肾替代性治疗课件

肾替代性治疗RenalReplacementTherapy

(RRT)

腎替代性治療

肾替代性治疗AcuteKidneyInjury(AKI)

[AcuteRenalFailureARF]肾替代性治疗肾替代性治疗PreventionIdentificationofhigh-riskpatientsforpharmacologicagents-inducednephrotoxicityiodinatedradiocontrastmedium,NSAIDsAggressivesurveillancefornephrotoxin-inducedrenaldysfunctioncisplatin,amphotericinB,aminoglycosideUseofvolumeexpansioninselectedclinicalsettingsHyperpigmenturia:hemoglobinuria,myoglobinuriaCrystaluria:uricacid,acyclovir,methotrexate,sulfonamidesMinimalizationofcathetersusetoavoidnosocomialsepsis肾替代性治疗EtiologyTreatment

CorrectpostrenalfactorCorrectprerenalfactorTreatunderlyingsepsisStopnephrotoxicdrugs肾替代性治疗Evaluationofintravascularvolume肾替代性治疗GuideofVolumeExpansionCVP8-14cmH2OPAWP12-16mmHgUrineoutput0.5-1.0ml/kg/hourWeighingthepatientdailyInsensiblewaterlossfromtheskinandrespiratorytract(500ml/day)肾替代性治疗ConservativeMeasurementFluidbalanceCarefulmonitoringofI/OandbodyweightFluidrestriction(usuallylessthan1L/dayinoliguricARF)Totalintake<urineoutput+extrarenallossesElectrolytesandacid-basebalancehyperkalemiahyponatremiaKeepserumbicarbonate>15hyperphosphatemiaTreathypocalcemiaonlyifsymptomatic肾替代性治疗Uremia-nutritionRestrictionproteinbutmaintaincaloricintakeCarbohydrate≥100gm/daytominimizeketosisandproteincatabolismDrugReviewallmedication,Stopmagnesium-containingmedicationAdjusteddosageforrenalfailure,ReadjustwithimprovementofGFRConservativeMeasurement肾替代性治疗DietarymodificationTotalcaloricintake–35~50kcal/kg/daytoavoidcatabolismSaltrestriction–2~4g/dayPotassiumintake–40meq/dayPhosphorusintake–800mg/day肾替代性治疗RenalReplacementTherapy肾替代性治疗IndicationsforRenalReplacementTherapyProphylacticdialysis:BUN80-100mg/dl,creatinine8-10mg/dlVolumeoverloadingwithrefractorytodiureticsPulmonaryedemaHyperkalemia>6.5mEq/lSeveremetabolicacidosis<7.1UremicpericarditisUremicencephalopathy:coma,seizureAcuteuricacidnephropathy肾替代性治疗MethodsforRenalReplacementTherapyIntermittenthemodialysisPeritonealdialysisContinuousrenalreplacementtherapy:CAVH/CAVHD/CVVHDF,CVVH/CVVHD/CVVHDF肾替代性治疗MechanismsDiffusion:movementofsolutetowardsthesameconcentrationoneachsideofmembrane.Convection:soluteis‘carried’togetherwithsolventacrossthemembranebyfiltration.Ultrafiltration:plasmawaterandcrystalloidsseparatedfromthewholebloodacrossasemipermeablemembraneinresponsetoaTMP.Osmosis:operatesinperitonealdialysis.(glucoseistheosmoticagent)肾替代性治疗Dialysis肾替代性治疗Ultrafiltration

肾替代性治疗IntermittenthemodialysisinARFandcriticallyillpatients肾替代性治疗PeritonealdialysisInfusionofpyogen-freesolutionintotheperitonealcavity,drainedinsubsequentcycles.Mechanism:diffusion,convection,andosmoticultrafilationIndications:patientsatriskofbleedingfluidoverloadinCVinstability肾替代性治疗Peritonealdialysis肾替代性治疗肾替代性治疗Continuousrenalreplacementtherapy(CRRT)連續性腎替代性治療

