CRRT枸橼酸抗凝介绍

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1、9thCongressofChineseCriticalCareMedicineFreseniusLunchSymposiumCRRT枸橼酸抗凝现在&未来DrYanWingWaMBBS(HK),MSc(CUHK),FRCP(Lond,Edin),FHKCP,FHKAM(Medicine)ICUDirector,ICUofPamelaYoudeNethersoleEasternHospitalChairman,Central-coordination-Committee(IntensiveCare),HospitalAutho

2、rityHongKongSAR,China23May2015Scope大纲•Mechanism&evidenceofregionalcitrateanticoagulation(RCA)inCRRT•CRRT局域性枸橼酸抗凝的机制和证据•MyexperienceofRCAinCRRT•CRRT局域性枸橼酸抗凝我们的经验•CriticalsuccessfactorsofRCAimplementationinfuture•未来RCA实施关键的成功因素Managementofsevereacuterenalfailureincri

3、ticallyillpatients:aninternationalsurveyin345centresRoncoC.etal.Nephrol.Dial.Transplant.16:230-237.2001March2012www.kdigo.org/clinical_practice_guidelines/pdf/KDIGO%20AKI%20Guideline.pdfCitratecalciuminteraction枸橼酸钙的相互作用Citrate+iCaCalciumcitrateBiologicallyinactive

4、无活性Butmeasurableastotalcalcium总钙Circuit[iCa]decreasedto~0.3mmol/liCa浓度下降到~0.3mmol/lThislevelisincompatiblewithlife!终止RCA效果VenousreturnfromSVC+IVCwithiCa1.1mmol/lFlow4,850ml/minCRRTcircuitwithiCa~0.3mmol/lFlow150ml/minFlow5,000ml/miniCa~1.08mmol/lMixedvenousbloodAdv

5、antagesofRCARCA优点Nosystemicanticoagulation无全身抗凝Nosystemicbleedingrisk无全身出血风险Lessbleedingcomplications少出血并发症Lesstransfusionrequirement少输血需求Effectiveanticoagulationoftheextracorporealcircuit体外回路有效抗凝LessClotting少凝块Longerfilterlifetimes更长的滤器时间ChinMedJ2013,126:13

6、44-9IntensiveCareMed2012,38:20-8AmJKidneyDis2012,59:810-8CritCareMed2015Apr6.[Epubaheadofprint]CitrateanticoagulationforcontinuousvenovenoushemofiltrationOudemanns-vanStraatenHMet-al•RCT,non-blind•SinglecentreCitrate•215patientsrandomized•200patientsunderwentNadrop

7、arinCVVHperprotocol–97citrate–103nadroparinCritCareMed2009,37:545-521.SchilderLet-al,CritCare2014,18:4722.Oudemans-vanStraatenHMet-al,CritCareMed2009,37:545-523.HetzelGRet-al,NephrolDialTransplant2011,26:232-39LessclottinginHollowFibersmembrane中空纤维膜少凝块KidInt1999Oth

8、eradvantagesofRCARCA其他优点•Ahighenergyfuelforcriticallyill.重症的高能燃料–Entercellswithoutinsulin,~0.59kcal/mmol–无胰岛素就进入细胞,~0.59kcal/mmol–BalikMetal,Inte