TipsforimprovingfilterlifeAquariusSystemPM-0063-11/2015-1

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

3CRRT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）

4CRRT的特點(diǎn)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(hù)血流動(dòng)力學(xué)穩(wěn)定；容量波動(dòng)小；溶質(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

5

CRRT的分類SCUF-緩慢連續(xù)超濾CAVH-連續(xù)動(dòng)靜脈血液濾過(guò)CVVH-連續(xù)靜靜脈血液濾過(guò)HVHF－高容量血液濾過(guò)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(guò)CVVHDF-連續(xù)靜靜脈血液透析濾過(guò)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(lái)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。

6原理與機(jī)制彌散對(duì)流吸附500500050000SoluteClassesbyMolecularWeightDaltons?

InflammatoryMediators(1,200-50,000)“small”“middle”“l(fā)arge”Jean-MichelLannoyNikkisoABPDirector8炎癥介質(zhì)的特征介質(zhì)分子量C3a2500C5a2800TNF-a17500x3C5a2800IL-62125000IL-1Ra14000IL-89000LPS100000FactorD2300023000Jean-MichelLannoyNikkisoABPDirector9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450FactorDyes2300012/7/202510PSHF系列濾器篩選系數(shù)/高截留分子量如何選擇血濾器？Jean-MichelLannoyNikkisoABPDirector11MolecularWeights（分子的重量或分子量的大小）12Ashleyetall.TheRenalDrugHandbook,2ndEd.2004,MedicalPress,Abingdon,UK.ISBN:1857758730NewfunctionalmembranewithdefinedlargerporesizeHCOmembrane

<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.16MolecularWeight[Da]StandardHighFluxHighCut-OffHF,UF=1L/h,t=2hMedian,25th-75thpercentiles)ICM(2002)28:651-655HCOMembranewithincreasedpermeabilityforinflammatorymediatorsmembranecharacteristics

Molecularweight18HF1200HaemofilterCut-Off55000daltonsComparisonofInterleukin-6RemovalPropertiesamongHemofiltersConsistingofVaryingMembraneMaterialsandSurfaceAreas12/7/202519RecentStudiesinMembrane20全身抗凝

局部抗凝

無(wú)肝素抗凝肝素低分子肝素鈣魚精蛋白枸櫞酸抗凝的選擇積極主動(dòng)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(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21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22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(guò)侵泡更加的飽滿，改善血流通過(guò)

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.23FiltrationFraction（濾過(guò)分?jǐn)?shù)）FiltrationFraction濾過(guò)分?jǐn)?shù)是

總液體通過(guò)

濾器的量與超濾量的相比

濾過(guò)分?jǐn)?shù)通常是盡可能的低，理想是25%FiltrationFraction濾過(guò)分?jǐn)?shù)是

不會(huì)受到前

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

的影響

.

24超濾比率FiltrationRatio25FiltrationRatio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.FiltrationRatioandbloodpumpspeed26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(guò)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)優(yōu)勢(shì):

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(diǎn):

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.

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)Whatcitratebindstocalciumwhichinhibitscoagulation合適的枸櫞酸劑量30離子

Calcium50%1.1–1.3

mmol/l蛋白

Calcium40%0.95–1.2

mmol/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.WhatdoesthebodydowithCitrate?Citrateisconvertedintocitricacid.轉(zhuǎn)化成枸櫞酸Yielding/resultinginthereleaseofbicarbonate.釋放碳酸鹽AlsometabolisedintheKrebscycleintheliver,skeletalmuscleandrenalcortex.（肝臟，肌肉，腎皮質(zhì)）Ormetabolisedintoglucose代謝到糖.Excreted分泌，排泄.Therapymonitoring32Theselectionandadjustmentoftherapyparameters,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/basemonitoringElectrolytesmonitoringFluidbalancemonitoringAquariusRegionalCitrateAnticoagulationProtocolJohnRProwleMDFRCPFFICMAdultCriticalCareUnitRoyalLondonHospitalEligibilityforRCAContra-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)UsethistableonlywhenfirststartingRCAAdjustingCalciumInfusion[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*Likelytochangetocheckin6hinfinalprotocolMonitoringBaselineABGfor

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*Likelytochangetocheckin6hinfinalprotocolStart35ml/kg/hCVVHIfpH>7.5orHCO3->40Reduceto25ml/kg/hIfpH>7.5orHCO3->40Use25ml/kg/hwith25%FRIfpH>7.5orHCO3->40StopRCAMetabolicAlkalosisMonitorpHandBicarbonate3hly**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*Step3:ifstillpH<7.5orHCO3->40mmol/LDISCONTINUERCAStep1:

ifpH>7.5orHCO3->40mmol/LonProtocol1

ChangethesettingstoProtocol2(25ml/kg/h)belowandcontinuetomonitorevery3h*.(Protocol2mayalsobeselectedfordosereduction)Protocol2Protocol3*Likelytochangetocheckin6hinfinalprotocolHowitworks…Jean-MichelLannoyNikkisoABPDirector44THANKS!12/7/202545IndicationsforCitrateAnticoagulation8PalssonR,NilesJL,RegionalcitrateanticoagulationincontinuousvenovenoushemofiltrationincriticallyillpatientswithahighriskofbleedingKidneyInt1999,55:1991-1997.9FlaniganMetal.Reducingthehemorrhagiccomplicationsofhemodialysis:Acontrolledcomparisonoflow-doseheparinandcitrateanticoagulation.AmJKidneyDis1987;2:147-153ContraindicationsChronicLiverDisease-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.49OptimizeAnticoagulationHighreturnpressureisonesignofunderanti-coagulation.Thebloodpumpwantstopushthebloodthroughthereturnchamberwherepartiallyformedbloodclotsmayincreaseinsize,makingitdifficultforthebloodtosqueezethrough.Aroutineofregularobservation,followedbyacheckofthepatientclotting,andadjustmentofanticoagulantwhereindicated,maypreventearlyreturnchamberclotting.Considerincreasingtheproportionofpre-dilutionifanticoagulation

adjustmentisnotindicated.Forexample:alteringthepre-dilutionto90%andreducingpost-dilutionto10%maythinthebloodpassingthroughthefilterandreducetheeffectsofhaemoconcentration.Againinlifespanmaybeoffsetbyasmalllossinclearance,easilyadjustedbyusingtheRenalDosedisplay.50Theeffectofbloodpumpspeed51Filtrateremovedisapercentageoftotalflowthroughthefilterfibres.Whyisthetotalbloodflowimportant?Withafasterbloodpumpspeed,thetotalflowisincreasedandeffectsofhaemoconcentrationarereduced.Increasingbloodflowgivesareducedfiltrationratiowhichmayslowfiltercloggingandextendfilterlifespan.TheeffectofPre-dilution52Filtrateremovedisapercentageoftotalflowthroughthefilterfibres.Theproportionofpredilutionflowmaybeadjustedtooptimisetreatment.Withagreaterproportionofpredilution,thefiltrationfractionandeffectsofhaemoconcentrationarereduced.Animprovedfiltrationfractionmayslowfiltercloggingandextendfilterlifespan.Considerations53Diameter,lengthandtypesofcatheters(II)Type:MaterialfeaturesSiliconeelastomercathetershavelowerthrombogenicity

an