CRRT的局部枸櫞酸抗凝課件

1、CRRT的局部枸櫞酸抗凝血透室 方詠梅第1頁，共41頁。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. Acute renal failure in critically ill patients: a multinational, multicenter study. JAMA 2019

2、; 294: 813-818第2頁，共41頁。急性腎功能衰竭的定義: RIFLE標準GFR標準UO標準Risk肌酐增加x 1.5或GFR降低 25%UO 50%UO 75%UO 4周ESRD終末期腎病 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

3、 of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care 2019; 8: R204-R212第3頁，共41頁。ICU的急性腎臟損傷(AKI)Ostermann M, Chang RWS. Acute kidney injury in the intensive care unit according to RIFLE. Crit Care Med 2019; 35: 1837-184335.8%第4頁，共41頁。急性腎功能衰竭的治療(n = 646)Perez-Valdivieso JR, Bes-Rastrollo

4、M, Monedero P, et al. Prognosis and serum creatinine levels in acute renal failure at the time of nephrology consultation: an observational cohort study. BMC Nephrology 2019; 8: 14-22第5頁，共41頁。持續(xù)腎臟替代治療管路壽命滿足治療要求降低治療費用減少重新安裝管路的護理時間18 30 hrHolt AW, Bierer P, Glover P, Plummer JL, Bersten AD. Convention

5、al coagulation and thromboelastograph parameters and longevity of continuous renal replacement circuits. Intensive Care Med 2019; 28: 1649-55.Stefanidis I, Hagel J, Frank D, Maurin N. Hemostatic alterations during continuous venovenous hemofiltration in acute renal failure. Clin Nephrol 2019; 46(3):

6、 199-205.Kox WJ, Rohr U, Waurer H. Practical aspects of renal replacement therapy. Int J Artif Organs 2019; 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.第6頁，共41頁。持續(xù)腎臟替代治療的影響因素血管通路位置中心

7、靜脈導管: 口徑, 管腔設(shè)計血流可靠性血濾管路設(shè)計透析膜的生物相容性護理人員的培訓及專業(yè)技能抗凝效果第7頁，共41頁。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第8頁，共41頁。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)驗第9頁，共41頁。國內(nèi)文獻報告的抗凝方法抗凝方法病例數(shù)(%)單藥抗凝普通肝素844(37.9)低分子肝素686(30.8)枸櫞酸26(1.2)聯(lián)合抗凝普通肝素+低分子肝素483(21.7)普通肝素+枸櫞酸52(2.3)無抗凝137(6.1)第10頁，共41頁。CRRT時的肝素抗凝出血危險負荷劑量IU/kg維持劑量IU/kg/hrAPTTsecACTsec

8、無危險性5010 2060 250危險較小15 255 1045160 180危險較大102.5 530120第11頁，共41頁。肝素抗凝的優(yōu)缺點優(yōu)點最常用的抗凝方法臨床方案成熟半衰期短過量時魚精蛋白對抗缺點出血危險APTT與濾器壽命無關(guān)肝素誘導血小板缺乏(HIT)第12頁，共41頁。枸櫞酸抗凝的原理第13頁，共41頁。局部枸櫞酸抗凝的原理凝血過程需要游離鈣參與枸櫞酸螯合游離鈣, 補充鈣離子可以恢復血庫使用枸櫞酸保存血液采用枸櫞酸可以在RRT時進行局部抗凝:血液進入體外循環(huán)后即加入枸櫞酸血液進入體內(nèi)前補充游離鈣體外循環(huán)對血液進行抗凝, 體內(nèi)血液正常通過測定游離鈣監(jiān)測抗凝第14頁，共41頁。肝素

9、抗凝時的濾器中空纖維Hofbauer R, Moser D, Frass M, et al. Effect of anticoagulation on blood membrane interactions during hemodialysis. Kidney Int第15頁，共41頁。低分子肝素抗凝時的濾器中空纖維Hofbauer R, Moser D, Frass M, et al. Effect of anticoagulation on blood membrane interactions during hemodialysis. Kidney Int第16頁，共41頁。枸櫞酸抗凝

10、時的濾器中空纖維Hofbauer R, Moser D, Frass M, et al. Effect of anticoagulation on blood membrane interactions during hemodialysis. Kidney Int第17頁，共41頁。血濾終止的原因枸櫞酸(n = 36)肝素(n = 43)管路凝血6 (16.7%)23 (53.5%)改為IHD1 (2.8%)0血管通路問題2 (5.6%)0管路斷裂或滲漏1 (2.8%)0管路打折1 (2.8%)0轉(zhuǎn)運至放射科或手術(shù)室8 (22.2%)8 (18.6%)濾器壓力高1 (2.8%)2 (4.7%

