腎透析醫(yī)療技術(shù)基礎(chǔ)課件

腎透析醫(yī)療技術(shù)基礎(chǔ)MedicalandTechnicalBasics

相關(guān)醫(yī)學(xué)和技術(shù)基礎(chǔ)29/09/2024腎透析醫(yī)療技術(shù)基礎(chǔ)腎臟生理生成尿液，排除代謝終末產(chǎn)物、毒物和藥物調(diào)節(jié)體內(nèi)水、電解質(zhì)、滲透壓和酸堿平衡調(diào)節(jié)血壓分泌腎素、促紅細(xì)胞生成素、1,25-(OH)2D3、前列腺素等29/09/2024腎透析醫(yī)療技術(shù)基礎(chǔ)血液透析的作用清除體內(nèi)的毒素（彌散、對(duì)流、吸附）糾正酸堿平衡紊亂（彌散）清除體內(nèi)過(guò)多的水份（超濾）糾正電解質(zhì)失衡（彌散）29/09/2024腎透析醫(yī)療技術(shù)基礎(chǔ)

Diffusion彌散Start開始時(shí):Different

Concentrations膜兩側(cè)濃度有差別End結(jié)束時(shí):Equal

Concentrations膜兩側(cè)濃度相同time彌散是微分子物質(zhì)隨機(jī)的運(yùn)動(dòng)可導(dǎo)致均勻分布的結(jié)果

Diffusionisaconsequenceoftherandommovement

ofallmolecules(BrownianMovement).29/09/2024腎透析醫(yī)療技術(shù)基礎(chǔ)Ultrafiltration超濾TimePressureStart:End:Exertionofpressureononesideofthemembraneproducesfiltrationofwaterwithsolutes,aslongastheycanpassthemembrane.運(yùn)用壓力的作用將水份從膜一側(cè)推到另一側(cè)，膜孔夠大時(shí)溶質(zhì)也可以被擠出29/09/2024腎透析醫(yī)療技術(shù)基礎(chǔ)dialysateside透析液側(cè)bloodside血液側(cè)Adsorption

吸附afterchemicaldisinfection?hollowfiverendotoxins內(nèi)毒素-contactspace接觸空間Virus病毒29/09/2024腎透析醫(yī)療技術(shù)基礎(chǔ)H2OwatersolublemoleculesHFFmmHgmmHgBBHDBDBDHDFmmHgBmmHgDBDlow-flux低通透析器high-flux高通透析器high-flux高通透析器diffusionconvectionadsorptiondiffusion/convectionadsorptionTherapytypes治療模式Hemodialysis血液透析Hemofiltration血液濾過(guò)Hemodiafiltration血液透析濾過(guò)彌散原理對(duì)流吸附彌散對(duì)流吸附29/09/2024腎透析醫(yī)療技術(shù)基礎(chǔ)Hemodialysis血液透析利用血液和透析液中溶質(zhì)的濃度差別使溶質(zhì)在彌散作用下通過(guò)半透膜隨透析液排出Diffusivemetabolictransportthroughsemi-permeablemembraneswithbalanceofaconcentrationdifferencebetweenbloodanddialysisfluid.

小分子物質(zhì)可有效的被清除Smallmolecularsubstanceswillessentiallymoreeffective.diffusiveconvectiveadsorptiveclearanceBmmHgDBDhigh-fluxHemodialysis血液透析andHemofiltration血液透析濾過(guò)Hemofiltration血液透析濾過(guò)可溶物質(zhì)隨著通過(guò)高通透性半透膜的液體流動(dòng)而被清除（對(duì)流）。對(duì)流依靠跨膜壓和膜的物理性質(zhì)（面積、密度、質(zhì)量、孔徑）來(lái)實(shí)現(xiàn)。

Solublesubstancesaresweptalonginafluidstreamthroughhighpermeablemembranes(convection).Theconvectiondependsonthetransmembranepressureandonmembranefeatureslikesize,density,andqualityofthepores(?cut-off-value“).清除高分子量物質(zhì)（只要是低于膜孔的篩選值的物質(zhì)）的有效方法Highmolecularesubstances,aslongastheyarebelowthe?cut-off-value“,willbeeliminatedinabetterway.

