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1、ICU中的急性肾脏功能衰竭中的急性肾脏功能衰竭* *: BEST Kidney患病率n1738/29269 (5.7%, 95%CI 5.5 6.0%)危险因素n感染性休克(47.5%, 95%CI 45.2 49.5%)住院病死率n60.3% (95%CI 58.0 62.6%)*少尿( 84 mg/dL)Uchino S, Kellum JA, Bellomo R, et al. Acute renal failure in critically ill patients: a multinational, multicenter study. JAMA 2005; 294: 813-81
2、8急性肾功能衰竭的定义急性肾功能衰竭的定义: RIFLE标准标准GFR标准UO标准Risk肌酐增加x 1.5或GFR降低 25%UO 50%UO 75%UO 4周ESRD终末期肾病 3月Bellomo R, Ronco C, Kellum JA, et al. Acute renal failure: definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Ac
3、ute Dialysis Quality Initiative (ADQI) Group. Crit Care 2004; 8: R204-R212ICU的急性肾脏损伤的急性肾脏损伤(AKI)Ostermann M, Chang RWS. Acute kidney injury in the intensive care unit according to RIFLE. Crit Care Med 2007; 35: 1837-184335.8%急性肾功能衰竭的治疗急性肾功能衰竭的治疗(n = 646)Perez-Valdivieso JR, Bes-Rastrollo M, Monedero
4、 P, et al. Prognosis and serum creatinine levels in acute renal failure at the time of nephrology consultation: an observational cohort study. BMC Nephrology 2007; 8: 14-22持续肾脏替代治疗管路寿命持续肾脏替代治疗管路寿命满足治疗要求降低治疗费用减少重新安装管路的护理时间18 30 hr1.Holt AW, Bierer P, Glover P, Plummer JL, Bersten AD. Conventional coa
5、gulation and thromboelastograph parameters and longevity of continuous renal replacement circuits. Intensive Care Med 2002; 28: 1649-55.2.Stefanidis I, Hagel J, Frank D, Maurin N. Hemostatic alterations during continuous venovenous hemofiltration in acute renal failure. Clin Nephrol 1996; 46(3): 199
6、-205.3.Kox WJ, Rohr U, Waurer H. Practical aspects of renal replacement therapy. Int J Artif Organs 1996; 19: 100-5.4.Tan HK, Baldwin I, Bellomo R. Continuous veno-venous haemofiltration without anticoagulation in high-risk patients. Intensive Care Med 2000; 26: 1652-7.持续肾脏替代治疗的影响因素持续肾脏替代治疗的影响因素血管通路
7、位置中心静脉导管: 口径, 管腔设计血流可靠性血滤管路设计透析膜的生物相容性护理人员的培训及专业技能抗凝效果持续肾脏替代的抗凝持续肾脏替代的抗凝血滤滤器与管路的抗凝作用全身抗凝有害作用持续肾脏替代的抗凝选择持续肾脏替代的抗凝选择基础疾病现有抗凝措施临床经验国内文献报告的抗凝方法国内文献报告的抗凝方法抗凝方法抗凝方法病例数病例数(%)单药抗凝普通肝素844 (37.9)低分子肝素686 (30.8)枸橼酸26 (1.2)联合抗凝普通肝素+低分子肝素483 (21.7)普通肝素+枸橼酸52 (2.3)无抗凝137 (6.1)CRRT时的肝素抗凝时的肝素抗凝出血危险负荷剂量IU/kg维持剂量IU/k