11、)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 2019; 67: 2361-2367第18頁，共41頁。濾器壽命的Cox風險比例模型分析HR95%CIP值枸櫞酸0.3710.197 0.6990.002LOD評分1.2671.138 1.411

12、 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 2019; 67: 2361-2367第19頁，共41頁。出血或輸血的比例枸櫞酸肝素相對危險度P值明確或隱性出血0.01 (0 0.04

13、)0.13 (0.04 0.23)0.17 (0.03 1.04)0.06輸注RBC0.17 (0.10 0.25)0.33 (0.18 0.49)0.53 (0.24 1.20)0.13輸注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 replacement in criticall

14、y ill patients. Kidney Int 2019; 67: 2361-2367第20頁，共41頁。CRRT時出血的多因素Poisson回歸RR95%CIP值截距0.0010.00001 0.1740.008枸櫞酸0.1370.020 0.9590.05LOD評分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 anticoagulation for conti

15、nuous renal replacement in critically ill patients. Kidney Int 2019; 67: 2361-2367第21頁，共41頁。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 ill patients. Kidney Int 2019; 67: 2361-2367第2

16、2頁，共41頁。枸櫞酸局部抗凝方案第23頁，共41頁。枸櫞酸局部抗凝圖示RheaterACD-AVVPVPAUFBLDSAD葡萄糖酸鈣第24頁，共41頁。枸櫞酸局部抗凝方案說明血濾機常規(guī)預沖肝素鹽水根據(jù)患者病情選擇適當治療模式CVVHCVVHDCVVHDF第25頁，共41頁。枸櫞酸局部抗凝方案準備枸櫞酸抗凝液血液保存液(I) 600 ml/袋廣州華南醫(yī)療用品有限公司成分分子量含量(g)mmol枸櫞酸三鈉(二水)294.122.075枸櫞酸(一水)210.148.038葡萄糖(一水)198.1724.5120加注射用水至1000 mlRheaterACD-AVVPVPAUFBLDSAD葡萄糖酸鈣

17、第26頁，共41頁。枸櫞酸局部抗凝方案準備輸液泵將輸液管路與血濾管路的動脈端相連接最接近患者處(血泵前)根據(jù)患者病情, 設(shè)置血濾機的常規(guī)參數(shù)RheaterACD-AVVPVPAUFBLDSAD葡萄糖酸鈣第27頁，共41頁。枸櫞酸局部抗凝方案ACD-A初始泵速為血液流速(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/hrRheaterACD-AVVPVPAUFBLDSAD葡萄糖酸鈣第28頁，共41頁。枸櫞酸局部抗凝方案常規(guī)情況下選擇前稀釋方式RheaterACD-AVVP

18、VPAUFBLDSAD葡萄糖酸鈣第29頁，共41頁。枸櫞酸局部抗凝方案置換液中不含鈣RheaterACD-AVVPVPAUFBLDSAD葡萄糖酸鈣常規(guī)置換液配方0.9% NS2000 ml注射用水500 ml5% NaHCO3125 ml25% MgSO43 ml10% CaGlu20 ml15% KCl5 ml50% GS總量第30頁，共41頁。枸櫞酸局部抗凝方案準備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%)RheaterACD-AVVPVPAUFBLDSAD葡萄糖酸鈣第31頁，共41頁。枸櫞酸局部抗凝方案: 抗凝監(jiān)測Q2h x 4Q4h x 4Day 1Day 2Q 6 8 h第32頁，共41頁。枸櫞酸局部抗凝方案: 抗凝監(jiān)測RheaterACD-AVVPVPAUFBLDSAD枸櫞酸鈣動脈標本外周靜脈或動脈游離鈣1.00 1.20 mmol/L靜脈標本濾器后血濾管路游離鈣0.20 0.40 mmol/L第33頁，共41頁。枸櫞酸局部抗凝方案: 抗凝監(jiān)測靜脈標本游離鈣從濾器后靜脈取血部位取血ACD-A輸注速度調(diào)整 0.50 mmol/L增加10 ml/hr第34頁，共41頁。枸櫞酸局部抗凝方案: 抗凝監(jiān)測動脈標本游離鈣從外周靜脈或動脈取血10%葡萄糖酸鈣輸注速度調(diào)整