透析器復(fù)用經(jīng)驗(yàn)交流課件

透析器復(fù)用經(jīng)驗(yàn)交流Dialyserreuse提要ContentsⅠ

透析器復(fù)用Reason,disputes,methodsofreuse復(fù)用的原因和爭(zhēng)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(yàn)experienceofourcustomerⅢ復(fù)用中的可能問(wèn)題Potentialproblems透析器復(fù)用1復(fù)用的原因和爭(zhēng)議及現(xiàn)狀Reason,disputesa.復(fù)用的支持和反對(duì)意見Prosandconsb.復(fù)用現(xiàn)狀What’son2復(fù)用的方法Methodsa.自動(dòng)復(fù)用Automaticb.手工復(fù)用Manualc.兩者的比較Comparison

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(lái)的可能后果malpracticeofdisinfection殘余消毒劑帶來(lái)的不利影響adversereactionofdisinfectant血液交叉感染/對(duì)濾器處理人員的危險(xiǎn)crossinfectiona可能的不利因素consNationalKidneyFoundationreportondialyzerreuse.TaskForceonReuseofDialyzers,CouncilonDialysis,NationalKidneyFoundation.AmJKidneyDis.1997

美國(guó)腎病基金會(huì)報(bào)告

TheNationalKidneyFoundationtakesnopositionfororagainstdialyzerreuse.Theprincipalreasonforthepracticeofreuseiseconomical.

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

undertakenwitheachpatient.復(fù)用的考慮應(yīng)個(gè)體化DialyzersshouldnotbereprocessedfrompatientswhohavetestedpositiveforhepatitisBsurfaceantigen.HBV陽(yáng)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(duì)后續(xù)使用有很大影響Theeffectofdialyzerreuseondialysisdelivery.

ShermanRA,CodyRP,RogersME,SolanchickJC

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

濾器復(fù)用對(duì)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(duì)清除產(chǎn)生明顯負(fù)面的影響Ofthe23centersusingformalin-basedreprocessing,anaveragedifferenceof>or=0.12(mean,0.17)inKt/Vbetweenhighandlowreusetreatmentswasseenin10centers.Dialyzerreprocessingsignificantlyimpairsdialysisdelivery,aneffectthatmayberelatedtothemethodsandproceduresinindividualdialysiscenters.復(fù)用過(guò)程對(duì)治療效果有極大影響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(gè)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(jī)構(gòu)性質(zhì)有關(guān)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(guó)；尚無(wú)嚴(yán)格法規(guī)StatusofdialyserreuseinKorea.

ChoHKChoHK,ShinGT,KimH

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

DepartmentofNephrology,AjouUniversitySchoolofMedicine,Suwon,Korea.

韓國(guó)的復(fù)用

2.復(fù)用方法methodsa.自動(dòng)復(fù)用automaticreuse標(biāo)記labeling自動(dòng)沖洗rinse自動(dòng)安全測(cè)試safetytest自動(dòng)消毒液灌注disinfection科學(xué)化管理（條碼識(shí)別）managementc.兩者的比較comparison自動(dòng)復(fù)用automatic對(duì)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(shí)的個(gè)體差異universalinpractice節(jié)約了人力和時(shí)間用于病員護(hù)理savingofmanpower保證復(fù)用質(zhì)量betterQC手工復(fù)用manual節(jié)約成本，機(jī)動(dòng)靈活costeffectiveforsmallscalepractice,flexibleB.Braun客戶使用Polysulfone的經(jīng)驗(yàn)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(huì)醫(yī)院血透中心7馬來(lái)西亞用戶經(jīng)驗(yàn)上海華山醫(yī)院血透中心目前有血透機(jī)40臺(tái)貝朗機(jī)器12臺(tái)，其中Advance6臺(tái)，HDFonline機(jī)4臺(tái)，Dialog+2臺(tái)固定透析病員數(shù)約150人1.下機(jī)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(shí)，用溫水沖洗，低溫水會(huì)促使血液凝結(jié)，使凝塊更難沖洗。沖洗時(shí)逆血流方向進(jìn)行，即濾器內(nèi)由靜脈端向動(dòng)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(guò)氧乙酸浸泡，直至目測(cè)洗出液變清。將過(guò)氧乙酸注入透析液室及血室，依靠彌散來(lái)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(duì)所用消毒劑的濃度進(jìn)行檢查，明確是否使用了適當(dāng)?shù)臐舛取Ｔ俅螞_洗直至洗出液清亮2.安全檢測(cè)safetytest血室容積試驗(yàn)，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(duì)下次的透析產(chǎn)生影響破膜試驗(yàn)(MembraneRuptureTest)將血路一端堵死，使用250-270mmHg的壓力在另一端進(jìn)行檢測(cè)，沒有泄漏為準(zhǔn)不能通過(guò)兩項(xiàng)試驗(yàn)者應(yīng)棄去。(Discardforthosecannotpassthetest)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(shí)用于循環(huán)管路。5.預(yù)充及循環(huán)管路primingandcirculation預(yù)充血泵速度為150ml/min。過(guò)快的預(yù)充速度會(huì)在管路中導(dǎo)致湍流，產(chǎn)生小氣泡，對(duì)以后的凝血起重要的促進(jìn)作用。預(yù)充時(shí)仔細(xì)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。上海浦東新區(qū)人民醫(yī)院腎臟科

