20100721 Haemodialysis Ms Tam Yeuk Ming

7/26/2019 20100721 Haemodialysis Ms Tam Yeuk Ming

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Professional Certificate in Renal Nursing

Renal Nurse Tam Yeuk Ming

22/07/2010


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An Overvie of !aemo"ial#sis

A$ !istor# an" evolution of %aemo"ial#sis

&$ Pro'lem of vascular access

C$ (evelo)ment of "ial#sers

i$ Rotating "rums

ii$ Coil

iii$ Parallel )lates

iv$ !ollo fi'res

($ Mo"ern "ial#ser

i$ &iocom)ati'le "ial#ser

ii$ !ig% flu* "ial#ser

+$ (evelo)ment of !( mac%ines


3/45

Thomas Graham, -cottis% c%emist

1. law of diffusion

A$ T%e %istor# evolution of !aemo"ial#sis


4/45

Process of (ial#sis

T%e 'ells%a)e" vessel as covere" '# amem'ranecreate" from an o*'la""er an" fille"

it% urine3 4t as sus)en"e" insi"e a larger

container5 fille" it% "istille" ater3 After several

%ours5 t%e vessel as remove"3 T%e container as

%eate" so t%at t%e flui" insi"e 'oile" to "r#ness3

T%e resi"ue in t%e container consiste" mainl# of

so"ium c%lori"e an" urea t%e com)onents ofurine3 T%is )rove" t%at urea %a" )asse" t%roug%

t%e mem'rane Diffusion$3


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Anticoagulation

181. !e)arinas isolate"

1827 9se %e)arin in %uman

18:: Purifie" form of %e)arin as availa'le


6/45

History of Artificial Kidney

181: ;irst "evice )ermitte" "iffusion (r3 illiam T%al%imer $

18: Cello)%ane mem'rane


7/45

History of Artificial Kidney

18@ 9se a vertical"rumt#)e ki"ne# Prof3 Nils Alall$

18. 1st%aemo"ial#sis mac%ine in 9-A ?olff&rig%am$

188 Multic%annele" "ial#ser-keggs eonar"s $

18 Tin coil "ial#ser (r3 ?olff >atsc%inger $


8/45

&$ Pro'lems of Bascular Access

13 Permanent Bascular Accessa3 Arteriovenous ;istula

en"tosi"e veinarter# anastomosis of ce)%alic vein an"ra"ial arter#

;ail to mature 2D27D it%in )osto)erative eeksor more5 )ersistentl# lo 'loo" flo rates

T%rom'osis

tec%nical errors "uring fistula construction

)remature fistula cannulation

venous / arterial stenosis e*cessive )ost %aemo"ial#sis fistula com)ression

)oor fistula cannulation tec%niEue

%#)otension / inatravascular volume "e)letion

fistula com)ression "uring slee)


9/45

Arteriovenous fistula
http://3.bp.blogspot.com/_-WsaCfPPjYQ/SpudEMhNtrI/AAAAAAAABXY/vJDvgsE95os/s1600-h/radiocephalic_fistula.png


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infection local5 s#stemic

%an" isc%emia steal s#n"rome$

aneur#sm / )seu"oaneur#sm / %aemorr%age

e"ema of arm "ue to central vein stenosis

e*cessive 'loo" flo )ro*imal AB access5 risk of %ig%

out)ut car"iac failure$


13/45

&$ Pro'lems of Bascular Access13 Permanent Bascular Access

'3 -#nt%etic arteriovenous graft

s#nt%etic fistula com)ose" of )ol#tetrafluoroet%#lenePT;+$ )lace" in forearm eit%er in a straig%t "istal ra"ial

arter# to 'asilic vein$ or loo) 'rac%ial arter# to 'asilicvein$ configuration

PT;+ graft ma# 'e )lace" in multi)le sites u))er arm5 in

t%e t%ig% femoral arter# to femoral vein$5 a*illar# arter#to a*illar# vein5 a*illar# arter# to Fugular vein

t%rom'osis an" infection rates are %ig%er t%an AB fistula


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oo)e" =raft
http://4.bp.blogspot.com/_-WsaCfPPjYQ/SpucODwK-wI/AAAAAAAABXI/39zKJUMrk6s/s1600-h/arteriovenous-graft.jpg


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-teal -#n"rome


16/45

-tenosis ulceration


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Permcat%


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23 Tem)orar# Bascular Access

a3 Noncuff "ou'lelumen central venous cat%eter

"ou'lelumen cat%eter ma# 'e inserte" into femoral5su'clavian5 or internal Fugular veins

femoral vein "uallumen cat%eter s%oul" remain in )laceno longer t%an t%ree "a#s 'ecause of %ig% rate infection

su'clavian vein "uallumen cat%eter %as %ig%est risk of

central vein stenosis

internal Fugular vein "uallumen cat%eter %as lesscomforta'le t%an ot%er site

&$ P 'l f B l A


19/45


23 Tem)orar# Bascular Access

a3 Noncuff "ou'lelumen central venous cat%eter

com)lications "uring insertion atrial an" ventricular "#sr%#t%mias5 arterial )uncture5

