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

AquariusSystemCopyright?201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)用腎臟替代治療“的內(nèi)容腎臟替代治療的基本內(nèi)容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）3CRRT命名的發(fā)展CRRT：ContinuousrenaCRRT的特點和優(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)，能較好地維護血流動力學穩(wěn)定；容量波動??；溶質(zhì)清除率高；有利于營養(yǎng)改善及能清除細胞因子，從而改善危重ARF患者的預(yù)后，更好的血液動力學穩(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)改善營養(yǎng)支持4CRRT的特點和優(yōu)越性CRRT是緩慢、連續(xù)排除水分，模

CRRT的分類SCUF-緩慢連續(xù)超濾CAVH-連續(xù)動靜脈血液濾過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以一種更符合機體生理特性的方式，連續(xù)地清除機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。5

CRRT的分類SCUF-緩慢連續(xù)超濾5原理與機制彌散對流吸附5005000500006原理與機制彌散對流吸附5005000500006SoluteClassesbyMolecularWeightDaltons?

InflammatoryMediators(1,200-50,000)“small”“middle”“l(fā)arge”SoluteClassesbyMolecularWe炎癥介質(zhì)的特征介質(zhì)分子量C3a2500C5a2800TNF-a17500x3C5a2800IL-62125000IL-1Ra14000IL-89000LPS100000FactorD23000230008Jean-MichelLannoyNikkisoABPDirector炎癥介質(zhì)的特征介質(zhì)分子量C3a2500C5a2800TNF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450FactorDyes230009Jean-MichelLannoyNikkisoABPDirector介質(zhì)蛋白結(jié)合分子量C3ano2500C5ano2800TNFPSHF系列濾器篩選系數(shù)/高截留分子量1012/29/2022PSHF系列濾器篩選系數(shù)/高截留分子量1012/29/202如何選擇血濾器？11Jean-MichelLannoyNikkisoABPDirector如何選擇血濾器？11Jean-MichelLannoMolecularWeights（分子的重量或分子量的大小）Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.Ashleyetall.TheRenalDrugHandbook,2ndEd.2004,MedicalPress,Abingdon,UK.ISBN:185775873012MolecularWeights（分子的重量或分子量的大NewfunctionalmembranewithdefinedlargerporesizeHCOmembraneNewfunctionalmembranewithd<0,01μm<0,02μm~0,09μm~0,30μm:porediameterhighfluxhighcut-off*proteinseparationmembraneplasmaseparationmembraneVariationofmembraneporesizeElectronmicrographsofinnermembranesurface<0,01μm<0,02μm~0,09sievingcoefficient100100010000100000100000000.81Molecularweight[D]ClassicalFilter30kDhumankidneyhighcut-offHighCut-OffHemofiltersievingcoefficient10010001000SievingCoefficientAsievingcoefficientisthemeasureofhoweasilyasubstancepassesfromthebloodcompartmenttothedialysatecompartmentinahaemofilter.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.Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.16SievingCoefficientAsievingcMolecularWeight[Da]StandardHighFluxHighCut-OffHF,UF=1L/h,t=2hMedian,25th-75thpercentiles)ICM(2002)28:651-655HCOMembranewithincreasedpermeabilityforinflammatorymediatorsmembranecharacteristics

MolecularWeight[Da]StandardMolecularweightAshleyetall.TheRenalDrugHandbook,2ndEd.2004,MedicalPress,Abingdon,UK.ISBN:1857758730Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.HF1200HaemofilterCut-Off55000daltons18MolecularweightAshleyetall.ComparisonofInterleukin-6RemovalPropertiesamongHemofiltersConsistingofVaryingMembraneMaterialsandSurfaceAreasRecentStudiesinMembrane1912/29/2022ComparisonofInterleukin-6Re全身抗凝

局部抗凝

無肝素抗凝肝素低分子肝素鈣魚精蛋白枸櫞酸抗凝的選擇Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.20全身抗凝局部抗凝無肝素抗凝魚精蛋白抗凝的選擇Copy積極主動預(yù)防管路的凝血

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Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.21積極主動預(yù)防管路的凝血

利用重新預(yù)沖和循環(huán)模式清除管路及濾器預(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

進入濾器和多少液體排除的比較。

目標血流速度的目的制定達到低的超濾比率，

從而達到更長的濾器使用壽命.高的血流速度可以達到低的超濾比率

如果臨床需求允許可以提高血流速10—15%當連接病人時，可以延長治療直到血流速度達到要求盡可能的在病人開始治療時防止血液的濃縮Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.22預(yù)防濾器內(nèi)的凝血(FiltrationRatio%)保持超預(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.