8、g/hrAPTTsecACTsec无危险性5010 2060 250危险较小15 255 1045160 180危险较大102.5 530120肝素抗凝的优缺点肝素抗凝的优缺点优点最常用的抗凝方法临床方案成熟半衰期短过量时鱼精蛋白对抗缺点出血危险APTT与滤器寿命无关肝素诱导血小板缺乏(HIT)枸橼酸抗凝的原理枸橼酸抗凝的原理局部枸橼酸抗凝的原理局部枸橼酸抗凝的原理凝血过程需要游离钙参与枸橼酸螯合游离钙, 补充钙离子可以恢复血库使用枸橼酸保存血液采用枸橼酸可以在RRT时进行局部抗凝:n血液进入体外循环后即加入枸橼酸n血液进入体内前补充游离钙n体外循环对血液进行抗凝, 体内血液正常n通过测定游离
9、钙监测抗凝肝素抗凝时的滤器中空纤维肝素抗凝时的滤器中空纤维Hofbauer R, Moser D, Frass M, et al. Effect of anticoagulation on blood membrane interactions during hemodialysis. Kidney Int低分子肝素抗凝时的滤器中空纤维低分子肝素抗凝时的滤器中空纤维Hofbauer R, Moser D, Frass M, et al. Effect of anticoagulation on blood membrane interactions during hemodialysis. K
10、idney Int枸橼酸抗凝时的滤器中空纤维枸橼酸抗凝时的滤器中空纤维Hofbauer R, Moser D, Frass M, et al. Effect of anticoagulation on blood membrane interactions during hemodialysis. Kidney Int血滤终止的原因血滤终止的原因枸橼酸(n = 36)肝素(n = 43)管路凝血6 (16.7%)23 (53.5%)改为IHD1 (2.8%)0血管通路问题2 (5.6%)0管路断裂或渗漏1 (2.8%)0管路打折1 (2.8%)0转运至放射科或手术室8 (22.2%)8 (18
11、.6%)滤器压力高1 (2.8%)2 (4.7%)其他原因16 (44.4%)10 (23.3%)Kutsogiannis DJ, Gibney RTN, Stollery D et al. Regional citrate versus systemic heparin anticoagulation for continuous renal replacement in critically ill patients. Kidney Int 2005; 67: 2361-2367滤器寿命的滤器寿命的Cox风险比例模型分析风险比例模型分析HR95%CIP值枸橼酸0.3710.197 0.69
12、90.002LOD评分1.2671.138 1.411 0.001女性0.5240.314 0.8740.01AT-III水平0.2140.065 0.7120.01Kutsogiannis DJ, Gibney RTN, Stollery D et al. Regional citrate versus systemic heparin anticoagulation for continuous renal replacement in critically ill patients. Kidney Int 2005; 67: 2361-2367出血或输血的比例出血或输血的比例枸橼酸肝素相
13、对危险度P值明确或隐性出血0.01 (0 0.04)0.13 (0.04 0.23)0.17 (0.03 1.04)0.06输注RBC0.17 (0.10 0.25)0.33 (0.18 0.49)0.53 (0.24 1.20)0.13输注FFP0.40 (0.29 0.52)0.08 (0.01 0.16)4.95 (0.47 52.3)0.18Kutsogiannis DJ, Gibney RTN, Stollery D et al. Regional citrate versus systemic heparin anticoagulation for continuous renal
14、 replacement in critically ill patients. Kidney Int 2005; 67: 2361-2367CRRT时出血的多因素时出血的多因素Poisson回归回归RR95%CIP值截距0.0010.00001 0.1740.008枸橼酸0.1370.020 0.9590.05LOD评分0.9240.571 1.4940.75AT-III水平6.6470.789 56.0030.08Kutsogiannis DJ, Gibney RTN, Stollery D et al. Regional citrate versus systemic heparin a
