crrt的局部枸櫞酸抗凝

1、持續(xù)腎臟替代治療的局部枸櫞酸抗凝,北京協(xié)和醫(yī)院杜斌,ICU中的急性腎臟功能衰竭*: BEST Kidney,患病率1738/29269 (5.7%, 95%CI 5.5 – 6.0%)危險(xiǎn)因素感染性休克(47.5%, 95%CI 45.2 – 49.5%)住院病死率60.3% (95%CI 58.0 – 62.6%)*少尿( 84 mg/dL),Uchino S, Kellum JA, Bellomo R, et al

2、. Acute renal failure in critically ill patients: a multinational, multicenter study. JAMA 2005; 294: 813-818,急性腎功能衰竭的定義: RIFLE標(biāo)準(zhǔn),Bellomo R, Ronco C, Kellum JA, et al. Acute renal failure: definition, outcome measures, a

3、nimal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care 2004; 8: R204-R212,ICU的急性腎臟損傷(AKI),Ostermann M

4、, Chang RWS. Acute kidney injury in the intensive care unit according to RIFLE. Crit Care Med 2007; 35: 1837-1843,35.8%,急性腎功能衰竭的治療(n = 646),Perez-Valdivieso JR, Bes-Rastrollo M, Monedero P, et al. Prognosis and serum cre

5、atinine levels in acute renal failure at the time of nephrology consultation: an observational cohort study. BMC Nephrology 2007; 8: 14-22,持續(xù)腎臟替代治療管路壽命,滿足治療要求降低治療費(fèi)用減少重新安裝管路的護(hù)理時(shí)間,18 – 30 hr,Holt AW, Bierer P, Glover P,

6、Plummer JL, Bersten AD. Conventional coagulation and thromboelastograph parameters and longevity of continuous renal replacement circuits. Intensive Care Med 2002; 28: 1649-55.Stefanidis I, Hagel J, Frank D, Maurin N. H

7、emostatic alterations during continuous venovenous hemofiltration in acute renal failure. Clin Nephrol 1996; 46(3): 199-205.Kox WJ, Rohr U, Waurer H. Practical aspects of renal replacement therapy. Int J Artif Organs 19

8、96; 19: 100-5.Tan HK, Baldwin I, Bellomo R. Continuous veno-venous haemofiltration without anticoagulation in high-risk patients. Intensive Care Med 2000; 26: 1652-7.,持續(xù)腎臟替代治療的影響因素,血管通路位置中心靜脈導(dǎo)管: 口徑, 管腔設(shè)計(jì)血流可靠性血濾管路設(shè)計(jì)透

9、析膜的生物相容性護(hù)理人員的培訓(xùn)及專業(yè)技能抗凝效果,持續(xù)腎臟替代的抗凝,,,血濾濾器與管路的抗凝作用,全身抗凝有害作用,持續(xù)腎臟替代的抗凝選擇,基礎(chǔ)疾病現(xiàn)有抗凝措施臨床經(jīng)驗(yàn),國(guó)內(nèi)文獻(xiàn)報(bào)告的抗凝方法,CRRT時(shí)的肝素抗凝,肝素抗凝的優(yōu)缺點(diǎn),優(yōu)點(diǎn)最常用的抗凝方法臨床方案成熟半衰期短過(guò)量時(shí)魚(yú)精蛋白對(duì)抗,缺點(diǎn)出血危險(xiǎn)APTT與濾器壽命無(wú)關(guān)肝素誘導(dǎo)血小板缺乏(HIT),枸櫞酸抗凝的原理,局部枸櫞酸抗凝的原理,凝血過(guò)程需要游

