血液净化原理-模式及治疗的选择.ppt

,单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,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,（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,CVVHD-,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,Inflammatory,Mediators(1,200-50,000),“small”,“middle”,“large”,Jean-Michel Lannoy Nikkiso ABP Director,8,炎症介质的特征,介质,分子量,C3a,2500,C5a,2800,TNF-a,17500 x3,C5a,2800,IL-621,25000,IL-1Ra,14000,IL-,89000,LPS,100000,Factor D 23000,23000,Jean-Michel Lannoy Nikkiso ABP Director,9,炎症介质的特征,介质,蛋白结合,分子量,C3a,no,2500,C5a,no,2800,TNF-a,部分,17500 x3,STNRFI,yes,55000,STNRFI,I,yes,75000,IL-621,yes,25000,IL-1Ra,no,14000,IL-la,no,89000,PAF,部分,450,Factor D,yes,23000,12/11/2024,10,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,2,nd,Ed.2004,Medical Press,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 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 HCO,3,-,40mmol/L at commencement of RCA,Serum Sodium 160 at commencement of RCA,Uncontrolled hyperglycaemia,6U/h,Insulin,IBW 90kg,35ml,/kg/h CVVH RCA Protocol,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,IBW,kg,Post dilution,mL/h,Blood Pump,mL/min,ACD-A(Citrate),mL/h,80,2700,230,350,Protocol 1,Calcium Replacement,Accusol replacement solution contains 1.75mmol/L Calcium which will provide,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,C,alcium Chloride(10mmol)in 990ml Normal Saline given via integrated Calcium Pump on Aquarius-Citrate device only,Infusion rate 0-175ml/h,Initial Calcium Rate,Then check arterial Ca,i,in 1h,Systemic iCa,Initial,rate of CaCl solution,1.0,0mL/h(0mmol/h),Use this table,only,when first starting RCA,Adjusting Calcium Infusion,iCa,CaCl infusion adjustment(MAXIMUM RATE=175mL/hr):,Recheck,1.3,Decrease CaCl infusion by,25ml/h,If CaCl infusion off then check systemic iCa in 3 hours,Inform Doctor if iCa rises to 1.5,3h,*Likely to change to check in 6h in final protocol,Monitoring,Baseline ABG,for,iCa,2+,&HCO,3,-,Lab Bloods,within 12h for U&E Mg,2+,Total Ca,2+,After the one hour:,ABG for iCa,2+,&HCO,3,-,Thereafter every 3h*:,ABG for,iCa,2+,&HCO,3,-,monitoring(unless earlier check required after adjustment of Calcium infusion),Around every 12 hours:,Lab,Bloods:U Total,Ca,2+,;Mg,2+,(,Aim Mg 1mmol/L),Post Filter iCa,2+,(Take from return-line sample port),Record all Results on RCA Pro-forma,*Likely to change to check in 6h in final protocol,Start 35ml/kg/h CVVH,If pH 7.5 or HCO,3,-,40,Reduce to 25ml/kg/h,If pH 7.5 or HCO,3,-,40,Use 25ml/kg/h with 25%FR,If pH 7.5 or HCO,3,-,40,Stop RCA,Metabolic Alkalosis,Monitor pH and Bicarbonate 3 hly*,*Likely to change to check in 6h in final protocol,IBW,kg,Post dilution,mL,/h,Blood Pump,mL/min,ACD-A(Citrate),mL/h,80,1900,160,240,IBW,kg,Post dilution,mL/h,Blood Pump,mL/min,ACD-A(Citrate),mL/h,80,1900,130,200,Step 2:,if pH7.5,or HCO,3,-,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 HCO,3,-,40mmol/L on,Protocol,1,Change the settings 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,How it works,Jean-Michel Lannoy Nikkiso ABP Director,44,THANKS!,12/11/2024,45,Indications for Citrate Anticoagulation,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,8,Palsson,R,Niles JL,Regional citrate anticoagulation in continuous venovenous hemofiltration in critically ill patients with a high risk of bleeding,Kidney,Int 1999,55:1991-1997.,9,Flanigan,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.All rights reserved,.,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 HCO,3,-,40mmol/L at commencement of RCA,Reduction of r,equirements 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 2015 NIKKISO Co.,LTD.All rights reserved,.,10,Prowle et al.,Service,Development Plan and Protocol for Regional Citrate Anticoagulation,The Royal London Hospital,Therapy monitoring,I,onised Calcium:,Ionized,calcium is a measure of free