Continuous Veno-venous Hemofiltration.pptVIP

Continuous Veno-venous Hemofiltration R4 周信旭 / VS 邱元佑 93.5.21 CVVH 簡介 CVVH 是以連續的血液過濾再加上適當的液體補充。 治療過程中對人體的血流動力變化穩定，容易達到水分移除與平衡，連續性去除體內毒性物質（如內毒素）。 Indications for CVVH Oliguria/Anuria Significant organ edema (especially lung) Severe electrolyte imbalance (Na, K, Ca) Severe acidemia Uremic pericarditis Uremic encephalopathy/neuropathy/myopathy Drug overdose or intoxication Life-threatening hyperthermia Inborn error of metabolism CVVH(D)之原理 (1) 超過濾(Ultrafiltration):Filtration across an ultrafiltration membrane is convective, similar to that found in the glomerulus of the kidney. 影響對流(convective)效應之因素: Clearance factors Transmembrane pressure WATER (not solute) permeability of membrane blood flow rate 擴散(diffusion): solute molecules are transferred across the membrane in the direction of the lower solute concentration CVVH(D)之原理 (2) 血液過濾(Hemofiltration):no dialysate is used diffusive transport cannot occur Solute transfer is entirely dependent on convective transport, making hemofiltration relatively inefficient at solute removal 血液透析(Hemodialysis): diffusive transport Clearance factors surface area and unit SOLUTE permeability of membrane blood flow/dialysis flow duration of dialysis 血液過濾膜之特性 CVVH的技術 幫浦：可區分為靠動靜脈壓力差推動或洗腎機幫浦推動。 抗凝劑：包括使用肝素或其他抗凝劑如Citrate於出血傾向的病患。 血管通路: CVVHD較CAVHD安全，不會引起動脈阻塞、出血、及栓塞。但是使用CVVHD則要注意是否有空氣跑入，或管路連接脫落導致大量出血。 透析器：一般使用高透量的短型人工腎臟，當然傳統的人工腎臟透析器也可使用。 補充液及透析液：可以使用一般腹膜透析的含1.5%葡萄糖透析液，或CAVHD專用補充液；或自己泡製。 CVVH Order (1) Check baselines ACT, PT, APTT, bleeding time Heparin infusion: titrating to keep ACT: 1.5 ~ 2.0X or 200 ~ 300 sec (Normal: 100 sec) Blood flow rate: ml/min Replacement fluid: LR or Two-bag formulation: Solution A: 1L 0.9% N/S + 15ml Ca-gluconate (7 mEq) Solution B: 1L 0.45% N/S + 80ml NaHCO3 (67 mEq) (Keep negative balance: ml/min) Check dialyzer arterial and venous side Hct simultaneously qd CVVH Order (2) Check ACXT q1hr initially, if stable, check q2hr ? q4hr ? q8hr ? q12hr Check filtrate BUN, Cr, Na, K, Ca, P qd Check blood g