29/09/2024腎透析醫(yī)療技術(shù)基礎(chǔ)HDF–Hemodiafiltration血液透析濾過(guò)結(jié)合兩種治療模式：血液透析和血液濾過(guò)結(jié)合由彌散產(chǎn)生的小分子物質(zhì)的高清除率和由對(duì)流產(chǎn)生的中大分子物質(zhì)的高清除率兩種方式的優(yōu)點(diǎn)。Combinationoftwodialysistechnics,hemodialysisandhemofiltration:highclearanceofconventionelsmallmoleculesbydiffusionlinkedwithhighclearanceofmiddlemoleculesbyconvection.mmHgBmmHgDBDDiffusion+Convection+Adsorptionhigh-flux高通濾器29/09/2024腎透析醫(yī)療技術(shù)基礎(chǔ)ReplacementSolutionforHFandHDF置換液常規(guī)離子范圍常用配方29/09/2024腎透析醫(yī)療技術(shù)基礎(chǔ)RheaterheparinVVPVPAUFBLDSADPostdilution后稀釋Predilution前稀釋HDF-Online在線透析濾過(guò)–Medical醫(yī)學(xué)29/09/2024腎透析醫(yī)療技術(shù)基礎(chǔ)Clearance

inHD,HFandHDF各治療模式的清除率0408012010102103104105Urea尿素氮Creatinine肌酐Vit.B12?2-Microglob.AlbumineClearance清除率ml/minMGDalton道爾頓（質(zhì)量單位）HFHDHDFKidney腎臟29/09/2024腎透析醫(yī)療技術(shù)基礎(chǔ)SemipermeableMembrane半透膜Virus病毒Bacteria細(xì)菌Mediumsized

molecules,e.g.

b2-MicroglobulinWaterflowis

easilypossible水最容易通過(guò)Erythrocyte,

redbloodcell紅血球Albumin,as

exampleofabig

proteinmolecule白蛋白等大蛋白分子Electrolytes電解質(zhì)Thesemipermeablemembranefunctionssimilartoafinesieve,

onlymoleculesthataresmallenoughcanpass.半透膜就是性能良好的篩網(wǎng)，僅有小于篩孔的物質(zhì)可以通過(guò)29/09/2024腎透析醫(yī)療技術(shù)基礎(chǔ)PressureDroponDialyser-LowFlux透析器內(nèi)的壓力分布示意圖200250300350400bloodsidepressuredropdialysatesidepressuredropfiltration=netUF凈超濾450PBEPVPDAUltrafiltration超濾作用mediumTMPpressureinthefilter29/09/2024腎透析醫(yī)療技術(shù)基礎(chǔ)AdvantagesoftheDialogBalanceChamberControlDialog機(jī)器的改良的容量平衡控制系統(tǒng)的優(yōu)點(diǎn)permanentmonitoringofthemembraneposition持續(xù)監(jiān)測(cè)平衡腔膜片位置

continuouscontrol連續(xù)控制nopressurespikesatthedialyser透析器內(nèi)沒有壓力尖峰

smoothUFandpreventionofreverseUFintheswitching moment超濾平穩(wěn)并且避免了液流切換時(shí)產(chǎn)生反超continuousdialysateflowevenintheswitchingmoment

透析液持續(xù)不斷（包括液流切換時(shí)刻）

bettertherapyresults(K*t/V)bymaintainingthediffussion pressure維持住彌散壓力可帶來(lái)更好的治療效果(K*t/V值)protectionofthemembranematerial,valvesandpumps

對(duì)膜片、閥門和泵都有保護(hù)作用。

extendedlifetime延長(zhǎng)配件壽命Dialog+competitor29/09/2024腎透析醫(yī)療技術(shù)基礎(chǔ)

TheAccessPoints-onPatient

病人血管通路CiminoFistulaV.jugularisinternaV.subclaviaV.cubitalisV.femoralisThebloodflowinthefistulamustbeatleastthedoubledfromtherequiredbloodflowattherapytominimizetherecirculation.29/09/2024腎透析醫(yī)療技術(shù)基礎(chǔ)TheSievingCoefficientoftheDialyser透析器的篩選系數(shù)Albumine69000DaUrea60DaCreatinin113DaPhosphat96DaVitaminB121355DaInulin5200Da

?2-Microglobuline

Membranepores

0,003μmErythozyt8,5*2μm29/09/2024腎透析醫(yī)療技術(shù)基礎(chǔ)UFFactor–SubstanceTransportFactor超濾系數(shù)

Diacap?HE1400-factor7,47,4ml/hpermmHgPressuredifference300mmHg*7,4ml/h/mmHg=2220ml/h200mmHg-100mmHgTMP300mmHgfactor7,4Cuprophan?CE2000factor8,6transportUF1500perhourvenouspressure220mmHgTMP=PDA=1500:8,6=174,4mmHgTMP-PV=-45,6mmHgvenouspressurePDAcalculationofUFremovalpressurecalculationmemorize:thefactorofthefiltercaneveninonechargedupto±15%changed.29/09/2024腎透析醫(yī)療技術(shù)基礎(chǔ)DialyserTypes透析器類型Syntheticmembrane

Cellulosemembrane

modifiedcelluloseregeneratedcellulose

Polysulfone(PSU)Polyamide(PA)Polycarbonate(PC)