People’sHospital,PuDongNewArea,Shanghai血透機(jī)20臺(tái)Dialogadvance單泵6臺(tái)，雙泵2臺(tái)，plus4臺(tái)，Secura2臺(tái)透析病員數(shù)約85人反滲水沖洗，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38臺(tái)透析機(jī)28臺(tái)B.Braun機(jī)器90個(gè)病人四川大學(xué)華西醫(yī)院血透中心

WesternChinaHospital,SichuanUniversity四川大學(xué)華西醫(yī)院血透中心

WesternChinaHospital,SichuanUniversity反滲水沖洗至目測(cè)洗出液清晰1%次氯酸鈉透析器膜內(nèi)短時(shí)灌注兩次，除蛋白，去除沉積物過(guò)氧乙酸浸泡消毒，濃度至少0.5%以上,0.8%兩小時(shí)可復(fù)用四川大學(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

深圳紅會(huì)醫(yī)院血透中心

HongHuiHospital,Shengzhen血透機(jī)12臺(tái)貝朗機(jī)器9臺(tái)透析病員數(shù)約60人深圳紅會(huì)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(jī)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。馬來(lái)西亞用戶使用方法

MalaysianExperience40%人工復(fù)用,60%自動(dòng)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(guò)氧乙酸/3.5~4.5%福爾馬林消毒；自動(dòng)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(cè)殘余Renalin濃度肝素:2000IU首劑,1000IU追加/3hrs可隨病人體重調(diào)整

復(fù)用中的可能問(wèn)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不適當(dāng)?shù)氖褂孟緞?huì)導(dǎo)致透析膜的損傷，在膜上形成毛糙面，有利于蛋白及血細(xì)胞的沉積，并進(jìn)而導(dǎo)致凝血。Improperuseofdisinfectants推薦使用3.5%Renalin，在美國(guó)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(qiáng)大氧化作用對(duì)膜可能產(chǎn)生巨大的傷害。TheeffectofbleachDialyzer-dependentchangesinsoluteandwaterpermeabilitywithbleachreprocessing.

ScottMK,MuellerBA,SowinskiKM,ClarkWR

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

（漂白劑對(duì)復(fù)用濾器清除率影響）Wecomparedtheeffectsofautomatedbleach/formaldehydereprocessingonsoluteandhydraulicpermeabilityforcellulosetriacetate(CT190)andpolysulfone(F80B)dialyzersusinganinvitromodel.Dialyzerswerestudiedafterinitialbloodexposure(R0)andafter1(R1),5(R5),10(R10),and15(R15)reusecycles.對(duì)比自動(dòng)復(fù)用時(shí)漂白劑對(duì)兩種濾器的影響Urea,creatinine,andvancomycinclearancesandsievingcoefficients(SC)sdidnotsignific