血液凈化原理,模式及治療的選擇

TipsforimprovingfilterlifeAquariusSystemCopyright?2015NIKKISOCo.,LTD.Allrightsreserved.PM-0063-11/2015-1

01腎臟替代治療的基本內(nèi)容02濾器的選擇03抗凝劑的應(yīng)用腎臟替代治療“的內(nèi)容CRRT命名的發(fā)展3CBP：ContinuousBloodpurification（連續(xù)血液凈化）CRRT：Continuousrenalreplacementtherapy（連續(xù)腎臟替代治療）ICBP:Intensivecarebloodpurification（重癥血液凈化）MOST：MultiOrganSupportTherapy（多臟器支持療法）CRRT的特點(diǎn)和優(yōu)越性4CRRT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)?。蝗苜|(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CRRT的分類5SCUF-緩慢連續(xù)超濾CAVH-連續(xù)動(dòng)靜脈血液濾過CVVH-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。原理與機(jī)制6彌散對(duì)流吸附500005000500010203040506SoluteClassesbyMolecularWeightDaltons?InflammatoryMediators(1,200-50,000)“small”“middle”“l(fā)arge”炎癥介質(zhì)的特征Jean-MichelLannoyNikkisoABPDirector8介質(zhì)分子量C3a2500C5a2800TNF-a17500x3C5a2800IL-62125000IL-1Ra14000IL-89000LPS100000FactorD2300023000炎癥介質(zhì)的特征介質(zhì)蛋白結(jié)合分子量C3ano2500C5ano2800TNF-a部分17500x3STNRFIyes55000STNRFIIyes75000IL-621yes25000IL-1Rano14000IL-lano89000PAF部分450FactorDyes23000PSHF系列濾器篩選系數(shù)/高截留分子量如何選擇血濾器？MolecularWeights（分子的重量或分子量的大?。㎞ewfunctionalmembranewithdefinedlargerporesizeHCOmembrane

<0,01μm

<0,02μm

~0,09μm

~0,30μm:porediameterhighfluxhighcut-off*proteinseparationmembraneplasmaseparationmembraneVariationofmembraneporesizeElectronmicrographsofinnermembranesurfacesievingcoefficient100100010000100000100000000.20.40.60.81Molecularweight[D]ClassicalFilter30kDhumankidneyhighcut-offHighCut-OffHemofilterSievingCoefficientAsievingcoefficientisthemeasureofhoweasilyasubstancepassesfromthebloodcompartmenttothedialysatecompartmentinahaemofilter.Thus,asievingcoefficientof1.0meansthesoluteis100%filterable;i.e.inahaemofilter,thesolutewillequilibrateonbothsidesofthemembrane.So…thereturningbloodandtheeffluentbothhavethesameconcentration(50:50).Anexampleispotassium(sievingcoefficientis1.0)Asievingcoefficientof0meansthesolutedoesnotcrossthemembrane,eg.albumin.Ofcourse,thisalldependsonthemembrane,andsievingcoefficientswillvarydependingontheporesize.DEFINITION:Thecut-offpointofasoluteforanymembraneisasievingcoefficientof0.1.Thismeansthat10%ofthemoleculeswillpassand90%willnotpass.MolecularWeight[Da]StandardHighFluxHighCut-OffHF,UF=1L/h,t=2hMedian,25th-75thpercentiles)ICM(2002)28:651-655HCOMembranewithincreasedpermeabilityforinflammatorymediatorsmembranecharacteristics

Molecularweight18Ashleyetall.TheRenalDrugHandbook,2ndEd.2004,MedicalPress,Abingdon,UK.ISBN:1857758730Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.HF1200HaemofilterCut-Off55000daltonsComparisonofInterleukin-6RemovalPropertiesamongHemofiltersConsistingofVaryingMembraneMaterialsandSurfaceAreasRecentStudiesinMembrane抗凝的選擇20Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.無肝素抗凝肝素低分子肝素鈣全身抗凝局部抗凝魚精蛋白枸櫞酸積極主動(dòng)預(yù)防管路的凝血21Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.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預(yù)防濾器內(nèi)的凝血(FiltrationRatio%)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(zhǎng)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(zhǎng)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23預(yù)防濾器內(nèi)的凝血(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?2015NIKKISOCo.,LTD.Allrightsreserved.FiltrationFraction（濾過分?jǐn)?shù)）FiltrationFraction濾過分?jǐn)?shù)是

