1、Our greatest weakness lies in giving up.The most certain way to succeed is always to try just one more time Our greatest weakness lies in giving up.The most certain way to succeed is always to try just one more time 病人血管导管的评估病人血管导管的评估 按无菌操作规程消毒深静脉插管按无菌操作规程消毒深静脉插管 用用5ml5ml注射器抽出注射器抽出A A管腔内残留的肝素水管腔内残留的
2、肝素水2ml2ml，打到无菌纱布，打到无菌纱布上，看看有没有血凝块上，看看有没有血凝块 用用20ml20ml空注射器抽出空注射器抽出A A管腔回血（管腔回血（3 3秒钟之内抽秒钟之内抽20ml20ml血没阻血没阻力说明力说明A A管通畅）再将血液注回体内管通畅）再将血液注回体内 用用20ml20ml注射器推注射器推10ml10ml盐水将盐水将A A端血液冲干净端血液冲干净 用同样的方法将用同样的方法将V V端管腔准备好端管腔准备好Our greatest weakness lies in giving up.The most certain way to succeed is always t
3、o try just one more time 了解病情 原发病 生命体征：血压、呼吸、心率、体温 血凝指标 生化指标：肝肾功能、电解质、血气 容量指标：出入水量、CVPOur greatest weakness lies in giving up.The most certain way to succeed is always to try just one more time 需明确的事项治疗模式稀释法置换液配方抗凝剂治疗时间平衡要求（超滤）Our greatest weakness lies in giving up.The most certain way to succeed i
4、s always to try just one more time 肝素盐水NS 3000ml肝素 300mg(用于预冲管路和滤器）准备一袋肝素盐水和一袋置换液用于机器预冲置换液根据患者的病情和医生开具的医嘱进行配置注意无菌原则Our greatest weakness lies in giving up.The most certain way to succeed is always to try just one more time 四、自检及预冲 -预充以以CVVHCVVH治疗模式为例治疗模式为例Our greatest weakness lies in giving up.The
5、most certain way to succeed is always to try just one more time 注意在屏幕右上角的第二行是运行状态提示注意在屏幕右上角的第二行是运行状态提示 要解决问题首先要知道机器在做什么要解决问题首先要知道机器在做什么?整个冲洗阶段血路管冲洗用生理盐水需要整个冲洗阶段血路管冲洗用生理盐水需要1600 ml1600 ml2000ml2000ml预冲透析预冲透析/置换管路液体约需要置换管路液体约需要1000ml1000ml注意：确认预冲前一定要检查所有压力保护罩安装是否良好注意：确认预冲前一定要检查所有压力保护罩安装是否良好自检及预冲 -需要关注
6、的Our greatest weakness lies in giving up.The most certain way to succeed is always to try just one more time ADAD自检自检(Air detector test)(Air detector test)ADAD状态变化：有空气状态变化：有空气 无空气无空气(气过水的探测）气过水的探测）置换液管子的空气测试：置换液管子的空气测试：置换液泵启动置换液泵启动4 4秒后，置换液才流至空气探测器秒后，置换液才流至空气探测器(AD)(AD)处。如报警处。如报警则可能是置换液（透析液）管路不够畅通，或
7、管路已经有液体。则可能是置换液（透析液）管路不够畅通，或管路已经有液体。如果报警如果报警ADAD自检失败自检失败处理步骤：处理步骤：1 1、按、按“AQAQ”消音，消音，2 2、打开、打开ADAD取出管路取出管路,3 3、按、按“AQAQ”复位即灯灭，复位即灯灭，4 4、灯灭同时数、灯灭同时数4 4秒，秒，5 5、将置换液管路装入、将置换液管路装入ADAD中。中。如果还不能正常，请用干纱布清洁传感器，或用酒精擦拭管路。如果还不能正常，请用干纱布清洁传感器，或用酒精擦拭管路。自检及预冲 -预冲自检过程Our greatest weakness lies in giving up.The most
