Clinical Practice Guidelines for Acute raum Injury Nyob rau hauv Tuam TshojⅧ

Kev kho lub raum hloov rau AKI

Cov lus nug 13: Tag nrho cov ntsiab lus ntawm RRT rau cov neeg mob AKI

RRT yog ib txoj hauv kev tseem ceeb ntawm AKI kev kho mob, suav nrog kev tsis sib haum xeeb hemodialysis (IHD), CRRT, txuas ntxiv sib quas ntus RRT (PIRRT), kev lim ntshav qis qis (SLED) thiab Hybrid ntshav purification kev kho mob xws li peritoneal dialysis. Tam sim no, tseem muaj kev sib cav txog txoj kev npaj kho mob RRT rau cov neeg mob AKI, tshwj xeeb tshaj yog lub sijhawm pib thiab nres. Hom kev kho mob RRT zoo tshaj plaws rau cov neeg mob AKI yog maj mam tshem tawm cov co toxins, kho qhov ntim sib npaug, tsis txhob muaj qhov hloov pauv loj hauv hemodynamics, thiab simulate physiological txheej txheem ntawm tib neeg lub raum kom ntau li ntau tau. Txhua txoj kev hloov lub raum muaj nws tus yam ntxwv. Hauv kev siv tshuaj kho mob, hom kev kho mob tsim nyog thiab koob tshuaj yuav tsum raug xaiv raws li tus neeg mob tus mob thiab qhov ua tau ntawm txoj kev kho mob.

Nyem rau cistanche rau mob raum

Cov Lus Nug 14: Kev Xaiv thiab Kev Saib Xyuas Kev Nkag Mus Rau Vascular hauv AKI

【Cov lus pom zoo】

1. Rau cov neeg mob AKI uas npaj yuav tau txais RRT, nws raug pom zoo tias cov kws kho mob tshwj xeeb cuam tshuam los ntsuas qhov xwm txheej tam sim no thiab RRT txoj kev npaj, thiab tsim cov phiaj xwm nkag mus rau vascular (1C).

2. Before catheterization, ultrasound must be used to evaluate the vascular conditions of the proposed catheterization site. The right internal jugular vein and femoral vein are recommended as the preferred catheterization sites. Indwelling subclavian vein catheters are not recommended (1A). For patients with body mass index (BMI) >28.4 kg / m2, sab hauv jugular leeg yog pom zoo raws li qhov nyiam catheter tso chaw. Rau cov neeg mob uas muaj BMI<24.0 kg/m2, the femoral vein is recommended as the preferred catheter placement site (2B). The femoral vein is recommended as the preferred catheterization site for patients with known severe respiratory tract disease (1C).

3. Rau cov neeg mob uas xav tau lub sijhawm RRT ntawm<1 month, it is recommended to use a non-cuffed catheter (NCC) without a tunnel and a Dacron sheath as a vascular access; for patients with an expected RRT time of >3 lub hlis, lossis cov uas xav tau RRT mus sij hawm ntev Rau cov neeg mob, nws raug nquahu kom siv lub qhov taub-cuffed catheter (TCC) nrog lub qhov thiab Dacron sheath ua cov hlab ntsha lossis hloov NCC tam sim nrog TCC (1A) .

4. Nws raug pom zoo tias cov neeg laus ib txwm siv lub dual-lumen NCC nrog ib ncig ntawm 10 mus rau 12 Fr lossis dual-lumen TCC nrog lub voj voog ntawm 11 txog 14 Fr raws li cov vascular nkag rau RRT (1B).

5. Nws raug nquahu kom ua puncture thiab catheterization los tsim kom muaj vascular nkag mus rau hauv chav ua haujlwm tsis muaj menyuam lossis chav ua haujlwm raws li ECG saib xyuas (1A); rau AKI cov neeg mob hauv ICU, nws raug nquahu kom ua catheterization ntawm txaj txaj raws li cov qauv kev ua haujlwm tsis muaj menyuam (2B).

6. Nws raug nquahu kom ua qhov puncture thiab catheterization los tsim kom muaj vascular nkag hauv ultrasound localization lossis real-time ultrasound kev taw qhia; Tom qab ua tiav ntawm catheterization, lub hauv siab los yog lub plab radiography raug coj mus rau paub meej tias txoj hauj lwm ntawm lub catheter taub (1A).

7. Nws raug nquahu kom saib xyuas lub catheter puncture site thiab qhov chaw nres nkoj sab nraud ntawm TCC ua ntej txhua txoj kev kho ntshav purification, thiab siv cov kua sealing uas tsim nyog los muab lub raj xa dej tom qab txhua qhov kev kho mob (1A); Nws raug nquahu kom siv cov concentration ntawm 10 mg / ml lossis siab dua Unfractionated heparin kua lossis 4% mus rau 30% citric acid kua yog siv los ua cov tshuaj tiv thaiv kom tsis txhob muaj cov kab mob intracatheter thrombosis (1B).

