持續(xù)腎臟替代治療的局部枸櫞酸抗凝學(xué)習(xí)教案

1、會計學(xué)1持續(xù)腎臟替代治療持續(xù)腎臟替代治療(zhlio)的局部枸櫞酸的局部枸櫞酸抗凝抗凝第一頁，共42頁。Uchino S, Kellum JA, Bellomo R, et al. Acute renal failure in critically ill patients: a multinational, multicenter study. JAMA 2005; 294: 813-818第1頁/共41頁第二頁，共42頁。GFR標(biāo)準(zhǔn)UO標(biāo)準(zhǔn)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, Kell

2、um JA, et al. Acute renal failure: definition, outcome measures, animal 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第2頁/共41頁第三頁，共42頁。Ostermann M, Chang RWS. Ac

3、ute kidney injury in the intensive care unit according to RIFLE. Crit Care Med 2007; 35: 1837-184335.8%第3頁/共41頁第四頁，共42頁。Perez-Valdivieso JR, Bes-Rastrollo M, Monedero P, et al. Prognosis and serum creatinine levels in acute renal failure at the time of nephrology consultation: an observational cohor

4、t study. BMC Nephrology 2007; 8: 14-22第4頁/共41頁第五頁，共42頁。18 30 hrHolt AW, Bierer P, Glover P, 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,

5、Maurin N. Hemostatic 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 1996; 19: 100-5.Tan HK, Baldwin I, Bellomo R. Continuous veno-venous hae

6、mofiltration without anticoagulation in high-risk patients. Intensive Care Med 2000; 26: 1652-7.第5頁/共41頁第六頁，共42頁。第6頁/共41頁第七頁，共42頁。血濾濾器(lq)與管路的抗凝作用全身(qun shn)抗凝有害作用第7頁/共41頁第八頁，共42頁。第8頁/共41頁第九頁，共42頁。抗凝方法抗凝方法病例數(shù)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

7、凝137 (6.1)第9頁/共41頁第十頁，共42頁。出血危險負(fù)荷劑量IU/kg維持劑量IU/kg/hrAPTTsecACTsec無危險性5010 2060 250危險較小15 255 1045160 180危險較大102.5 530120第10頁/共41頁第十一頁，共42頁。第11頁/共41頁第十二頁，共42頁。第12頁/共41頁第十三頁，共42頁。第13頁/共41頁第十四頁，共42頁。Hofbauer R, Moser D, Frass M, et al. Effect of anticoagulation on blood membrane interactions during hem

8、odialysis. Kidney Int第14頁/共41頁第十五頁，共42頁。Hofbauer R, Moser D, Frass M, et al. Effect of anticoagulation on blood membrane interactions during hemodialysis. Kidney Int第15頁/共41頁第十六頁，共42頁。Hofbauer R, Moser D, Frass M, et al. Effect of anticoagulation on blood membrane interactions during hemodialysis. K

9、idney Int第16頁/共41頁第十七頁，共42頁。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%)其他原因16 (44.4%)10 (23.3%)Kutsogiannis DJ, Gibney RTN, Stollery D et al. Regional citrate versus systemic heparin anticoagu

10、lation for continuous renal replacement in critically ill patients. Kidney Int 2005; 67: 2361-2367第17頁/共41頁第十八頁，共42頁。HR95%CIP值枸櫞酸0.3710.197 0.6990.002LOD評分1.2671.138 1.411 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 sy

11、stemic heparin anticoagulation for continuous renal replacement in critically ill patients. Kidney Int 2005; 67: 2361-2367第18頁/共41頁第十九頁，共42頁。枸櫞酸肝素相對危險度P值明確或隱性出血0.01 (0 0.04)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.

12、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 critically ill patients. Kidney Int 2005; 67: 2361-2367第19頁/共41頁第二十頁，共42頁。RR95%CIP值截距0.0010.00001 0.1740.008枸櫞酸0.1370.020 0.9590.05LOD評分0

13、.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 continuous renal replacement in critically ill patients. Kidney Int 2005; 67: 2361-2367第20頁/共41頁第二十一頁，共42頁。Kutsogiannis DJ, Gibney RTN, Stollery

14、 D et al. Regional citrate versus systemic heparin anticoagulation for continuous renal replacement in critically ill patients. Kidney Int 2005; 67: 2361-2367第21頁/共41頁第二十二頁，共42頁。第22頁/共41頁第二十三頁，共42頁。RheaterACD-AVVPVPAUFBLDSAD葡萄糖酸鈣第23頁/共41頁第二十四頁，共42頁。第24頁/共41頁第二十五頁，共42頁。成分成分分子量分子量含量含量(g)mmol枸櫞酸三鈉(二水)2

15、94.122.075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(p to)糖酸鈣第25頁/共41頁第二十六頁，共42頁。RheaterACD-AVVPVPAUFBLDSAD葡萄(p to)糖酸鈣第26頁/共41頁第二十七頁，共42頁。RheaterACD-AVVPVPAUFBLDSAD葡萄(p to)糖酸鈣第27頁/共41頁第二十八頁，共42頁。RheaterACD-AVVPVPAUFBLDSAD葡萄(p to)糖酸鈣第28頁/共41頁第二十九頁，共42頁。RheaterACD-

16、AVVPVPAUFBLDSAD葡萄(p to)糖酸鈣常規(guī)置換液配方常規(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29頁/共41頁第三十頁，共42頁。RheaterACD-AVVPVPAUFBLDSAD葡萄(p to)糖酸鈣第30頁/共41頁第三十一頁，共42頁。Q2h x 4Q4h x 4Day 1Day 2Q 6 8 h第31頁/共41頁第三十二頁，共42頁。RheaterACD-AVVPVPAUFBLDSAD枸櫞(u yun)酸鈣動脈標(biāo)本動脈標(biāo)本(bi

17、obn)外周靜脈或動脈外周靜脈或動脈游離鈣游離鈣1.00 1.20 mmol/L靜脈標(biāo)本靜脈標(biāo)本濾器后血濾管路濾器后血濾管路游離鈣游離鈣0.20 0.40 mmol/L第32頁/共41頁第三十三頁，共42頁。靜脈標(biāo)本游離鈣靜脈標(biāo)本游離鈣從濾器后靜脈取血部位取血從濾器后靜脈取血部位取血ACD-A輸注速度調(diào)整輸注速度調(diào)整 0.50 mmol/L增加10 ml/hr第33頁/共41頁第三十四頁，共42頁。動脈標(biāo)本游離鈣動脈標(biāo)本游離鈣從外周靜脈或動脈取血從外周靜脈或動脈取血10%葡萄糖酸鈣輸注速度調(diào)整葡萄糖酸鈣輸注速度調(diào)整 1.45 mmol/L降低6.1 ml/hr1.21 1.45 mmol/L降低3.1 ml/hr1.00 1.20 mmol/L維持不變0.90 1.00 mmol/L增加3.1 ml/hr 0.90 mmol/L推注3.1 ml/kg后, 增加6.1 ml/hr第34頁/共41頁第三十五頁，共42頁。第35頁/共41頁第三十六頁，共42頁。第36頁/共41頁第三十七頁，共42頁。第37頁/共41頁第三十八頁，共42頁。第38頁/共41頁第三十九頁