calcium.,A,fter hemofilter typically 0.25-0.35 mmol/l,From patient typically 1.05-1.3 mmol/l,T,otal 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:,B,lood,glucose monitored for hyperglycaemia,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,.,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,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 against the vessel wall(,you may,need to momentarily stop the blood pump to do this).,C,onsider,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,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 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: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 small loss in clearance,easily adjusted by using the Renal Dose display.,50,Copyright 2015 NIKKISO Co.,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 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 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 reduced.,An improved filtration,fraction,may slow filter clogging and extend filter lifespan.,Considerations,53,Copyright 2015 NIKKISO Co.,LTD.All rights reserved,.,Diameter,length and types of catheters(II),Type:Material features,Silicone elastomer catheters have lower,thrombogenicity,and,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 reverse AV connection,Patient Preparation,54,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,Assessment of catheter patency,Connection techniques,Special circumstances,Catheter Characteristics,55,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 problems,Biocompatible:to reduce complication risks,Amenability to guide wire change:to optimise therapy,Side-by-Side Polyurethane Catheters,56,Copyright 2015 NIKKISO Co.,LTD.All rights reserved,.,Coaxial Polyurethane Catheters,57,Copyright 2015 NIKKISO Co.,LTD.All rights reserved,.,Triple lumen Catheters,58,Copyright 2015 NIKKISO Co.,LTD.All rights reserved,.,Silicone Catheters,59,Copyright 2015 NIKKISO Co.,LTD.All rights reserved,.,Reversing the Lines,60,Copyright 2015 NIKKISO Co.,LTD.All rights reserved,.,1 Lewington A,Kanagasundaram S.Acute Kidney Injury.Renal Association guidelines:,Guideline 8.1 AKI:Vascular access for RRT,.Guideline 8.2,Page 45 of 59,Para 3 Rationale for 8.1-8.9 lines 7-9 www.renal.org/Clinical/GuidelinesSection/AcuteKidneyInjury.aspx,Vascular Access,61,Copyright 2015 NIKKISO Co.,LTD.All rights reserved,.,Vascular Access is continuously tested during,CRRT,treatment,Practical understanding about vascular access is necessary for optimal treatment,Catheter site,size,type and patient preparation may be considered,Inadequacies in vascular access may limit delivered therapy,Troubleshooting choices,Vascular Access Troubleshooting,62,Copyright 2015 NIKKISO Co.,LTD.All rights reserved,.,Starting blood flow,Gradual increase,Optimising blood flow rates,Starting treatment,Using Aquarius History,Using Recirculation,Troubleshooting choices,Access Is KING,Vascular,Access is,continuously tested,during,CRRT treatment.,Catheter,site,size,type and patient preparation,should,be,considered.,Practical understanding about vascular access is necessary for optimal,treatment.,Inadequacies in vascular access may limit delivered,therapy.,63,Copyright 2015 NIKKISO Co.,LTD.All rights reserved,.,Summary of Classifications of AKI,Kristensen et al(2014)ESC/ESA Guidelines on non-cardiac surgery:cardiovascular assessment and management The Joint Task Force on non-cardiac surgery:cardiovascular assessment and management of the European Society of Cardiology(ESC)and the European Society of Anaesthesiology(ESA).,European Heart Journal,35(35)23832431,Copyright 2015 NIKKISO Co.,LTD.All rights reserved,.,Jean-Michel Lannoy Nikkiso ABP Director,65,The clotting cascade.,Intrinsic Pathway,XII XIIa,XI XIa,IX IXa,Ca+,Clotting Factors,Copyright 2015 NIKKISO Co.,LTD.All rights reserved,.,