肾替代性治疗急性腎衰竭仍是重症病患常見併發症之一，且死亡率極高(>50%)重症病患常合併有低血壓，血行動力不穩，多重器官衰竭；且常需大量輸液(升壓劑,輸血)合併急性腎衰竭需透析時常合併

(1)血行動力不穩定

(2)大量輸液無法依需要給予（如TPN)CRRT提供另類腎替代療法的選擇，並可避免傳統間歇性血液透析(intermittenthemodialysis,IHD)執行上的缺點CRRT肾替代性治疗CRRT種類連續性動脈靜脈血液過濾術(CAVH)Continuousarteriovenoushemofiltraton連續性靜脈靜脈血液過濾術（CVVH）Continuousvenous-venoushemodialysis連續性動脈靜脈血液透析術（CAVHD）連續性靜脈靜脈血液透析術（CVVHD）Continuousvenous-venoushemodialysis連續性動脈靜脈血液透析過濾術（CAVHDF）連續性靜脈靜脈血液透析過濾術（CVVHDF）Continuousvenous-venoushemodiafiltration肾替代性治疗肾替代性治疗CAVH肾替代性治疗CVVH肾替代性治疗肾替代性治疗肾替代性治疗肾替代性治疗肾替代性治疗肾替代性治疗CRRT的適應症A.Renalindications -hemodynamicinstability -multipleorgansdysfunctionsyndromeaccompaniedbyrenalfailure -acuterenalfailurewithcerebraledemaB.Non-Renalindications-possibleremovalofsubstancesactiveas‘mediators’肾替代性治疗適應症(1)急慢性腎衰竭及血壓不穩定休克患者之併發症。

(2)呼吸窘迫症候群。(3)多重器官衰竭。(4)鬱血性心衰竭、或肝衰竭。(5)敗血性休克。(6)燙傷併血壓不穩。(7)器官移植後急性腎衰竭。(8)毒藥物中毒。肾替代性治疗CRRT的優點Avoidanceofelectrolyte,waterandureafluctuationGradualurearemovalHemodynamicstabilitywithslowultrafiltrationOptimalfluidbalanceandunlimitedalimentationEliminationofsepticmediatorsLowerintracranialpressureImprovedoutcome肾替代性治疗CRRT的缺點出血危險性（常需使用抗凝劑）limitedmobilityslowersoluteandfluidremoval肾替代性治疗MMHCRRTOrder

Modality:(CVVH,CVVHD,CVVHDF)

AKpriming:N/S500ccx2BTaaheparin0.5cc

Anticoagulation:PrepareHeparin12,500U+N/S500ccIVD10cc/hrwithpumptokeepaPPT1.5-2

andadjustasfollowed

aPTT hold dose(ml/h)

<1.5

- +2

1.5-2.0x - Notchange

2.0-2.5x 30mins -2

>2.5x 60mins -4Ifnon-heparin,N/S(250)ccQ30minstorinsetheAK

肾替代性治疗

Predilution:run999cc/hralternatelyasfollowedviaarteryend

1stbottleN/S500cc+Sinca1amp

2ndbottleN/S500cc+10%MgSO44cc

3rdbottleN/S500cc

4thbottleD5W500cc+NaHCO35ampDialysate:1.5%PDsolutionrun999cc/hrWarmPredilution&Dialysateto37.0℃

RecordI/O&BPQ1H

UFtarget:I-O=(-40)cc/hr

Monitor:BUN,Cr,Na,K,ClQ12Hx1dayandthenQDCa,PQD;MgQW1,4aPTTQ12HKClsupplement:肾替代性治疗肾替代性治疗MMH配方

(Predilution)Predilutionrun500cc/hralternatelyasfollowedviaarteryend:1stbottleN/S500cc+Sinca1amp2ndbottleN/S500cc+10%MgSO44cc3rdbottleN/S500cc4thbottleD/W500cc+NaHCO35amp電解質

mEg/LNa+Mg2+Ca2+Cl-HCO3-K+MMH配方148.401.512.12109.0739.420肾替代性治疗肾替代性治疗Dialy