一個循環(huán)時間在20–20/minutes.濾器和管路基本可以72小時使用,

但這包括重復(fù)使用的時間.Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.23預(yù)防濾器內(nèi)的凝血(Recirculation)

重復(fù)循環(huán)模式FiltrationFraction（濾過分數(shù)）FiltrationFraction濾過分數(shù)是

總液體通過

濾器的量與超濾量的相比

濾過分數(shù)通常是盡可能的低，理想是25%FiltrationFraction濾過分數(shù)是

不會受到前

稀釋泵的影響FiltrationFraction濾過分數(shù)是會受到血流速

的影響. Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.24FiltrationFraction（濾過分數(shù)）Filtr超濾比率FiltrationRatioCopyright?2015NIKKISOCo.,LTD.Allrightsreserved.FiltrationRatio是表示濾器中血液濃度增加.理想的超濾比率在低于

25%.FiltrationRatio是受到前稀釋泵的影響.FiltrationRatio是受到血流速的影響.25超濾比率FiltrationRatioCopyrighFiltrationRatioandbloodpumpspeed

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

Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.26FiltrationRatioandbloodpum肝素是如何工作的?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):26-30Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.肝素是如何工作的?5Roncoetal.Effects肝素;優(yōu)勢和劣勢優(yōu)勢:

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.缺點:

增加出血的風險.

血小板減少.

增加肝素的劑量.

抗凝血酶元水平下降會影響肝素的作用.

Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.肝素;優(yōu)勢和劣勢優(yōu)勢:Copyright?2015NI枸櫞酸是如何工作的?枸櫞酸螯合了血循中的鈣.抑制了凝血ACD-A(CitrateSolution)WhatcitratebindstocalciumwhichinhibitscoagulationCopyright?2015NIKKISOCo.,LTD.Allrightsreserved.枸櫞酸是如何工作的?枸櫞酸螯合了血循中的鈣.抑制了凝血ACD合適的枸櫞酸劑量離子

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.30合適的枸櫞酸劑量離子Calcium50%蛋白CalciWhatdoesthebodydowithCitrate?Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.WhatdoesthebodydowithCitTherapymonitoringTheselectionandadjustmentoftherapyparameters,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/basemonitoringElectrolytesmonitoringFluidbalancemonitoringCopyright?2015NIKKISOCo.,LTD.Allrightsreserved.32TherapymonitoringTheselectiAquariusRegionalCitrateAnticoagulationProtocolJohnRProwleMDFRCPFFICMAdultCriticalCareUnitRoyalLondonHospitalAquariusRegionalCitrateAntiEligibilityforRCARequiringRRTwithintheICU(eitherneworon-goingtreatment)forconventionalRenalindicationsConsideredbythetreatingPhysiciantohaveacontraindicationtoheparinanticoagulationorunabletoachieveadequatefilterlifespan(>12h)usingheparinAppropriatelytrainednursingstaffavailableEligibilityforRCARequiringRContra-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>90kgContra-indicationstoRCAinp35ml/kg/hCVVHRCAProtocolAllpatientswillstartat35ml/kg/hunlessdirectedbyphysicianDoseincludescitratevolumepre-filterFiltrationRatiois20%Pre-filtercitrateconcentrationwillbe~2.8mmol/LIBWkgPost–dilutionmL/hBloodPumpmL/minACD-A(Citrate)mL/h<50140012018050-59180015023060-69210018027070-792400200300>802700230350Protocol135ml/kg/hCVVHRCAProtocolAlCalciumReplacementAccusolreplacementsolutioncontains1.75mmol/LCalciumwhichwillprovidemostoralloftheCalciumreplacementA10mmol/LCalciumChloridesolutionwillbeusedforadditionalCalciumreplacementifrequired:1x10mlampuleofCalciumChloride(10mmol)in990mlNormalSalinegivenviaintegratedCalciumPumponAquarius-CitratedeviceonlyInfusionrate0-175ml/hCalciumReplacementAccusolrepInitialCalciumRateThencheckarterialCaiin1hSystemiciCaInitialrateofCaClsolution<0.8DoNOTcommenceRCAMedicalteamtoreview&correctCalcium0.8-0.975mL/h(0.75mmol/h)0.9-1.050mL/h(0.5mmol/h)>1.00mL/h(0mmol/h)Usethistable

