《血液净化原理,模式及治疗的选择专业ppt课件.pptx》由会员分享，可在线阅读，更多相关《血液净化原理,模式及治疗的选择专业ppt课件.pptx（61页珍藏版）》请在金锄头文库上搜索。
1、Tips for improving filter life Aquarius System Copyright 2015 NIKKISO Co LTD All rights reserved PM 0063 11 2015 1 1 肾脏替代治疗 的内容 1 肾脏替代治疗的基本内容 2 滤器的选择 3 抗凝剂的应用 2 Jean Michel Lannoy Nikkiso ABP Director 3 CRRT命名的发展 CRRT Continuous renal replacement therapy 连续肾脏替代治疗 ICBP Intensive care blood purificati
2、on 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 Jean Michel Lannoy Nikkiso ABP Director 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
3、质 改善营养支持 Jean Michel Lannoy Nikkiso ABP Director 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
4、还是救治许多危重病症的有力辅助手段 Jean Michel Lannoy Nikkiso ABP Director 6 原理与机制 弥散 对流 吸附 500 5000 50000 Jean Michel Lannoy Nikkiso ABP Director Solute Classes by Molecular Weight Daltons Inflammatory Mediators 1 200 50 000 small middle large 7 8 炎症介质的特征 介质质分子量 C3a2500 C5a2800 TNF a17500 x3 C5a2800 IL 62125000 IL
5、1Ra 14000 IL 89000 LPS100000 Factor D 23000 23000 9 炎症介质的特征 介质质蛋白结结合分子量 C3ano2500 C5ano2800 TNF a部分17500 x3 STNRFIyes55000 STNRFIIyes75000 IL 621yes25000 IL 1Ra no14000 IL la no89000 PAF部分450 Factor D yes23000 6 18 201910 PSHF系列滤器筛选系数 高截留分子量 Jean Michel Lannoy Nikkiso ABP Director 如何选择血滤器 11 Molecul
6、ar 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 Abingdon UK ISBN 1857758730 New functional membrane with defined larger pore size HCO membrane 13 Jean Michel Lannoy Nikkiso ABP Director 0 01 m 12h using hep
7、arin Appropriately trained nursing staff available 34 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 4 mol L Post hepatic resection Severe shock Noradrenaline 0 5mcg kg min
8、and or Lactate 4 mol L Arterial Blood Ionized Calcium 7 5 or HCO3 40mmol L at commencement of RCA Serum Sodium 160 at commencement of RCA Uncontrolled hyperglycaemia 6U h Insulin IBW 90kg 35 35ml kg h CVVH RCA Protocol All patients will start at 35ml kg h unless directed by physician Dose includes c
9、itrate 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 802700230350 Protocol 1 36 Calcium Replacement Accusol replacement solution contains 1 75mmol L Calcium which will provide most or all of
10、the Calcium replacement A 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 only Infusion rate 0 175ml h 37 Initial Calcium Rate T
11、hen check arterial Cai in 1h Systemic iCa Initial rate of CaCl solution 1 00mL h 0mmol h Use this table only when first starting RCA 38 Adjusting Calcium Infusion iCa CaCl infusion adjustment MAXIMUM RATE 175mL hr Reche ck 1 3 1 Decrease CaCl infusion by 25ml h 2 If CaCl infusion off then check syst
12、emic iCa in 3 hours 3 Inform Doctor if iCa rises to 1 5 3h Likely to change to check in 6h in final protocol Monitoring Baseline ABG for iCa2 Total Ca2 Mg2 Aim Mg 1mmol L Post Filter iCa2 Take from return line sample port Record all Results on RCA Pro forma Likely to change to check in 6h in final p
13、rotocol Start 35ml kg h CVVH If pH 7 5 or HCO3 40 Reduce to 25ml kg h If pH 7 5 or HCO3 40 Use 25ml kg h with 25 FR If pH 7 5 or HCO3 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 C
14、itrate mL h 801900160240 IBW kg Post dilution mL h Blood Pump mL min ACD A Citrate mL h 801900130200 Step 2 if pH 7 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
15、 pH 7 5 or HCO3 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 43 Jean Michel Lannoy Nikkiso ABP Director
16、 44 THANKS THANKS 6 18 201945 Jean Michel Lannoy Nikkiso ABP Director 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 8Palsson R Niles JL Regional citrate anticoagulation in continuous venovenous hemofiltration in critically ill patients with a high risk of bleeding Kidney
