持续肾脏替代治疗的局部枸橼酸抗凝.PPTX

持续肾脏替代治疗的局部枸橼酸抗凝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 0.5 ml/kg/hr x 6 hrInjury肌酐增加x 2或GFR降低 50%UO 0.5 ml/kg/hr x 12 hrFailure肌酐增加x 3或GFR降低 75%UO 0.3 ml/kg/hr x 24 hr或无尿x 12 hrLoss持续ARF = 肾脏功能完全丧失 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 of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care 2004; 8: R204-R212ICU的急性肾脏损伤(AKI)35.8%Ostermann M, Chang RWS. Acute kidney injury in the intensive care unit according to RIFLE. Crit Care Med 2007; 35: 1837-1843急性肾功能衰竭的治疗(n = 646)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 cohort study. BMC Nephrology 2007; 8: 14-22持续肾脏替代治疗管路寿命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, 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 haemofiltration without anticoagulation in high-risk patients. Intensive Care Med 2000; 26: 1652-7.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持续肾脏替代治疗的影响因素血管通路位置中心静脉导管: 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)CRRT时的肝素抗凝出血危险负荷剂量IU/kg维持剂量IU/kg/hrAPTTsecACTsec无危险性5010 – 2060 250危险较小15 – 255 – 1045160 – 180危险较大102.5 – 530120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价格低廉药代动力学不稳定缺点出血危险APTT与滤器寿命无关肝素诱导血小板缺乏(HI