onlywhenfirststartingRCAInitialCalciumRateThencheckAdjustingCalciumInfusion[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*Likelytochangetocheckin6hinfinalprotocolAdjustingCalciumInfusion[iCaMonitoringBaselineABGfor

iCa2+&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*Likelytochangetocheckin6hinfinalprotocolMonitoringBaselineABGforiCaMetabolicAlkalosisMonitorpHandBicarbonate3hly**Likelytochangetocheckin6hinfinalprotocolMetabolicAlkalosis*LikelytoIBWkgPost–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*Step3:ifstillpH<7.5orHCO3->40mmol/LDISCONTINUERCAStep1:

ifpH>7.5orHCO3->40mmol/LonProtocol1

ChangethesettingstoProtocol2(25ml/kg/h)belowandcontinuetomonitorevery3h*.(Protocol2mayalsobeselectedfordosereduction)Protocol2Protocol3*Likelytochangetocheckin6hinfinalprotocolIBWPost–dilutionBloodPumpAHowitworks…Howitworks…44Jean-MichelLannoyNikkisoABPDirector44Jean-MichelLannoyNikkisoATHANKS!4512/29/2022THANKS!4512/29/2022IndicationsforCitrateAnticoagulationRequiringRRTwithintheICU(eitherneworon-goingtreatment)forconventionalRenalindicationsConsideredbythetreatingPhysiciantohaveacontraindicationtoheparinanticoagulationAppropriatelytrainednursingstaffavailable8PalssonR,NilesJL,RegionalcitrateanticoagulationincontinuousvenovenoushemofiltrationincriticallyillpatientswithahighriskofbleedingKidneyInt1999,55:1991-1997.9FlaniganMetal.Reducingthehemorrhagiccomplicationsofhemodialysis:Acontrolledcomparisonoflow-doseheparinandcitrateanticoagulation.AmJKidneyDis1987;2:147-153Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.IndicationsforCitrateAnticoContraindicationsChronicLiverDisease-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.Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.10Prowleetal.ServiceDevelopmentPlanandProtocolforRegionalCitrateAnticoagulation,TheRoyalLondonHospitalContraindicationsCopyright?20TherapymonitoringIonisedCalcium: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?Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.TherapymonitoringIonisedCalOptimizeVascularAccessConsiderusingahighflowsiliconevascularaccesscatheterthatdoesnothave“kinkmemory”,andwithanappropriatelengthforthechosensite.AvoidattachingtheAquariustoacatheterwithpoorflow.Forexample,beingabletowithdraw20mlofbloodin6secondsor10mlofbloodin3secondswithouthesitancyorinterruptionmayhelpacatheterassessment.Considerrotatingthehubofthecatheter90°sothattheholesontheaccesslumenarefacingtheflowofblood,notagainstthevesselwall(youmayneedtomomentarilystopthebloodpumptodothis).Considerthepatientsintravascularvolume.Eventhoughthepatientmaybefluidoverloaded,iftheirintravascularspaceisdehydrated,theremaybepoorflowthroughthecatheterwhichwillencourageclotting.Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.49OptimizeVascularAccessConsidOptimizeAnticoagulationHighreturnpressureisonesignofunderanti-coagulation.Thebloodpumpwantstopushthebloodthroughthereturnchamberwherepartiallyformedbloodclotsmayincreaseinsize,makingitdifficultforthebloodtosqueezethrough.Aroutineofregularobservation,followedbyacheckofthepatientclotting,andadjustmentofanticoagulantwhereindicated,maypreventearlyreturnchamberclotting.Considerincreasingtheproportionofpre-dilutionifanticoagulationadjustmentisnotindicated.Forexample:alteringthepre-dilutionto90%andreducingpost-dilutionto10%maythinthebloodpassingthroughthefilterandreducetheeffectsofhaemoconcentration.Againinlifespanmaybeoffsetbyasmalllossinclearance,easilyadjustedbyusingtheRenalDosedisplay.Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.50OptimizeAnticoagulationHighrTheeffectofbloodpumpspeedCopyright?2015NIKKISOCo.,LTD.Allrightsreserved.Filtrateremovedisapercentageoftotalflowthroughthefilterfibres.Whyisthetotalbloodflowimportant?Withafasterbloodpumpspeed,thetotalflowisincreasedandeffectsofhaemoconcentrationarereduced.Increasingbloodflowgivesareducedfiltrationratiowhichmayslowfiltercloggingandextendfilterlifespan.51TheeffectofbloodpumpspeedTheeffectofPre-dilutionCopyright?2015NIKKISOCo.,LTD.Allrightsreserved.Filtrateremovedisapercentageoftotalflowthroughthefilterfibres.Theproportionofpredilutionflowmaybeadjustedtooptimisetreatment.Withagreaterproportionofpredilution,thefiltrationfractionandeffectsofhaemoconcentrationarereduced.Animprovedfiltrationfractionmayslowfiltercloggingandextendfilterlifespan.52TheeffectofPre-dilutionCopyConsiderationsCopyright?2015NIKKISOCo.,LTD.Allrightsreserved.Diameter,lengthandtypesofcatheters(II)Type:MaterialfeaturesSiliconeelastomercathetershavelowerthrombogenicityandbetterflexibility.BiocompatibleandkinkresistanceConformtovesselanatomy,thereforereduceriskoftraumaDiameterandbloodflow:11French:250-300ml/minBloodFlow13.5French:450-500ml/minBloodFlowRecirculation-upto20%Especiallyiffemoralaccessislessthan20cmAvoidreverseAVconnection53ConsiderationsCopyright?2015PatientPreparationCopyright?2015NIKKISOCo.,LTD.Allrightsreserved.PatientbodystatusCoagulationandIntravascularfillingMobilityinfluencesPresenceofothercentrallinesInfluencesoncatheterchoiceClinicianchoiceAvailabilityofultrasoundguidanceAssessmentofcatheterpatencyConnectiontechniquesSpecialcircumstances54PatientPreparationCopyright?CatheterCharacteristics

Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.

Easeofinsertion:toavoidvesseltraumaGoodflowcharacteristics:tooptimisebloodflowKinkresistant:toavoidaccesspressureproblemsBiocompatible:toreducecomplicationrisksAmenabilitytoguidewirechange:tooptimisetherapy55CatheterCharacteristics

CopyrSide-by-SidePolyurethaneCathetersCopyright?2015NIKKISOCo.,LTD.Allrightsreserved.56Side-by-SidePolyurethaneCathCoaxialPolyurethaneCathetersCopyright?2015NIKKISOCo.,LTD.Allrightsreserved.57CoaxialPolyurethaneCathetersTriplelumenCathetersCopyright?2015NIKKISOCo.,LTD.Allrightsreserved.58TriplelumenCathetersCopyrighSiliconeCathetersCopyright?2015NIKKISOCo.,LTD.Allrightsreserved.59SiliconeCathetersCopyright?ReversingtheLinesCopyright?2015NIKKISOCo.,LTD.Allrightsreserved.1LewingtonA,KanagasundaramS.AcuteKidneyInjury.RenalAssociationguidelines:Guideline8.1–AKI:VascularaccessforRRT.Guideline8.2,Page45of59,Para3‘Rationalefor8.1-8.9’lines7-9/Clinical/GuidelinesSection/AcuteKidneyInjury.aspx60ReversingtheLinesCopyright?VascularAccessCopyright?2015NIKKISOCo.,LTD.Allrightsreserved.VascularAccessiscontinuouslytestedduringCRRTtreatmentPracticalunderstandingaboutvascularaccessisnecessaryforoptimaltreatmentCathetersite,size,typeandpatientpreparationmaybeconsideredInadequaciesinvascularaccessmaylimitdeliveredtherapyTroubleshootingchoices61VascularAccessCopyright?201VascularAccessTroubleshootingCopyright?2015NIKKISOCo.,LTD.Allrightsreserved.StartingbloodflowGradualincreaseOptimisingbloodflowratesStartingtreatmentUsingAquariusHistoryUsingRecirculationTroubleshootingchoices62VascularAccessTroubleshootin

AccessIsKINGVascularAccessiscontinuouslytestedduringCRRTtreatment.Cathetersite,size,typeandpatientpreparationshouldbeconsidered.Practicalunderstandingaboutvascularaccessisnecessaryforoptimaltreatment.Inadequaciesinvascularaccessmaylimitdeliveredtherapy.Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.63

AccessIsKINGCopyright?201SummaryofClassificationsofAKI

Kristensenetal(2014)ESC/ESAGuidelinesonnon-cardiacsurgery:cardiovascularassessmentandmanagementTheJointTaskForceonnon-cardiacsurgery:cardiovascularassessmentandmanagementoftheEuropeanSocietyofCardiology(ESC)andtheEuropeanSocietyofAnaesthesiology(ESA).EuropeanHeartJournal35(35)2383–2431Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.SummaryofClassificationsof65Jean-MichelLannoyNikkisoABPDirector65Jean-MichelLannoyNikkisoATheclottingcascade.Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.Theclottingcascade.CopyrightTipsforimprovingfilterlifeAquariusSystemCopyright?2015NIKKISOCo.,LTD.Allrightsreserved.PM-0063-11/2015-1