總液體通過

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%FiltrationFraction濾過分?jǐn)?shù)是

不會(huì)受到前

稀釋泵的影響FiltrationFraction濾過分?jǐn)?shù)是會(huì)受到血流速

的影響. 超濾比率FiltrationRatioFiltrationRatio是表示濾器中血液濃度增加.1理想的超濾比率在低于25%.2FiltrationRatio是受到前稀釋泵的影響.3FiltrationRatio是受到血流速的影響.4FiltrationRatioandbloodpumpspeed

Postdilution(l/h)BloodPumpSpeed(mls/min)

60(mins)=FiltrationRatio /1000

3l/hExchange

3

1

100mls/minx60mins=6=2=50%FiltrationRatio/1000

3l/hExchange

3

1

200mls/minx60mins=12=4=25%FiltrationRatio

3l/hrExchange

3

1

300mls/minx60mins=18=6=17%FiltrationRatio

肝素是如何工作的?Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.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FactorX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的壽命.5Roncoetal.Effectsofdifferentdosesincontinuousveno-venoushaemofiltrationonoutcomesofacuterenalfailure:aprospectiverandomisedtrial.Lancet.2000Jul1;356(9223):26-30肝素;優(yōu)勢(shì)和劣勢(shì)Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.容易管理和監(jiān)控ICU非常熟悉肝素抗凝.便宜.短的半衰期.肝素可以中和.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.20162015優(yōu)勢(shì):缺點(diǎn):枸櫞酸是如何工作的?Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.01040203枸櫞酸螯合了血循中的鈣.抑制了凝血ACD-A(CitrateSolution)Whatcitratebindstocalciumwhichinhibitscoagulation合適的枸櫞酸劑量30離子

Calcium50%1.1–1.3mmol/l蛋白

Calcium40%0.95–1.2mmol/l復(fù)合

Calcium10%0.1mmol/l圖表顯示鈣在血漿中的分布情況.枸櫞酸劑量考慮是

TotalCalcium(typically2.2-2.6mmol/l)andTotalMagnesium(typically1.1–1.4mmol/l).影響到選擇枸櫞酸的量

Citratedosingbetween3.3–4.0mmol/l.Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.WhatdoesthebodydowithCitrate?TherapymonitoringTheselectionandadjustmentoftherapyparameters,replacementfluidsandanticoagulantfluidsremainsaprescriptionatthephysician'sdiscretion.Achangeinanindividualprescriptionwillrequirephysicianrevieworbeclearlydefinedinalocallyapproveddocument.Tomonitorandadjustthetherapy,thefollowingtypicalparametersmaybeconsideredintheindividualizedprescriber’slocalprotocol:IonisedCalcium(afterhemofilter)typically0.25-0.35mmol/lIonisedCalcium(frompatient)typically1.05-1.3mmol/lTotalCitrate(frompatient)typicallylessthan2.5mmol/lCalciumRatio(acomparisonofCalciumdistribution)typicallylessthan2.3Acid/basemonitoringElectrolytesmonitoringFluidbalancemonitoringAquariusRegionalCitrateAnticoagulationProtocolJohnRProwleMDFRCPFFICMAdultCriticalCareUnitRoyalLondonHospitalEligibilityforRCARequiringRRTwithintheICU(eitherneworon-goingtreatment)forconventionalRenalindicationsConsideredbythetreatingPhysiciantohaveacontraindicationtoheparinanticoagulationorunabletoachieveadequatefilterlifespan(>12h)usingheparinAppropriatelytrainednursingstaffavailable010302Contra-indicationstoRCAinpilotRequirementforsystemicanticoagulant(otherthanprophylaxis)ChronicLiverDisease-ChildsBorCAcuteLiverInjurywithINR>2orLactate>4μmol/LPost-hepaticresectionSevereshock:Noradrenaline>0.5mcg/kg/minand/orLactate>4μmol/LArterialBloodIonizedCalcium<0.8μmol/LatcommencementofRCAArterialBloodpH>7.5orHCO3-

>40mmol/LatcommencementofRCASerumSodium<120or>160atcommencementofRCAUncontrolledhyperglycaemia>6U/hInsulinIBW>90kg35ml/kg/hCVVHRCAProtocolAllpatientswillstartat35ml/kg/hunlessdirectedbyphysicianDoseincludescitratevolumepre-filterFiltrationRatiois20%Pre-filtercitrateconcentrationwillbe~2.8mmol/LIBWkgPost–dilutionmL/hBloodPumpmL/minACD-A(Citrate)mL/h<50140012018050-59180015023060-69210018027070-792400200300>802700230350Protocol1CalciumReplacementAccusolreplacementsolutioncontains1.75mmol/LCalciumwhichwillprovidemostoralloftheCalciumreplacementA10mmol/LCalciumChloridesolutionwillbeusedforadditionalCalciumreplacementifrequired:1x10mlampuleofCalciumChloride(10mmol)in990mlNormalSalinegivenviaintegratedCalciumPumponAquarius-CitratedeviceonlyInfusionrate0-175ml/hInitialCalciumRateThencheckarterialCaiin1hSystemiciCaInitialrateofCaClsolution<0.8DoNOTcommenceRCAMedicalteamtoreview&correctCalcium0.8-0.975mL/h(0.75mmol/h)0.9-1.050mL/h(0.5mmol/h)>1.00mL/h(0mmol/h)Usethistable

onlywhenfirststartingRCAAdjustingCalciumInfusion[iCa]CaClinfusionadjustment(MAXIMUMRATE=175mL/hr):Recheck<0.8Doctortogive5ml,10%CaCl(3.4mmol)‘minijet’byslowIVbolusviaacentrallineimmediatelyIfCaClalreadyrunningthenincreaseinfusionby50ml/hIfstartingCaClthenstartat100ml/hIfCaClinfusionalreadyat175ml/hceaseRCA

&informICUConsultant1h0.8-0.89IfCaClalreadyrunningthenincreaseinfusionby25ml/hIfstartingCaClthenstartat75ml/hIfCaClinfusionalreadyat175ml/hceaseRCA&informICUConsultant3h0.9-1.3Nochange3h*>1.3DecreaseCaClinfusionby25ml/hIfCaClinfusionoffthenchecksystemic[iCa]in3hoursInformDoctorif[iCa]risesto>1.53h*Likelytochangetocheckin6hinfinalprotocolMonitoringBaselineABGforiCa2+&HCO3-LabBloodswithin12hforU&EMg2+TotalCa2+Aftertheonehour:ABGforiCa2+&HCO3-Thereafterevery3h*:ABGforiCa2+&HCO3-monitoring(unlessearliercheckrequiredafteradjustmentofCalciuminfusion)Aroundevery12hours:LabBloods:U&E;TotalCa2+;Mg2+

(AimMg>1mmol/L)PostFilteriCa2+(Takefromreturn-linesampleport)RecordallResultsonRCAPro-forma*Likelytochangetocheckin6hinfinalprotocol21MetabolicAlkalosisMonitorpHandBicarbonate3hly*Likelytochangetocheckin6hinfinalprotocolIBWkgPost–dilutionmL/hBloodPumpmL/minACD-A(Citrate)mL/h<50110010015050-59130011017060-69150013020070-791700140210>801900160240IBWkgPost–dilutionmL/hBloodPumpmL/minACD-A(Citrate)mL/h<50Reachedminimumbloodflowrate–DISCONTINUERCA50-59Reachedminimumbloodflowrate–DISCONTINUERCA60-69150010015070-791700120180>801900130200Step2:ifpH>7.5orHCO3->40mmol/LonProtocol2changesettingstoProtocol3(25ml/kg/hwithincreasedfiltrationratio)belowandmonitorevery3h*Protocol2Protocol3Howitworks…”45THANKS!IndicationsforCitrateAnticoagulationRequiringRRTwithintheICU(eitherneworon-goingtreatment)forconventionalRenalindicationsConsideredbythetreatingPhysiciantohaveacontraindicationtoheparinanticoagulationAppropriatelytrainednursingstaffavailable8PalssonR,NilesJL,RegionalcitrateanticoagulationincontinuousvenovenoushemofiltrationincriticallyillpatientswithahighriskofbleedingKidneyInt1999,55:1991-1997.9FlaniganMetal.Reducingthehemorrhagiccomplicationsofhemodialysis:Acontrolledcomparisonoflow-doseheparinandcitrateanticoagulation.AmJKidneyDis1987;2:147-153ContraindicationsCopyright?2015NIKKISOCo.,LTD.Allrightsreserved.ChronicLiverDisease-ChildsBorCAcuteLiverInjurywithINR>2orLactate>4μmol/LPost-hepaticresectionSevereshock:Noradrenaline>0.5mcg/kg/minand/orLactate>4μmol/LArterialBloodIonizedCalcium<0.8μmol/LatcommencementofRCAArterialBloodpH>7.5orHCO3-