10、離鈣參與枸櫞酸螯合游離鈣, 補(bǔ)充鈣離子可以恢復(fù)血庫(kù)使用枸櫞酸保存血液采用枸櫞酸可以在RRT時(shí)進(jìn)行局部抗凝:血液進(jìn)入體外循環(huán)后即加入枸櫞酸血液進(jìn)入體內(nèi)前補(bǔ)充游離鈣體外循環(huán)對(duì)血液進(jìn)行抗凝, 體內(nèi)血液正常通過(guò)測(cè)定游離鈣監(jiān)測(cè)抗凝,肝素抗凝時(shí)的濾器中空纖維,Hofbauer R, Moser D, Frass M, et al. Effect of anticoagulation on blood membrane interact

11、ions during hemodialysis. Kidney Int,低分子肝素抗凝時(shí)的濾器中空纖維,Hofbauer R, Moser D, Frass M, et al. Effect of anticoagulation on blood membrane interactions during hemodialysis. Kidney Int,枸櫞酸抗凝時(shí)的濾器中空纖維,Hofbauer R, Moser D, Frass

12、M, et al. Effect of anticoagulation on blood membrane interactions during hemodialysis. Kidney Int,血濾終止的原因,Kutsogiannis DJ, Gibney RTN, Stollery D et al. Regional citrate versus systemic heparin anticoagulation for conti

13、nuous renal replacement in critically ill patients. Kidney Int 2005; 67: 2361-2367,濾器壽命的Cox風(fēng)險(xiǎn)比例模型分析,Kutsogiannis DJ, Gibney RTN, Stollery D et al. Regional citrate versus systemic heparin anticoagulation for continuous r

14、enal replacement in critically ill patients. Kidney Int 2005; 67: 2361-2367,出血或輸血的比例,Kutsogiannis DJ, Gibney RTN, Stollery D et al. Regional citrate versus systemic heparin anticoagulation for continuous renal replacemen

15、t in critically ill patients. Kidney Int 2005; 67: 2361-2367,CRRT時(shí)出血的多因素Poisson回歸,Kutsogiannis DJ, Gibney RTN, Stollery D et al. Regional citrate versus systemic heparin anticoagulation for continuous renal replacement i

16、n critically ill patients. Kidney Int 2005; 67: 2361-2367,不同抗凝方法的濾器壽命,Kutsogiannis DJ, Gibney RTN, Stollery D et al. Regional citrate versus systemic heparin anticoagulation for continuous renal replacement in critically

17、 ill patients. Kidney Int 2005; 67: 2361-2367,枸櫞酸局部抗凝方案,,枸櫞酸局部抗凝圖示,,,R,heater,,ACD-A,,,V,,V,,PV,PA,,,UF,,,,BLD,,SAD,,,葡萄糖酸鈣,枸櫞酸局部抗凝方案說(shuō)明,血濾機(jī)常規(guī)預(yù)沖肝素鹽水根據(jù)患者病情選擇適當(dāng)治療模式CVVHCVVHDCVVHDF,枸櫞酸局部抗凝方案,準(zhǔn)備枸櫞酸抗凝液血液保存液(I) 600 ml/袋

18、廣州華南醫(yī)療用品有限公司,,,R,heater,,ACD-A,,,V,,V,,PV,PA,,,UF,,,,BLD,,SAD,,,,葡萄糖酸鈣,枸櫞酸局部抗凝方案,準(zhǔn)備輸液泵將輸液管路與血濾管路的動(dòng)脈端相連接最接近患者處(血泵前)根據(jù)患者病情, 設(shè)置血濾機(jī)的常規(guī)參數(shù),,,R,heater,,ACD-A,,,V,,V,,PV,PA,,,UF,,,,BLD,,SAD,,,,葡萄糖酸鈣,枸櫞酸局部抗凝方案,ACD-A初始泵速為

19、血液流速(BFR)的2.0 – 2.5%泵速(ml/hr) = 1.2 – 1.5 x BFR (ml/min)例如BFR = 120 ml/minACD-A泵速 = 144 – 180 ml/hr,,,R,heater,,ACD-A,,,V,,V,,PV,PA,,,UF,,,,BLD,,SAD,,,,葡萄糖酸鈣,枸櫞酸局部抗凝方案,常規(guī)情況下選擇前稀釋方式,,,R,heater,,ACD-A,,,V,,V,,PV,PA,,

