquariustoacatheterwithpoorflow.Forexample,beingabletowithdraw20mlofbloodin6secondsor10mlofbloodin3secondswithouthesitancyorinterruptionmayhelpacatheterassessment.Considerrotatingthehubofthecatheter90sothattheholesontheaccesslumenarefacingtheflowofblood,notagainstthevesselwall(youmayneedtomomentarilystopthebloodpumptodothis).Considerthepatientsintravascularvolume.Eventhoughthepatientmaybefluidoverloaded,iftheirintravascularspaceisdehydrated,theremaybepoorflowthroughthecatheterwhichwillencourageclotting.,Copyright2015NIKKISOCo.,LTD.Allrightsreserved.,50,OptimizeAnticoagulation,Highreturnpressureisonesignofunderanti-coagulation.Thebloodpumpwantstopushthebloodthroughthereturnchamberwherepartiallyformedbloodclotsmayincreaseinsize,makingitdifficultforthebloodtosqueezethrough.Aroutineofregularobservation,followedbyacheckofthepatientclotting,andadjustmentofanticoagulantwhereindicated,maypreventearlyreturnchamberclotting.Considerincreasingtheproportionofpre-dilutionifanticoagulationadjustmentisnotindicated.Forexample:alteringthepre-dilutionto90%andreducingpost-dilutionto10%maythinthebloodpassingthroughthefilterandreducetheeffectsofhaemoconcentration.Againinlifespanmaybeoffsetbyasmalllossinclearance,easilyadjustedbyusingtheRenalDosedisplay.,Copyright2015NIKKISOCo.,LTD.Allrightsreserved.,51,Theeffectofbloodpumpspeed,Copyright2015NIKKISOCo.,LTD.Allrightsreserved.,Filtrateremovedisapercentageoftotalflowthroughthefilterfibres.Whyisthetotalbloodflowimportant?Withafasterbloodpumpspeed,thetotalflowisincreasedandeffectsofhaemoconcentrationarereduced.Increasingbloodflowgivesareducedfiltrationratiowhichmayslowfiltercloggingandextendfilterlifespan.,52,TheeffectofPre-dilution,Copyright2015NIKKISOCo.,LTD.Allrightsreserved.,Filtrateremovedisapercentageoftotalflowthroughthefilterfibres.Theproportionofpredilutionflowmaybeadjustedtooptimisetreatment.Withagreaterproportionofpredilution,thefiltrationfractionandeffectsofhaemoconcentrationarereduced.Animprovedfiltrationfractionmayslowfiltercloggingandextendfilterlifespan.,53,Considerations,Copyright2015NIKKISOCo.,LTD.Allrightsreserved.,Diameter,lengthandtypesofcatheters(II)Type:MaterialfeaturesSiliconeelastomercathetershavelowerthrombogenicityandbetterflexibility.BiocompatibleandkinkresistanceConformtovesselanatomy,thereforereduceriskoftraumaDiameterandbloodflow:11French:250-300ml/minBloodFlow13.5French:450-500ml/minBloodFlowRecirculation-upto20%Especiallyiffemoralaccessislessthan20cmAvoidreverseAVconnection,54,PatientPreparation,Copyright2015NIKKISOCo.,LTD.Allrightsreserved.,PatientbodystatusCoagulationandIntravascularfillingMobilityinfluencesPresenceofothercentrallinesInfluencesoncatheterchoiceClinicianchoiceAvailabilityofultrasoundguidanceAssessmentofcatheterpatencyConnectiontechniquesSpecialcircumstances,55,CatheterCharacteristics,Copyright2015NIKKISOCo.,LTD.Allrightsreserved.,Easeofinsertion:toavoidvesseltraumaGoodflowcharacteristics:tooptimisebloodflowKinkresistant:toavoidaccesspressureproblemsBiocompatible:toreducecomplicationrisksAmenabilitytoguidewirechange:tooptimisetherapy,56,Side-by-SidePolyurethaneCatheters,Copyright2015NIKKISOCo.,LTD.Allrightsreserved.,57,CoaxialPolyurethaneCatheters,Copyright2015NIKKISOCo.,LTD.Allrightsreserved.,58,TriplelumenCatheters,Copyright2015NIKKISOCo.,LTD.Allrightsreserved.,59,SiliconeCatheters,Copyright2015NIKKISOCo.,LTD.Allrightsreserved.,60,ReversingtheLines,Copyright2015NIKKISOCo.,LTD.Allrightsreserved.,1LewingtonA,KanagasundaramS.AcuteKidneyInjury.RenalAssociationguidelines:Guideline8.1AKI:VascularaccessforRRT.Guideline8.2,Page45of59,Para3Rationalefor8.1-8.9lines7-9/Clinical/GuidelinesSection/AcuteKidneyInjury.aspx,61,VascularAccess,Copyright2015NIKKISOCo.,LTD.Allrightsreserved.,VascularAccessiscontinuouslytestedduringCRRTtreatmentPracticalunderstandingaboutvascularaccessisnecessaryforoptimaltreatmentCathetersite,size,typeandpatientpreparationmaybeconsideredInadequaciesinvascularaccessmaylimitdeliveredtherapyTroubleshootingchoices,62,VascularAccessTro