15、nticoagulation for continuous renal replacement in critically ill patients. Kidney Int 2005; 67: 2361-2367不同抗凝方法的滤器寿命不同抗凝方法的滤器寿命Kutsogiannis DJ, Gibney RTN, Stollery D et al. Regional citrate versus systemic heparin anticoagulation for continuous renal replacement in critically ill patients. Kidney
16、Int 2005; 67: 2361-2367枸橼酸局部抗凝方案枸橼酸局部抗凝方案枸橼酸局部抗凝图示枸橼酸局部抗凝图示RheaterACD-AVVPVPAUFBLDSAD葡萄糖酸钙枸橼酸局部抗凝方案说明枸橼酸局部抗凝方案说明血滤机常规预冲n肝素盐水根据患者病情选择适当治疗模式nCVVHnCVVHDnCVVHDF枸橼酸局部抗凝方案枸橼酸局部抗凝方案准备枸橼酸抗凝液n血液保存液(I) 600 ml/袋n广州华南医疗用品有限公司成分成分分子分子量量含量含量(g)mmol枸橼酸三钠(二水)294.122.075枸橼酸(一水)210.148.038葡萄糖(一水)198.1724.5120加注射用水至10
17、00 mlRheaterACD-AVVPVPAUFBLDSAD葡萄糖酸钙枸橼酸局部抗凝方案枸橼酸局部抗凝方案准备输液泵将输液管路与血滤管路的动脉端相连接n最接近患者处(血泵前)根据患者病情, 设置血滤机的常规参数RheaterACD-AVVPVPAUFBLDSAD葡萄糖酸钙枸橼酸局部抗凝方案枸橼酸局部抗凝方案ACD-A初始泵速为血液流速(BFR)的2.0 2.5%n泵速(ml/hr) = 1.2 1.5 x BFR (ml/min)例如nBFR = 120 ml/minnACD-A泵速= 144 180 ml/hrRheaterACD-AVVPVPAUFBLDSAD葡萄糖酸钙枸橼酸局部抗凝方案
18、枸橼酸局部抗凝方案常规情况下选择前稀释方式RheaterACD-AVVPVPAUFBLDSAD葡萄糖酸钙枸橼酸局部抗凝方案枸橼酸局部抗凝方案置换液中不含钙RheaterACD-AVVPVPAUFBLDSAD葡萄糖酸钙常规置换液配方常规置换液配方0.9% NS2000 ml注射用水500 ml5% NaHCO3125 ml25% MgSO43 ml10% CaGlu20 ml15% KCl5 ml50% GS总量枸橼酸局部抗凝方案枸橼酸局部抗凝方案准备10%葡萄糖酸钙溶液及注射器泵将输液管路连接至血滤管路静脉端葡萄糖酸钙溶液初始泵速为8.8 11.0 ml/hr (ACD-A泵速的6.1%)Rh
19、eaterACD-AVVPVPAUFBLDSAD葡萄糖酸钙枸橼酸局部抗凝方案枸橼酸局部抗凝方案: 抗凝监测抗凝监测Q2h x 4Q4h x 4Day 1Day 2Q 6 8 h枸橼酸局部抗凝方案枸橼酸局部抗凝方案: 抗凝监测抗凝监测RheaterACD-AVVPVPAUFBLDSAD枸橼酸钙动脉标本动脉标本外周静脉或动脉外周静脉或动脉游离钙游离钙1.00 1.20 mmol/L静脉标本静脉标本滤器后血滤管路滤器后血滤管路游离钙游离钙0.20 0.40 mmol/L枸橼酸局部抗凝方案枸橼酸局部抗凝方案: 抗凝监测抗凝监测静脉标本游离钙静脉标本游离钙从滤器后静脉取血部位取血从滤器后静脉取血部位取血
20、ACD-A输注速度调整输注速度调整 0.50 mmol/L增加10 ml/hr枸橼酸局部抗凝方案枸橼酸局部抗凝方案: 抗凝监测抗凝监测动脉标本游离钙动脉标本游离钙从外周静脉或动脉取血从外周静脉或动脉取血10%葡萄糖酸钙输注速度调整葡萄糖酸钙输注速度调整 1.45 mmol/L降低6.1 ml/hr1.21 1.45 mmol/L降低3.1 ml/hr1.00 1.20 mmol/L维持不变0.90 1.00 mmol/L增加3.1 ml/hr 10 mEq/L需要确认nACD-A输注部位正确, 未直接进入患者体内降低ACD-A泵速25%n2 4小时后测定HCO3若测定结果仍不正常n再次降低AC
21、D-A泵速25%枸橼酸局部抗凝方案枸橼酸局部抗凝方案: 抗凝监测抗凝监测若患者血Na上升10 mEq/L或 155 mEq/L需要确认nACD-A输注部位正确, 未直接进入患者体内降低ACD-A泵速25%n2 4小时后测定血Na若测定结果仍不正常n输注5%GS枸橼酸抗凝的并发症枸橼酸抗凝的并发症: 代谢性碱中毒代谢性碱中毒主要原因n枸橼酸转化为HCO3 (1 mmol枸橼酸能够产生3 mmol的HCO3)次要原因n溶液含有35 mEq/L HCO3n消化道丢失n含有乙酸成分的TPN治疗方法是增加酸负荷n生理盐水(pH 5.4)枸橼酸抗凝的并发症枸橼酸抗凝的并发症: Citrate Lock总钙增加, 而游离钙不变或降低n枸橼酸负荷超过肝脏代谢及CRRT清除能力治疗n降低或停止枸橼酸10 30分钟n然后按照之前70%的速度开始注意是否忽略大量输血时的枸橼酸负荷总结总结危重病患者常常发生急性肾功能损害(AKI)肾脏替代治疗是重要的治疗手段充分抗凝是保证肾脏替代治疗疗效的重要措施局部枸橼酸抗凝有效, 安全, 禁忌症少