%aemot%ora*5 )neumot%ora*5 air em'olism5 )erforation ofcentral vein or car"iac c%am'er5 )ericar"ial tam)ona"e

infection

e*it site infection tunnel infection

cat%eterrelate" 'acteremia

su))urative central vein t%rom'o)%le'itis

t%rom'osis central vein stenosis

sli) out or )ull out of cat%eter '# )atient

"amage or crack of t%e cat%er


20/45

2'3 Cuffe" (ou'leumen -ilastic Cat%eter Permcat%$

"ou'lelumen silastic cat%eter it% felt cuffs is inserte"t%roug% a su'cutaneous tunnel into t%e internal Fugular

vein

imme"iate com)lications

arterial )uncture5 )neumot%ora*5 %aemot%ora*5arr%#t%mias5 air em'olism5 )erforation of vein or car"iac

c%am'er5 )ericar"ial tam)ona"e5 erosion of su)erior venacava

"ela#e" com)lications

t%rom'osis5 infection5 vascular stricture5 arteriovenousfistula5 inFur# to a"Facent structures 'rac%ial )le*us5trac%ea5 recurrent lar#ngeal nerve$

cat%eter "#sfunction

mal)osition5 intracat%eter t%rom'osis5 cat%eter ti)t%rom'us5 fi'rin sleeves an" mural t%rom'i


21/45

&loo" clot insi"e t%e cat%eter


22/45

?inke" cat%eter


23/45

T%e (ial#sis Outcomes an" Practice Patterns -tu"#

(OPP-$

T%e )rimar# risk factor for access infection is access t#)e5it% cat%eters %aving t%e %ig%est risk for infection5 graft

interme"iate an" native arteriovenous fistula t%e loest

a'out 0D s#nt%etic grafts reEuire" intervention it%in

one #ear5 com)are" to :2D for AB; Cat%eters it% a 13@fol" %ig%er failure rate of

su'seEuentl# use" AB;

T%e total annual glo'al cost of vascular access mor'i"it#

%as 'een account for 117D of all s)en"ing on%aemo"ial#sis )er #ear at risk

AVF is the first priority


24/45

T#)es of 4ntravascular Access in "ifferent countries

G C%ronic ki"ne# "isease 'est )ractice 200

H National surveillance of "ial#sisassociate" infection in 9nite" -tate 2002

Countr# AB; AB= 4B Cuffe"

Cat%eter

4B Non

Cuffe"

Cat%eter

!ong ?ong D 8D 20D 17D

G


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C$ (evelo)ment of (ial#sers

4$ Rotating (rums

44$ Coil

444$ Parallel Plates

4B$ !ollo fi'res


26/45

4$ Rotating (rum

180 Cello)%ane as a mem'rance (r3 >illem ?olff $

18 Artificial ki"ne# it% cello)%ane tu'ing5 ru''er

'loo" tu'ing an" cannula connections

187'at% %eating mec%anisman" a)le*iglass %oo" to

control tem)erature5 a )lastic connector s#stem sot%e 'loo" line coul" 'e connecte" to mem'rane an"

)revent 'loo" leak


27/45

44$3 Coil "ial#ser

18. 9sing concentricall# ra))e" mem'rane tu'ingto t%e 'loo" volume in t%e mem'rane tu'ing3

(r3 &o"o Bon =arrelts $

180 IPressure cookerJ ki"ne#%ic% as

concentricall# ra))e" mem'rane it% la#ers

se)arate" '# fi'erglass screening3 T%is as a

close" s#stem an" t%e amount of ultrafiltrationcoul" 'e monitore"

(r3 >illiam 4nou#e $

Coil ?i"en


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Coil ?i"en#
http://www.homedialysis.org/images/learn/museum/lg_cd1000.jpg


29/45

18@ Tin coil "ial#ser
http://www.homedialysis.org/images/learn/museum/lg_u200a.jpg


30/45

Crosssection of Coil ?i"ne#


31/45

180 ?olff Tincoil ?i"ne#

(r3 ?olff5 (r3 Bictor Bertes an" (r3&runo >atssc%inger

"evelo)e" t%e Iorange FuiceJ ki"ne#5 %ic% as

concentricall# ra))e" coil ki"ne# using an orangeFuice can as t%e core3 T%e# use to lengt%s of cellulose

acetate tu'ing to re"uce t%e )ressure "ro) across t%e

"evice3 T%e term Itincoil evolve"3

Tin Coil ?i"ne#


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444$ Parallel Plates "ial#sers

