血液透析原理及临床适应症.pptVIP

血液透析原理及臨床適應症 台大醫院 外科部護理師 蔡壁如 Evolution of Renal Replacement Therapy Basic Principle of Renal Replacement Therapy Diffusion Ultra-filtration Convection Adsorption Clearance = QF x SC QF= filtration amount SC=sieving coefficients Hemodialysis Hemofiltration Component of renal replacement therapy Membrane Vascular access Anti-coagulant Dialysate Renal replacement fluid Choice of membrane Substituted cellulose dialyzers : hydroxyl group Cellulose acetate, diacetate, triacetate Synthetic dialyzers : Polysulfone (PS) Polyamide (PA) Polyacrylonitrile (PAN) Polymethylmethacrylate (PMMA) Choice of membrane Biocompatible membrane (activate less complement and greater higher ?2-microglobulin clearance, greater hydraulic permeability.low and high-flux synthetic membranes) Hypotension and prolongation of ARF in biocompatible membranes Adsorptive vs. nonadsorptive membrane in CRRT Vascular access Grade C : avoided subclavian in adults Grade D : avoided femoral vein in neonates and young (femoral vein thrombosis is a significant problem) Grade C : Internal jugular vein Level II and III studies : Ultrasound guidance Re-circulation is likely to be significant for blood flow in excess of 200 c.c/min, but depending on catheter design and location Double lumen : Re-circulation rate under 250cc/min blood flow Subclavian , internal jugular vein 3% Catheter length Femoral vein 24cm : 10%, 15cm : 18% Blood flow 400 cc/min : 38% in the femoral vein Anticoagulation Standard protocol Initial bolus 10-30 unit/kg of heparin Infusion 10-30 unit/kg to target ACT :170-220 seconds or PTT: 2 X N.J.Maxvold, T.E. Bunchman/Crit Care Clin 2003 19(2),563-575 Ideal replacement fluid/dialysate Principle: remove waste, supply lost Nearly plasma water Supply inadequate component Individualized Different disease Dialysate (透析液) Replacement Fluid (補充液) Hybrid therapies in ICU CRR