Ethyl-vinyl-alcoholcopolymer(EVAL)

Polyacrylonitrile(PAN)

Polymethylmethacrylate(PMMA)High-fluxandLow-flux Low-fluxSyntheticmodifiedcellulose(SMC)Celluloseacetate(CA)Cellulosediacetate(CDA)

Cellulosetriacetate(CTA)Hemophan(HE)Cuprophan(CU)Cuprammonium29/09/2024腎透析醫(yī)療技術(shù)基礎(chǔ)DialyserTypeshighbiocompatiblebutmoreheparinnecessaryhighclearanceatmiddlemolecularsubstancesmoreeffectiveon

smallmolecularsubstancesmembranewithhighadsorptioneffectDiacap?PolysulfoneDiacap?

SMCSyntheticmodifiedCelluloseexcellentbalancedbiocompatibleprofile

29/09/2024腎透析醫(yī)療技術(shù)基礎(chǔ)102103104105106107108ExotoxicfragmentsExotoxicsMuramylpeptidPeptidoglykaneEndotoxicfragmentsLipidAEndotoxicsVirusBacteriaverificationCISCISCISCISCISLALLALCut-OffPointofDialyserMolecularweight/Daltonlowfluxhighflux29/09/2024腎透析醫(yī)療技術(shù)基礎(chǔ)MicrobiologicRequest微生物要求AAMI=AmericanAssociationfortheAdvancementofMedicalInstrumentationPh.Eur.=Europ?ischePharmacopoeiaCFU=ColonyFormingUnitsEU=EndotoxinUnits29/09/2024腎透析醫(yī)療技術(shù)基礎(chǔ)QualityofWaterandDialysate反滲水和透析液水質(zhì)Theusermustensurethatthewaterqualityiscontinuousmonitored.Thefollowingrequirementsmustbefulfilled:?TheincomingwatermustbefreefromMg++andCa++.?pHvalueofbetween5and7Wateranddialysatemustcomplywiththecountryspecificstandards,i.e.:?ISO13959:2002Waterforhemodialysisandrelatedtherapies?DINVDE0753-4,issue:1986-09Applicationregulationsforhemodialysismachines?ANSI/AAMIRD5-03Hemodialysissystems?ANSI/AAMIRD61:2001Concentratesforhemodialysis?ANSI/AAMIRD62:2001Watertreatmentequipmentforhemodialysisapplications29/09/2024腎透析醫(yī)療技術(shù)基礎(chǔ)QualityofWaterandDialysateFluid反滲水和透析液水質(zhì)29/09/2024腎透析醫(yī)療技術(shù)基礎(chǔ)ContextpHValue,HCO3-andpCO2Normalvalueonblood pH 7,36–7,45 pCO2 33–45mmHg HCO3- 21–26mmol/LIncreasingordropthepHvalueintheblood,overorunderacriticalvalueisnonphysological.Consequenceslikeheadaches,cramps,hypotension,hypertensionoratotalcollapseofthebloodcircuitarepossible.pHvalue>7.45alkalosespHvalue<7.36acidosisThenormalvalueforpCO2isbetween33-45mmHg,i.e.,thepCO2increase(alkaloses)-automaticallythepatientstartsahypervitalisation.ThepatientstartsCO2

dismantleasacontrareaction.29/09/2024腎透析醫(yī)療技術(shù)基礎(chǔ)ContextpHValue,HCO3-andpCO2H++HCO3-?H2CO3?H2O+CO2hydrogen–bicarbonate–carbondioxide-buffersystempCO2(mmHg)HCO3-(mmol/LpH7,450403530242016121098712141620253040506070pH7,3AzidosepH7,5Alkalosestandardrange