8. Nyob rau hauv cov ntaub ntawv ntawm kev ua haujlwm tsis zoo, nws raug nquahu kom siv yam tsawg 5,000 txog 10,000 U / ml ntawm ib leeg-chain urokinase lossis 1 txog 2 mg / ml ntawm cov ntaub so ntswg plasminogen activator (t -PA) Thrombolytic therapy. Yog tias kev kho mob thrombolytic tsis muaj txiaj ntsig, nws raug pom zoo kom ua nyob rau hauv situ catheter hloov raws li cov lus qhia kev taw qhia tom qab tsis suav cov catheter tip thrombus (2B).

9. Yog tias muaj kab mob ntsig txog catheter tshwm sim, NCC cov neeg mob raug pom zoo kom tshem lub catheter tam sim ntawd thiab muab cov catheter tip cultured. Yog tias cov neeg mob TCC tsuas muaj qhov ncauj kab mob sab nraud, kev kho mob hauv zos thiab cov kab mob tuaj yeem raug txiav txim siab. Yog hais tias muaj qhov tunnel- thiab catheter-related bacteremia, nws raug nquahu kom tshem lub catheter tam sim ntawd. Tshem lub catheter. Yog tias tus neeg mob xav tau kev kho ntshav kom huv mus ntxiv, nws raug nquahu kom rov siv NCC los tsim cov hlab ntsha tom qab hloov txoj haujlwm. Yog tias tus neeg mob tseem muaj cov tsos mob ntawm cov kab mob hauv lub cev tom qab extubation, nws raug nquahu kom siv cov tshuaj tua kab mob rhiab rau 1 mus rau 2 lub lis piam ntawm kev kho mob raws li kab lis kev cai (2B).

Ntau qhov kev tshawb fawb tau taw qhia tias qhov ua tau zoo ntawm vascular nkag nrog kev koom tes lossis kev tsim kho ntawm nephrologist yog siab dua qhov kev nkag mus rau vascular yam tsis muaj kev koom tes ntawm nephrologist. Yog li ntawd, rau cov neeg mob AKI uas npaj yuav tau txais RRT, nws raug pom zoo tias tus kws kho mob nephrologist ua qhov kev ntsuam xyuas ntawm tus mob tam sim no thiab RRT txoj kev npaj, thiab tsim cov phiaj xwm nkag mus rau vascular tiav.

1. Selection of catheter insertion site: Research on the use of NCC as a dialysis access shows that there is no significant difference between the internal jugular vein and femoral vein. Compared with catheters in other locations, the right internal jugular vein catheter can achieve better dialysis. blood flow and lower rates of mechanical and infectious complications. Studies using TCC as vascular access have shown that there is no significant difference in TCC patency between the right internal jugular vein and femoral vein within 120 days. The infection rate of subclavian vein catheters is relatively small, but the risk of complications from puncture and catheterization is high, and the dialysis blood flow after catheterization is not ideal, which also affects the establishment of long-term vascular access in the future. Therefore, subclavian vein catheterization is not recommended. Alternatively, the subclavian vein may be recommended as the last resort for central venous catheter placement. A study on NCC catheter placement showed that when the patient's BMI was >28.4 kg / m2, qhov teeb meem ntawm femoral vein catheter yog siab dua li ntawm cov hlab ntsha hauv jugular catheter, thaum qhov sib txawv yog qhov tseeb thaum tus neeg mob BMI yog.<24.0 kg/m2. For patients with severe respiratory infectious diseases, because the internal jugular vein catheterization site is closer to the mouth and nose, the probability of contact with pathogenic bacteria is higher. After internal jugular vein or subclavian vein catheterization, there is a higher risk of infection than after femoral vein catheterization. There is a risk of infection, so it is recommended to give priority to femoral vein catheterization.

2. Kev xaiv hom catheter: Ib txoj kev tshawb nrhiav rov qab pom tias nyob rau hauv 2- lub lim tiam ntawm kev siv, TCC tau txo qis catheter tsis ua haujlwm thiab tus nqi catheter kis ntau dua NCC. Cov txiaj ntsig ntawm kev tshawb fawb yav tom ntej ntawm kev siv catheter rau cov neeg laus AKI cov neeg mob tau pom tias TCC tau zoo dua li NCC hauv cov ntsiab lus ntawm cov twj tso kua mis tswj cov ntshav khiav, catheter arteriovenous siab tsis nyob rau lub sijhawm lim ntshav, thiab qhov tshwm sim ntawm cov teeb meem kho tshuab. Cov pov thawj kev kho mob uas twb muaj lawm qhia tau hais tias cov catheters-coated heparin los yog silver-coated catheters tsis muaj teeb meem pom tseeb, tab sis tsis muaj pov thawj tseeb los ua pov thawj tias catheters ua los ntawm cov ntaub ntawv saum toj no tuaj yeem pab kho mob rau cov neeg mob AKI.

Cov kev tshawb fawb tau pom tias cov ntshav ntws thaum lub sij hawm kho cov ntshav purification yog ncaj qha cuam tshuam rau lub puab txoj kab uas hla ntawm lub catheter. Ob-lumen catheters nrog ib ncig ntawm<6 Fr are difficult to meet the blood flow required for hemodialysis (filtration) and cannot meet the needs of long-term RRT. