血液净化原理,模式及治疗的选择.pptx

1、Tips for improving filter life,Aquarius System,Copyright 2015 NIKKISO Co., LTD. All rights reserved.,PM-0063-11/2015-1,肾脏替代治疗“的内容,肾脏替代治疗的基本内容滤器的选择抗凝剂的应用,3,CRRT命名的发展,CRRT： Continuous renal replacement therapy（连续肾脏替代治疗）ICBP: Intensive care blood purification（重症血液净化）CBP： Continuous Blood purification （

2、连续血液净化）MOST：Multi Organ Support Therapy （多脏器支持疗法）,4,CRRT 的特点和优越性,CRRT是缓慢、连续排除水分，模拟尿的排泄方式。更符合生理状态，能较好地维护血流动力学稳定；容量波动小；溶质清除率高；有利于营养改善及能清除细胞因子，从而改善危重ARF患者的预后，更好的血液动力学稳定性 更好的溶液控制能力和清除多余水分 累积的更好溶质清除性 维持尿排泄并保存残余肾功能 清除炎症介质 改善营养支持,5,CRRT的分类,SCUF-缓慢连续超滤CAVH-连续动静脉血液滤过CVVH-连续静静脉血液滤过HVHF高容量血液滤过CAVHD-连续动静脉血液透析CV

3、VHD-连续静静脉血液透析CVVHFD连续静静脉高通量透析CAVHDF-连续动静静脉血液透析滤过CVVHDF-连续静静脉血液透析滤过MPS- 血浆置换HP- 血液灌流和免疫吸附CRRT 以一种更符合机体生理特性的方式，连续地清除机体多余的水分和毒素，调节酸碱和电解质的平衡，来有效地维持机体内环境的稳定。不单用于急性肾衰，还是救治许多危重病症的有力辅助手段。,6,原理与机制,弥散,对流,吸附,500,5000,50000,Solute Classes by Molecular Weight,Daltons,Jean-Michel Lannoy Nikkiso ABP Director,8,炎症介

4、质的特征,Jean-Michel Lannoy Nikkiso ABP Director,9,炎症介质的特征,7/18/2018,10,PSHF系列滤器筛选系数/高截留分子量,如何选择血滤器 ？,Jean-Michel Lannoy Nikkiso ABP Director,11,Molecular Weights （分子的重量或分子量的大小）,12,Copyright 2015 NIKKISO Co., LTD. All rights reserved.,Ashley et all. The Renal Drug Handbook, 2nd Ed. 2004, Medical Press,

5、Abingdon, UK. ISBN: 1857758730,New functional membrane with defined larger pore size,HCO membrane, 0,01 m, 12h) using heparin Appropriately trained nursing staff available,Contra-indications to RCA in pilot,Requirement for systemic anticoagulant (other than prophylaxis)Chronic Liver Disease - Childs

6、 B or CAcute Liver Injury with INR 2 or Lactate 4mol/LPost-hepatic resectionSevere shock: Noradrenaline 0.5mcg/kg/min and/or Lactate 4mol/LArterial Blood Ionized Calcium 7.5 or HCO3- 40mmol/L at commencement of RCASerum Sodium 160 at commencement of RCAUncontrolled hyperglycaemia 6U/h InsulinIBW 90k

7、g,35ml/kg/h CVVH RCA Protocol,All patients will start at 35ml/kg/h unless directed by physicianDose includes citrate volume pre-filterFiltration Ratio is 20%Pre-filter citrate concentration will be 2.8mmol/L,Protocol 1,Calcium Replacement,Accusol replacement solution contains 1.75mmol/L Calcium whic

8、h will provide most or all of the Calcium replacementA 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 onlyInfusion rate 0-175

9、ml/h,Initial Calcium Rate,Then check arterial Cai in 1h,Adjusting Calcium Infusion,* Likely to change to check in 6h in final protocol,* Likely to change to check in 6h in final protocol,Metabolic AlkalosisMonitor pH and Bicarbonate 3 hly*,* Likely to change to check in 6h in final protocol,Step 2:

10、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 settings to Protocol 2 (25ml/kg/h) below and continue

11、 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,How it works,Jean-Michel Lannoy Nikkiso ABP Director,44,THANKS!,7/18/2018,45,Indications for Citrate Anticoagulation,Requiring RRT within the ICU (eit

12、her new or on-going treatment) for conventional Renal indicationsConsidered by the treating Physician to have a contraindication to heparin anticoagulation Appropriately trained nursing staff available,8Palsson R ,Niles JL, Regional citrate anticoagulation in continuous venovenous hemofiltration in

13、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: 147-153,Copyright 2015 NIKKISO Co., LTD. A

14、ll rights reserved.,Contraindications,Chronic Liver Disease - Childs B or CAcute Liver Injury with INR 2 or Lactate 4mol/LPost-hepatic resectionSevere shock: Noradrenaline 0.5mcg/kg/min and/or Lactate 4mol/LArterial Blood Ionized Calcium 7.5 or HCO3- 40mmol/L at commencement of RCAReduction of requi

15、rements for systemic anticoagulant (other than prophylaxis)Serum Sodium 160 at commencement of RCAUncontrolled hyperglycaemia 6U/h InsulinIBW 90kgCitrate intoleranceClinical situation where citrate metabolism becomes uncertain.,Copyright 2015 NIKKISO Co., LTD. All rights reserved.,10Prowle et al. Se

16、rvice Development Plan and Protocol for Regional Citrate Anticoagulation , The Royal London Hospital,Therapy monitoring,Ionised Calcium: Ionized calcium is a measure of free calcium. After hemofilter typically 0.25 - 0.35 mmol/l From patient typically 1.05 - 1.3 mmol/lTotal Calcium: Total calcium in

17、cludes both protein-bound and free calcium. Total Calcium (from patient) typically less than 2.5 mmol/lAcid/base monitoring: Systemic pH will be monitored 3-6hrly.Glucose monitoring: Blood glucose monitored for hyperglycaemia 3-6hrlyElectrolyte monitoring: Levels to be monitored 3-6hrly.Fluid balanc

18、e monitoring.Any other clinical signs?,Copyright 2015 NIKKISO Co., LTD. All rights reserved.,Optimize Vascular Access,Consider using a high flow silicone vascular access catheter that does not have “kink memory” , and with an appropriate length for the chosen site. Avoid attaching the Aquarius to a

19、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 of the catheter 90 so that the holes on the access lumen are facing the flow of blood, not

20、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 dehydrated, there may be poor flow through the catheter which will encourage clotting.,49

21、,Copyright 2015 NIKKISO Co., LTD. All rights reserved.,Optimize Anticoagulation,High return pressure is one sign of under anti-coagulation. The blood pump wants to push the blood through the return chamber where partially formed blood clots may increase in size, making it difficult for the blood to

22、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 increasing the proportion of pre-dilution if anticoagulation adjustment is not indicated. For example: a

23、ltering 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 small loss in clearance, easily adjusted by using the Renal Dose display.,50,Copyright 2015 NIKKISO Co

24、., LTD. All rights reserved.,The effect of blood pump speed,51,Copyright 2015 NIKKISO Co., LTD. All rights reserved.,Filtrate removed is a percentage of total flow through the filter fibres.Why is the total blood flow important?With a faster blood pump speed, the total flow is increased and effects

25、of haemoconcentration are reduced.Increasing blood flow gives a reduced filtration ratio which may slow filter clogging and extend filter lifespan.,The effect of Pre-dilution,52,Copyright 2015 NIKKISO Co., LTD. All rights reserved.,Filtrate removed is a percentage of total flow through the filter fi

26、bres.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 reduced.An improved filtration fraction may slow filter clogging and extend filter lifespan.,Considerations,53,Copyrig

27、ht 2015 NIKKISO Co., LTD. All rights reserved.,Diameter, length and types of catheters (II)Type: Material featuresSilicone elastomer catheters have lower thrombogenicity and better flexibility.Biocompatible and kink resistanceConform to vessel anatomy, therefore reduce risk of traumaDiameter and blo

28、od flow:11 French : 250-300 ml/min Blood Flow13.5 French : 450-500 ml/min Blood FlowRecirculation- up to 20%Especially if femoral access is less than 20 cmAvoid reverse AV connection,Patient Preparation,54,Copyright 2015 NIKKISO Co., LTD. All rights reserved.,Patient body statusCoagulation and Intra

29、vascular fillingMobility influencesPresence of other central linesInfluences on catheter choiceClinician choiceAvailability of ultrasound guidanceAssessment of catheter patencyConnection techniquesSpecial circumstances,Catheter Characteristics,55,Copyright 2015 NIKKISO Co., LTD. All rights reserved.,