*Dialysate Safety 1透析透析机功能组件的临床使用机功能组件的临床使用北京大学第一医院肾内科北京大学第一医院肾内科, 100034, 100034 左力左力透析机功能组件的临床使用透析机功能组件的临床使用 背景背景 血容量监测血容量监测 透析充分性监测透析充分性监测 血温监测血温监测 血压监测血压监测 总结总结*Dialysate Safety 2低温保存盘管透析器低温保存盘管透析器Br Med J 1:5347:17161717, 1963*血液透析原理4最早的人工肾最早的人工肾*血液透析原理5改进后的早期人工肾改进后的早期人工肾*血液透析原理6转鼓式人工肾转鼓式人工肾*血液透析原理7早期的血泵早期的血泵*血液透析原理8平板式人工肾平板式人工肾透析器的化学消毒透析器的化学消毒JAMA 207:20872088, 1969Dial Transplant 2:1416, 32, 1973透析患者死亡率高透析患者死亡率高HFD10Am J Kidney DisAm J Kidney Dis. 1998; 32 (5 Suppl. 3):S112119. 1998; 32 (5 Suppl. 3):S112119中国中国ESRDESRD的患病和发病情况的患病和发病情况*CSBP, ESRD Registration11中国血液净化. 2010; 9: 47-49ESRDESRD的病因构成的病因构成*CSBP, ESRD Registration12中国血液净化. 2010; 9: 47-49死因构成死因构成*CSBP, ESRD Registration13中国血液净化. 2010; 9: 47-49我国香港我国香港/ /台湾台湾/ /日本的日本的ESRDESRD患病患病 率率ESRD Challenge 14大陆北京市血液透析患病率北京市血液透析患病率ESRD Challenge 15年代年代20022002200320032004200420052005200620062007200720082008患者患者数数76037603711071107654765480188018965896586907690786448644北京市北京市人口数人口数 （百万）（百万）14.5314.5314.8314.8315.1315.1315.4315.4315.7315.7316.0316.0316.3316.33患病率患病率 （每百万人口）（每百万人口）523523479479506506520520614614431431529529透析机功能组件的临床使用透析机功能组件的临床使用 背景背景 血容量监测血容量监测 透析充分性监测透析充分性监测 血温监测血温监测 血压监测血压监测 总结总结*Dialysate Safety 16血容量监测方法血容量监测方法 标志物稀释法标志物稀释法 HctHct 蛋白蛋白 胶体渗透压胶体渗透压 自动监测自动监测 超声法超声法 光电原理光电原理*血液透析原理17BV1BV1Hct1Hct1BV2BV2Hct2Hct2HctHct1 1 BVBV1 1= HCT= HCT2 2 BV BV2 2 BV=(HctBV=(Hct2 2-HCT-HCT1 1)/Hct)/Hct2 2HYPOTENSION !Possible causes of Hypotension during dialysisPossible causes of Hypotension during dialysisDrugsDrugsIncorrect weightIncorrect weightSodium InfluencesSodium InfluencesEatingEatingTemperature relatedTemperature relatedFluid removalFluid removalAcetate DialysateAcetate DialysateAutonomous nervousAutonomous nervoussystem dysfunction system dysfunctionIntracellular volume (ICV) 63% TBWExtracellular volume (ECV) 37% TBWLean body massFatTotal body water (60-65% BW)Plasma ( 7%) 35-40% BW人体人体组成组成透析过程中的体液重分布透析过程中的体液重分布Intracellular water (without blood cell water)Interstitial waterBloodcirculating BVperipheral BVultrafiltrationultrafiltration dialysate dialysate osmolarityosmolarity dialysate dialysate temperaturetemperatureInterstitial SpaceVascular SpaceUF(7 Litres)(12 Litres)Critical ! Vascular Refilling RateBV = UFR - VRRModel of Model of BVBV response to UF response to UFUltrafiltration BVBiofeedback based on detection of change in Biofeedback based on detection of change in (relative) blood volume(relative) blood volumeMeasuring Measuring Solid density of blood Solid density of bloodSound Speed for Blood Volume MeasurementControl SystemPulse, now!Start counting!Sound transmittert = 0Sound receiverControl SystemStop counting!t = t1Pulse detected!Sound transmitterSound receiverSound Speed, Hematocrit and TemperatureSound Speed, Hematocrit and Temperature25303540451500152015401560158016001620Sound speed m/sSound speed m/sTemperature CTemperature CwaterwatersalinesalineHct = Hct = 10%10%Hct = 20%Hct = 20%Hct = 30%Hct = 30%Hct = 40%Hct = 40%Hct = 50%Hct = 50%BloodBloodKRAEMER M, 1995few cells low protein density poor sound coupling long transient timesmany cells high protein density excellent sound coupling short transient timesWater (84.7%)ProteinsProteins (12.5%)(12.5%)Other (2.8%)Typical blood composition (in mass-%, for HCT=35%) Typical blood composition (in mass-%, for HCT=35%) Start of dialysisStart of dialysisRBV = 100%RBV = 100%HCT = 30%HCT = 30%v=1573.1 m/secv=1573.1 m/secEnd of dialysisEnd of dialysisRBV = 80% RBV = 80% HCT = 37.5% HCT = 37.5% v=1580.4 m/secv=1580.4 m/secExample:Example:1234512345Typical Sound Speed RangeTypical Sound Speed RangeKRAEMER M, 1995Pulse Transit TimeBlood temperatureFrom Ultrasound to Blood DataFrom Ultrasound to Blood DataSound speed in bloodBlood water concentration, blood protein concentrationRelative data relative blood volume (RBV)Absolute data hematocrit (HCT),hemoglobin (Hb)Different blood volume Different blood volume monitorsmonitorsFMC Ultrasonic Blood Volume Monitor (1)FMC Ultrasonic Blood Volume Monitor (1)TransmitterTemperature sensorReceiverPulse transit time: Pulse transit time: 10.8 s 10.8 sTime resolution:Time resolution:20 ps20 psFMC Ultrasonic Blood Volume Monitor (2)FMC Ultrasonic Blood Volume Monitor (2)Sensor head with cuvette disposableBVM electronics compartmentOn-line detection of the dry weight end pointRBV %889092949698100102UFR = 1.1l/hrChange rate of RBV = increase vascular refilling Change rate of RBV = stop/reduce vascular refilling UF Stress Test - overloaded patientUF Stress Test - overloaded patientTime mins0153045607590 105 120 135 150 165 180 195 210 225 240 255 270RBV %86889092949698100102104UF Stress Test - “dry” patientUF Stress Test - “dry” patientTime mins0153045607590105120135150165180195210225240255270RBV %828486889092949698100102104ARTVENUF controlHeater