8、 certain way to succeed is always to try just one more time PD2PD2压力高报警压力高报警检查：检查：1 1 废液管上有夹子没打开废液管上有夹子没打开 2 2 废液泵泵管装错方向废液泵泵管装错方向 3 3 废液管子打折废液管子打折 注意：做注意：做PEXPEX时尤其要重点检查废液管，一旦出错，时尤其要重点检查废液管，一旦出错，易造成血浆分离器出现破膜现象。易造成血浆分离器出现破膜现象。血浆分离器最大血浆分离器最大TMP100mmHgTMP100mmHg自检及预冲 -预冲自检过程Our greatest weakness lies i
9、n giving up.The most certain way to succeed is always to try just one more time 严密观察生命体征 密切监测 及时发现 及时处理 疗效观察Our greatest weakness lies in giving up.The most certain way to succeed is always to try just one more time 常规观察与护理 观察、记录神志、生命体征、CVP、A.V压力.跨膜压等。保持管路通畅：妥善固定导管和血液管路，防止滑脱、扭曲、污染、漏血等，并在可视范围；观察血液管路、
10、滤器有无覆盖层、颜色是否有变化，保持穿刺肢体的良好体位，保证充足的血流量。(常巡视）当我们使用枸橼酸抗凝时，要确保动脉端的三通的紧密性紧密Our greatest weakness lies in giving up.The most certain way to succeed is always to try just one more time 五：结束治疗时机何时结束治疗？目标完成：时间/脱水量 选择“结束治疗”通路、滤器内严重覆盖层/凝血，压力增高频繁报警：需立即结束治Our greatest weakness lies in giving up.The most certain w
11、ay to succeed is always to try just one more time 结束治疗结束治疗 使用使用20ml20ml盐水注射器分别冲净留置管各腔内残留血液盐水注射器分别冲净留置管各腔内残留血液,再使用再使用2020注射器抽取氯化钠注射器抽取氯化钠18ml18ml加肝素加肝素2ml2ml分别注入留置管分别注入留置管A.A.V V端内端内.最后以无菌肝素帽旋紧最后以无菌肝素帽旋紧A.VA.V端口端口,以无菌纱布包裹备用以无菌纱布包裹备用 （必要（必要时更换血滤置管处贴膜）时更换血滤置管处贴膜）嘱病人置管处肢体避免剧烈活动嘱病人置管处肢体避免剧烈活动.Our greates
12、t weakness lies in giving up.The most certain way to succeed is always to try just one more time 整整理理并并完完善善征征的的记记录录 上上机机过过程程中中突突发发情情况况 根根据据监监测测电电解解质质的的结结果，果，调调整整抗抗凝凝剂剂的的量量 各各压压力力值值的的监监测测 准准确确记记录录患患者者的的脱脱水水量，量，抗抗凝凝剂剂及及相相关关数数据据观观察、察、护护理理Our greatest weakness lies in giving up.The most certain way to s
13、ucceed is always to try just one more time 四:预防感染 严格病室和医疗用品的消毒制度，防止医源性感染的发生。开管、封管严格执行无菌技术操作，尽量保持整个管路的密闭。每次更换置换液时应仔细，检查液袋有无破损，液体有无混浊，要认真消毒连接口，减少致热源反应的发生。导管口局部敷料应保持清洁干燥，每天更换。潮湿、污染时要及时予以换药，注意观察局部有无渗血、渗液、红肿、及全身反应如发热、寒战等。在CRRT结束后用无菌肝素帽封口，以无菌纱布完全覆盖固定置管口及导管，防止滑脱。Our greatest weakness lies in giving up.The
14、most certain way to succeed is always to try just one more time 劳而有获-提醒医生开医瞩 切记要及时提醒医生开医嘱，切记要及时提醒医生开医嘱，根据医嘱合理收费根据医嘱合理收费Our greatest weakness lies in giving up.The most certain way to succeed is always to try just one more time Rheater枸橼酸钠VVPVPAUFBLDSAD葡萄糖酸钙血液滤过置换液枸橼酸钠抗凝核心是体外抗凝体内正常u滤器后补充的钙是枸橼酸螯合钙被滤器超
15、滤的部分Our greatest weakness lies in giving up.The most certain way to succeed is always to try just one more time STEP 2：常规药品准备：u枸橼酸钠抗凝剂（200ml:8g/袋）u10%葡萄糖酸钙（Ca-GS）u血液滤过置换液STEP1：枸橼酸钠抗凝准备工作STEP 1：机器型号与治疗模式及参数选择u液体输液泵、微量泵、两个三通u患者2个小时内的血气分析单Our greatest weakness lies in giving up.The most certain way to
