CRRT的局部枸橼酸抗凝课件

1、CRRT的局部枸橼酸抗凝血透室 方咏梅第1页，共41页。ICU中的急性肾脏功能衰竭*: BEST Kidney患病率1738/29269 (5.7%, 95%CI 5.5 6.0%)危险因素感染性休克(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页，共41页。急性肾功能衰竭的定义: RIFLE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

3、 of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care 2019; 8: R204-R212第3页，共41页。ICU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 2019; 35: 1837-184335.8%第4页，共41页。急性肾功能衰竭的治疗(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页，共41页。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 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页，共41页。持续肾脏替代治疗的影响因素血管通路位置中心

7、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第7页，共41页。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第8页，共41页。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第9页，共41页。国内文献报告的抗凝方法抗凝方法病例数(%)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)第10页，共41页。CRRT时的肝素抗凝出血危险负荷剂量IU/kg维持剂量IU/kg/hrAPTTsecACTsec

8、无危险性5010 2060 250危险较小15 255 1045160 180危险较大102.5 530120第11页，共41页。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)第12页，共41页。枸橼酸抗凝的原理第13页，共41页。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:血液进入体外循环后即加入枸橼酸血液进入体内前补充游离钙体外循环对血液进行抗凝, 体内血液正常通过测定游离钙监测抗凝第14页，共41页。肝素

9、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第15页，共41页。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. Kidney Int第16页，共41页。枸橼酸抗凝

10、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第17页，共41页。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 (18.6%)滤器压力高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页，共41页。滤器寿命的Cox风险比例模型分析HR95%CIP值枸橼酸0.3710.197 0.6990.002LOD评分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页，共41页。出血或输血的比例枸橼酸肝素相对危险度P值明确或隐性出血0.01 (0 0.04

13、)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 replacement in criticall

14、y ill patients. Kidney Int 2019; 67: 2361-2367第20页，共41页。CRRT时出血的多因素Poisson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 anticoagulation for conti

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

16、2页，共41页。枸橼酸局部抗凝方案第23页，共41页。枸橼酸局部抗凝图示RheaterACD-AVVPVPAUFBLDSAD葡萄糖酸钙第24页，共41页。枸橼酸局部抗凝方案说明血滤机常规预冲肝素盐水根据患者病情选择适当治疗模式CVVHCVVHDCVVHDF第25页，共41页。枸橼酸局部抗凝方案准备枸橼酸抗凝液血液保存液(I) 600 ml/袋广州华南医疗用品有限公司成分分子量含量(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1000 mlRheaterACD-AVVPVPAUFBLDSAD葡萄糖酸钙

17、第26页，共41页。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葡萄糖酸钙第27页，共41页。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%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葡萄糖酸钙第28页，共41页。枸橼酸局部抗凝方案常规情况下选择前稀释方式RheaterACD-AVVP

18、VPAUFBLDSAD葡萄糖酸钙第29页，共41页。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0.9% NS2000 ml注射用水500 ml5% NaHCO3125 ml25% MgSO43 ml10% CaGlu20 ml15% KCl5 ml50% GS总量第30页，共41页。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%)RheaterACD-AVVPVPAUFBLDSAD葡萄糖酸钙第31页，共41页。枸橼酸局部抗凝方案: 抗凝监测Q2h x 4Q4h x 4Day 1Day 2Q 6 8 h第32页，共41页。枸橼酸局部抗凝方案: 抗凝监测RheaterACD-AVVPVPAUFBLDSAD枸橼酸钙动脉标本外周静脉或动脉游离钙1.00 1.20 mmol/L静脉标本滤器后血滤管路游离钙0.20 0.40 mmol/L第33页，共41页。枸橼酸局部抗凝方案: 抗凝监测静脉标本游离钙从滤器后静脉取血部位取血ACD-A输注速度调整 0.50 mmol/L增加10 ml/hr第34页，共41页。枸橼酸局部抗凝方案: 抗凝监测动脉标本游离钙从外周静脉或动脉取血10%葡萄糖酸钙输注速度调整