K Parallel )late "ial#sers are com)ose" of a varia'le num'er

of com)artments in )arallel se)arate" '# rigi" su))ort

structures enclosing flat s%eets of mem'rane3 &loo" flos

'eteen t%e mem'rane la#ers %ile "ial#sate floscountercurrent across t%e su))ort )lates %ic% %ave

grooves or s)aces for flui" flo3 As 'loo" an" "ial#sate

flo resistances are lo5 ultrafiltration is easil# controlle"

an" no or onl# minor 'ackfiltration occurs3


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Parallel Plates (ial#ser
http://www.homedialysis.org/images/learn/museum/lg_flatplate14.jpg


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4B$ !ollo fi'er "ial#sers

!ollo fi'er "ial#sers consist of 1015000 %ollo fi'ers in a

'un"le5 eac% en" of %ic% is em'e""e" in a )otting

material3 T%e fi'ers %ave an internal "iameter of 200

:00Lm an" a all t%ickness of 100Lm3 T%e 'un"le isenclose" in a )lastic Facket it% )orts for 'loo" an"

"ial#sate line3 &loo" flos it%in t%e fi'ers %ile

"ial#sate flos countercurrent on t%e outsi"e of t%e fi'ers3

&ecause of its %ig% effective surface area to 'loo" volumeratio5 t%is "esign is t%eoreticall# t%e 'est3


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!ollo fi'er "ial#sers
http://www.homedialysis.org/images/learn/museum/lg_cf1200.jpg


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($ Mo"ern (ial#sers

i$3 &iocom)ati'ilit# (ial#ser

ii$3 !ig% ;lu* (ial#ser


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13 &iocom)ati'ilit# (ial#ser

&iocom)ati'ilit# is t%e interaction 'eteen 'loo"

an" t%e "ial#ser mem'rane3 4f t%e reaction is mil"

an" ell tolerate"5 t%e "ial#ser can 'e terme" as'iocom)ati'le3 ;or c%ronic %aemo"ial#sis

)atients5 t%e interactions are re)etitive an" occur

2: times a eek5 even mil" interaction ma# lea"

to a"verse con"ition3


38/45

Com)lement Activation

Mast cells !istamin release

Re" &loo" Cells #sis

4n long run5 2-microglo'ulin Am#loi"osis

activating mem'rane 9nsu'stitute" cellulosic mem'ranes

cu)ro)%ane$ are t%e most com)lement


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23 !ig% ;lu* (ial#ser

K (ial#sers it% larger )ore siQe5 'etter clearance of mi""le

moleculareig%t solutes an" %ig%er ultrafiltration rates5lea"ing to 'ot% "iffusion an" convective solute clearance

K Low and high fluxare 'ase" on t%e ultrafiltration

coefficient ?uf$

K o flu* ?uf 10ml/%/mm!gK !ig% flu* ?uf S20ml/%/mm!g

K High permeaility it% 'etter clearance of t%e mi""le

moleculeeig%t molecule eg3 2-microglo'ulin

2-microglo'ulin clearance S20ml/min

! High efficiency it% 'etter urea clearance

urea ?oA value S@00ml/min

?o mass transfer coefficient5 A surface area$


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+*am)les of commonl# use" "ial#sers

(ial#ser t#)e Material -urfacearea m2

?oA ml/min

o flu* lo efficienc#

CA80 / C;12

Cellulose acetate /

cu)rammonium

038

037

10

1.

o flu* %ig% efficienc#

CA10 / T10

Cellulose acetate /

cu)rammonium

13

13

@@0

7:0

!ig% flu* lo efficienc#

;0 / Pan10P

Pol#sulfone /

Pol#acrilonitrile

038

130

20

20

!ig% flu* %ig% efficienc#

CT180 / ;.0

Cellulose triacetate /

Pol#sulfone

138

13.

820

8

?o mass transfer coefficeint Asurface area


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+$ (evelo)ment of !( Mac%ines

K 18. ?olff ,&rig%am -tainless steel (ial#sis Mac%ine

"i" not allo for removal of e*cess flui"

K 180s (r3 Nils Alall negative )ressure coul" 'e a))l# to

remove e*cess flui"

KBolumetric control

K &icar'onate "ial#sate

K !aemo"iafiltration


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;resenius 00. !( mac%ine


43/45

=am'ro !( Mac%ine Artis

; i 00.- !( %i


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;resenius 00.- !( mac%ine


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T%ank You

Documents

20100721 Haemodialysis Ms Tam Yeuk Ming