H+=24________pCO2

HCO3-

29/09/2024腎透析醫(yī)療技術(shù)基礎(chǔ)BicarbonateTherapy碳酸鹽治療–Technical技術(shù)方面

ImportantforthefactorspecificationorrechecktackthesamplecarefullyonlyonthebluecouplingwithasyringeasecurespecificationonlywithtitrationpossiblePHvaluerecheckmeasurementinstrumentondialysatemodus.SchalterSendeelektrodenVerst?rkerGleichrichterTiefpa?+5VoltRef.4kHzLFSignalEmpfangselktrodeconductivitycell29/09/2024腎透析醫(yī)療技術(shù)基礎(chǔ)BicarbonateTherapy–CalcificationNormalvalueinblood24mmol/L(attheendoftherapy26-28mmol/L).Thedirectmeasurementofthebicarbonateisnotpossible,wemeasureonlythesodiumonthebiccell.Normallytheproportionis1:1.Thegrainsofthepowder(2Na+HCO3-)inthecartridgearecoatedwithcarbonate.Thiscoatingisdissolvedfirst,thepHincreasesandtheunitcangetcalcified.Followup:proportionisnotmore1:1strongercalcification(frompH>7,5critical)pHmovementondialysate,bloodandbuddyfluidblockofdialysatefiltercoatingonconductivitycells(ratioalarm,sodiumnotcorrect)bloodleakalarm29/09/2024腎透析醫(yī)療技術(shù)基礎(chǔ)BicarbonateTherapy–MedicalAcetatemustbemetabolizedintheliverandkidneyfirsttobicarbonate,sothattheacid/basebalance(pHvalue)iscorrected.Duetothedelayintheconversionthepatientcanbecomeacidotic.Thiscanleadtocramps,hypotensionandvomitingofthepatient.Thisisevenworseifthepatienthasaliverdysfunction.Todayismostlyonlybicarbonateused.WiththattreatmentthepHvalueismorestable.Thepatientfeelsbetterandhisbodyisnotsoheavilyused.Thefluidtransportandexchangeofionsstartdirectlyafterthestartofthetherapy.Normalvalueinblood:24-28mmol/L29/09/2024腎透析醫(yī)療技術(shù)基礎(chǔ)AtomsBasicnucleus

protonelectronelectronelectronnucleus

proton/neutronhydrogenhelium29/09/2024腎透析醫(yī)療技術(shù)基礎(chǔ)ElectrolytesandIonsH2

O

Na+Cl-

Na+Cl-dissolvertDefinition Electrolytesaresubstanceswheretheelectricalcurrent isguidedviaions

Definition

Ionsareatomswithelectronabsence(cations)

orelectronexcess(anions)

Forinstance NaCldissociateinwater inNa+cationsandCl-anions29/09/2024腎透析醫(yī)療技術(shù)基礎(chǔ)Conductivity電導(dǎo)率Theconductivityisbasedonelectrolytesandtemperature.ThephysicalunitismS/cm(milleSiemenspercm).

ThisisanAmericannotationfortheelectricalresistanceandthisisareciprocalvaluetoEuropewithOhm(

).

Cl-

Na+currentquellcurrentmeasurementmS/cmMinuspole負(fù)極Pluspole正極29/09/2024腎透析醫(yī)療技術(shù)基礎(chǔ)CellconstantsoftheConductivityCell電導(dǎo)度傳感器的傳感器系數(shù)Thecellconstantsarechangingdifferencewiththecoating傳感器敏感系數(shù)會(huì)隨附著層增加而變化82,5=3,2165,5=2,9183=2,666166=2,666cellconstants傳感器系數(shù)

Distance距離diameter直徑distanceholderflowdirection透析液流向referenceelectrodetransmitter-electrodereceiver-electrodemeasurementcell2measurementcell10,5mmcoatingtransmitter-electrode=29/09/2024腎透析醫(yī)療技術(shù)基礎(chǔ)QualityofWaterandDialysateFluid

水質(zhì)與透析液0,5mmcoating附著層MagnesiumCarbonate碳酸鎂CalciumCarbonate

碳酸鈣Thecellconstantsarechangingdifferencewiththecoating傳感器敏感系數(shù)會(huì)隨附著層增加而變化Damagetothemachineduetocalciumdepositionsduringbicarbonatedialysis!鈣質(zhì)沉淀物將會(huì)損壞機(jī)器！Decalcifythemachineaftereachbicarbonatedialysis.每次碳酸鹽透析治療后都需要脫鈣Warning29/09/2024腎透析醫(yī)療技術(shù)基礎(chǔ)ReasonsforCalcification生成沉淀的原因2Na+HCO-3

Na2CO3+H2O+CO2bicarbonatesoda+water+carbondioxideNa2CO3+MgCl2MgCO3+2NaClmagnesiumcarbonateNa2CO3+CaCl2CaCO3+2NaClandcalciumcarbonate-frequently(often,chemicalresolvable)2Na2CO3+CaCl2+MgCl2CaMg(CO3)2+4NaClmarble(seldom,andnoteasydissolvable)Thecalciumandmagnesiumoftheacidconcentratereactchemicallywiththecarbonateandprecipitatestonon-dissolvableMgCO3+CACO3.沉淀物質(zhì)是A液中的鈣鎂離子和B液中的碳酸根離子產(chǎn)生的碳酸鈣和碳酸鎂29/09/2024腎透析醫(yī)療技術(shù)基礎(chǔ)AccommodationSystemfortwoMachinesmainsupplycentralacidconnectorsinletconnectoroutletconnectorwithfreefallgrounding29/09/2024腎透析醫(yī)療技術(shù)基礎(chǔ)IonExchanger-Softener離子交換罐—軟化29/09/2024腎透析醫(yī)療技術(shù)基礎(chǔ)microbiologicdebitofthepermeatecircuitwaternetreverseosmo