20、,UF,,,,BLD,,SAD,,,,葡萄糖酸鈣,枸櫞酸局部抗凝方案,置換液中不含鈣,,,R,heater,,ACD-A,,,V,,V,,PV,PA,,,UF,,,,BLD,,SAD,,,葡萄糖酸鈣,,,枸櫞酸局部抗凝方案,準(zhǔn)備10%葡萄糖酸鈣溶液及注射器泵將輸液管路連接至血濾管路靜脈端葡萄糖酸鈣溶液初始泵速為8.8 – 11.0 ml/hr (ACD-A泵速的6.1%),,,R,heater,,ACD-A,,,V,,V,,

21、PV,PA,,,UF,,,,BLD,,SAD,,,,葡萄糖酸鈣,枸櫞酸局部抗凝方案: 抗凝監(jiān)測(cè),,,,,,,,,,,,,,,,,,,,,,,,,Q2h x 4,Q4h x 4,Day 1,Day 2Q 6 – 8 h,枸櫞酸局部抗凝方案: 抗凝監(jiān)測(cè),,,R,heater,,ACD-A,,,V,,V,,PV,PA,,,UF,,,,BLD,,SAD,,,枸櫞酸鈣,動(dòng)脈標(biāo)本外周靜脈或動(dòng)脈游離鈣1.00 – 1.20 mmol/L,

22、靜脈標(biāo)本濾器后血濾管路游離鈣0.20 – 0.40 mmol/L,,,枸櫞酸局部抗凝方案: 抗凝監(jiān)測(cè),枸櫞酸局部抗凝方案: 抗凝監(jiān)測(cè),枸櫞酸局部抗凝方案: 抗凝監(jiān)測(cè),每次更換輸液部位或管路后1 – 2小時(shí)內(nèi)應(yīng)監(jiān)測(cè)離子鈣若血泵停止數(shù)分鐘以上必須關(guān)閉ACD-A泵(防止枸櫞酸進(jìn)入患者體內(nèi))必須關(guān)閉葡萄糖酸鈣泵(防止過(guò)量鈣進(jìn)入患者體內(nèi))若因病情需要停止血濾(如診斷, 更換導(dǎo)管, 手術(shù), 凝血或更換管路), 應(yīng)在重新開(kāi)始血濾時(shí)按照停止

23、前的速度設(shè)置ACD-A及葡萄糖酸鈣泵速,枸櫞酸局部抗凝方案: 抗凝監(jiān)測(cè),若HCO3增加> 10 mEq/L需要確認(rèn)ACD-A輸注部位正確, 未直接進(jìn)入患者體內(nèi)降低ACD-A泵速25%2 – 4小時(shí)后測(cè)定HCO3若測(cè)定結(jié)果仍不正常再次降低ACD-A泵速25%,枸櫞酸局部抗凝方案: 抗凝監(jiān)測(cè),若患者血Na上升10 mEq/L或> 155 mEq/L需要確認(rèn)ACD-A輸注部位正確, 未直接進(jìn)入患者體內(nèi)降低ACD-

24、A泵速25%2 – 4小時(shí)后測(cè)定血Na若測(cè)定結(jié)果仍不正常輸注5%GS,枸櫞酸抗凝的并發(fā)癥: 代謝性堿中毒,主要原因枸櫞酸轉(zhuǎn)化為HCO3 (1 mmol枸櫞酸能夠產(chǎn)生3 mmol的HCO3)次要原因溶液含有35 mEq/L HCO3消化道丟失含有乙酸成分的TPN治療方法是增加酸負(fù)荷生理鹽水(pH 5.4),枸櫞酸抗凝的并發(fā)癥: Citrate Lock,總鈣增加, 而游離鈣不變或降低枸櫞酸負(fù)荷超過(guò)肝臟代謝及CRRT清