16、succeed is always to try just one more time 枸橼酸钠抗凝剂产品信息适应症规格有效期批准文号体外抗凝血200ml:8 g 24个月H20058912 批准文号四川南格尔生物科技有限公司浓度浓度4%4%Company Logo Our greatest weakness lies in giving up.The most certain way to succeed is always to try just one more time 枸橼酸钠抗凝NaHCO3根据置换量调整u枸橼酸螯合钙回到体内后会代谢成HCO3-和Ca2+u每10ml4%枸橼酸钠抗
17、凝剂将代谢出7ml5%碳酸氢钠Company Logo Our greatest weakness lies in giving up.The most certain way to succeed is always to try just one more time STEP3：管路连接及预冲u将枸橼酸钠输液管路连接至血滤管路的动脉端u管路预冲：通常采用肝素盐水管路预冲：通常采用肝素盐水/生理盐水预冲生理盐水预冲u将10%Ca-GS输液管路连接至血滤管路的静脉端Company Logo Our greatest weakness lies in giving up.The most cer
18、tain way to succeed is always to try just one more time Rheater枸橼酸钠VVPVPAUFBLDSAD葡萄糖酸钙STEP4：速度设定-枸橼酸钠速度u血流速度血流速度 通常为通常为150-200ml/min150-200ml/minu 枸橼酸钠泵速枸橼酸钠泵速(ml/hr)=(ml/hr)=1.3-1.6 x 1.3-1.6 x 血流速血流速 (ml/min)(ml/min)u 葡萄糖酸钙泵速葡萄糖酸钙泵速(ml/hr)=(ml/hr)=7.7%x 7.7%x 血流速血流速(ml/min)(ml/min)Company Logo Our
19、 greatest weakness lies in giving up.The most certain way to succeed is always to try just one more time 枸橼酸钠抗凝剂和补钙速度初始设定1u枸橼酸钠抗凝剂速度为血流速度的1.3-1.6倍(单位不同)u葡萄糖酸钙速度为枸橼酸钠抗凝剂速度的6.1%u实际的速度依照血气分析结果进行调整Company Logo Our greatest weakness lies in giving up.The most certain way to succeed is always to try just
20、one more time 枸橼酸钠抗凝剂和补钙速度初始设定2u表格数值仅做初始速度设定参考；u枸橼酸钠和补钙速度仍以血气分析结果做调整；备注：1-RFR(置换液速度)以升升/小时为单位；2-含钙置换液前置换量较大时，可适当增加补钙速度Our greatest weakness lies in giving up.The most certain way to succeed is always to try just one more time 滤器后补钙前滤器后补钙前(管路采血点管路采血点)STEP5：血气分析-监测游离钙水平患者外周血患者外周血(动静脉血皆可动静脉血皆可)监测安全性体内监
21、测抗凝效果体外游离钙游离钙1.00 1.20 mmol/L1.00 1.20 mmol/L游离钙游离钙0.20 0.40 mmol/L0.20 0.40 mmol/LOur greatest weakness lies in giving up.The most certain way to succeed is always to try just one more time 血气分析的监测频率Q2h x 4Q4h x 4Day 1Day 2Q 6 8 h0h24hu第一个2小时血气分析是调整剂量的基础！u通常Q4-6h的监测频率较为合理！Our greatest weakness lies in giving up.The most certain way to succeed is always to try just one more time u(低钙血症)患者体内钙离子治疗后比治疗前不下降为补钙基准；Our greatest weakness lies in giving up.The most certain way to succeed is always to try just one more time 謝謝謝謝!