>40mmol/LatcommencementofRCAReductionofrequirementsforsystemicanticoagulant(otherthanprophylaxis)SerumSodium<120or>160atcommencementofRCAUncontrolledhyperglycaemia>6U/hInsulinIBW>90kgCitrateintoleranceClinicalsituationwherecitratemetabolismbecomesuncertain.10Prowleetal.ServiceDevelopmentPlanandProtocolforRegionalCitrateAnticoagulation,TheRoyalLondonHospitalTherapymonitoringIonisedCalcium:Ionizedcalciumisameasureoffreecalcium.Afterhemofiltertypically0.25-0.35mmol/l

Frompatienttypically1.05-1.3mmol/lTotalCalcium:Totalcalciumincludesbothprotein-boundandfreecalcium.TotalCalcium(frompatient)typicallylessthan2.5mmol/lAcid/basemonitoring:SystemicpHwillbemonitored3-6hrly.Glucosemonitoring:Bloodglucosemonitoredforhyperglycaemia3-6hrlyElectrolytemonitoring:Levelstobemonitored3-6hrly.Fluidbalancemonitoring.Anyotherclinicalsigns?OptimizeVascularAccessConsiderusingahighflowsiliconevascularaccesscatheterthatdoesnothave“kinkmemory”,andwithanappropriatelengthforthechosensite.AvoidattachingtheAquariustoacatheterwithpoorflow.Forexample,beingabletowithdraw20mlofbloodin6secondsor10mlofbloodin3secondswithouthesitancyorinterruptionmayhelpacatheterassessment.Considerrotatingthehubofthecatheter90°sothattheholesontheaccesslumenarefacingtheflowofblood,notagainstthevesselwall(youmayneedtomomentarilystopthebloodpumptodothis).Considerthepatientsintravascularvolume.Eventhoughthepatientmaybefluidoverloaded,iftheirintravascularspaceisdehydrated,theremaybepoorflowthroughthecatheterwhichwillencourageclotting.OptimizeAnticoagulationHighreturnpressureisonesignofunderanti-coagulation.Thebloodpumpwantstopushthebloodthroughthereturnchamberwherepartiallyformedbloodclotsmayincreaseinsize,makingitdifficultforthebloodtosqueezethrough.Aroutineofregularobservation,followedbyacheckofthepatientclotting,andadjustmentofanticoagulantwhereindicated,maypreventearlyreturnchamberclotting.Considerincreasingtheproportionofpre-dilutionifanticoagulationadjustmentisnotindicated.Forexample:alteringthepre-dilutionto90%andreducingpost-dilutionto10%maythinthebloodpassingthroughthefilterandreducetheeffectsofhaemoconcentration.Againinlifespanmaybeoffsetbyasmalllossinclearance,easilyadjustedbyusingtheRenalDosedisplay.TheeffectofbloodpumpspeedFiltrateremovedisapercentageoftotalflowthroughthefilterfibres.Whyisthetotalbloodflowimportant?Withafasterbloodpumpspeed,thetotalflowisincreasedandeffectsofhaemoconcentrationarereduced.Increasingbloodflowgivesareducedfiltrationratiowhichmayslowfiltercloggingandextendfilterlifespan.TheeffectofPre-dilutionFiltrateremovedisapercentageoftotalflowthroughthefilterfibres.Theproportionofpredilutionflowmaybeadjustedtooptimisetreatment.Withagreaterproportionofpredilution,thefiltrationfractionandeffectsofhaemoconcentrationarereduced.Animprovedfiltrationfractionmayslowfiltercloggingandextendfilterlifespan.Considerations53Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.Diameter,lengthandtypesofcatheters(II)Type:MaterialfeaturesSiliconeelastomercathetershavelowerthrombogenicityandbetterflexibility.BiocompatibleandkinkresistanceConformtovesselanatomy,thereforereduceriskoftraumaDiameterandbloodflow:11French:250-300ml/minBloodFlow13.5French:450-500ml/minBloodFlowRecirculation-upto20%Especiallyiffemoralaccessislessthan20cmAvoidreverseAVconnectionPatientPreparationPatientbodystatus