AquariusSystemCopyright?201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)用腎臟替代治療“的內(nèi)容腎臟替代治療的基本內(nèi)容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）69CRRT命名的發(fā)展CRRT：ContinuousrenaCRRT的特點和優(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)，能較好地維護血流動力學穩(wěn)定；容量波動??；溶質(zhì)清除率高；有利于營養(yǎng)改善及能清除細胞因子，從而改善危重ARF患者的預(yù)后，更好的血液動力學穩(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)改善營養(yǎng)支持70CRRT的特點和優(yōu)越性CRRT是緩慢、連續(xù)排除水分，模

CRRT的分類SCUF-緩慢連續(xù)超濾CAVH-連續(xù)動靜脈血液濾過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以一種更符合機體生理特性的方式，連續(xù)地清除機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。71

CRRT的分類SCUF-緩慢連續(xù)超濾5原理與機制彌散對流吸附50050005000072原理與機制彌散對流吸附5005000500006SoluteClassesbyMolecularWeightDaltons?

InflammatoryMediators(1,200-50,000)“small”“middle”“l(fā)arge”SoluteClassesbyMolecularWe炎癥介質(zhì)的特征介質(zhì)分子量C3a2500C5a2800TNF-a17500x3C5a2800IL-62125000IL-1Ra14000IL-89000LPS100000FactorD230002300074Jean-MichelLannoyNikkisoABPDirector炎癥介質(zhì)的特征介質(zhì)分子量C3a2500C5a2800TNF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450FactorDyes2300075Jean-MichelLannoyNikkisoABPDirector介質(zhì)蛋白結(jié)合分子量C3ano2500C5ano2800TNFPSHF系列濾器篩選系數(shù)/高截留分子量7612/29/2022PSHF系列濾器篩選系數(shù)/高截留分子量1012/29/202如何選擇血濾器？77Jean-MichelLannoyNikkisoABPDirector如何選擇血濾器？11Jean-MichelLannoMolecularWeights（分子的重量或分子量的大小）Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.Ashleyetall.TheRenalDrugHandbook,2ndEd.2004,MedicalPress,Abingdon,UK.ISBN:185775873078MolecularWeights（分子的重量或分子量的大NewfunctionalmembranewithdefinedlargerporesizeHCOmembraneNewfunctionalmembranewithd<0,01μm<0,02μm~0,09μm~0,30μm:porediameterhighfluxhighcut-off*proteinseparationmembraneplasmaseparationmembraneVariationofmembraneporesizeElectronmicrographsofinnermembranesurface<0,01μm<0,02μm~0,09sievingcoefficient100100010000100000100000000.81Molecularweight[D]ClassicalFilter30kDhumankidneyhighcut-offHighCut-OffHemofiltersievingcoefficient10010001000SievingCoefficientAsievingcoefficientisthemeasureofhoweasilyasubstancepassesfromthebloodcompartmenttothedialysatecompartmentinahaemofilter.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.Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.82SievingCoefficientAsievingcMolecularWeight[Da]StandardHighFluxHighCut-OffHF,UF=1L/h,t=2hMedian,25th-75thpercentiles)ICM(2002)28:651-655HCOMembranewithincreasedpermeabilityforinflammatorymediatorsmembranecharacteristics

MolecularWeight[Da]StandardMolecularweightAshleyetall.TheRenalDrugHandbook,2ndEd.2004,MedicalPress,Abingdon,UK.ISBN:1857758730Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.HF1200HaemofilterCut-Off55000daltons84MolecularweightAshleyetall.ComparisonofInterleukin-6RemovalPropertiesamongHemofiltersConsistingofVaryingMembraneMaterialsandSurfaceAreasRecentStudiesinMembrane8512/29/2022ComparisonofInterleukin-6Re全身抗凝

局部抗凝

無肝素抗凝肝素低分子肝素鈣魚精蛋白枸櫞酸抗凝的選擇Copyright?2015NIKKISOCo.,LTD.Allrightsreserved.86全身抗凝局部抗凝無肝素抗凝魚精蛋白抗凝的選擇Copy積極主動預(yù)防管路的凝血

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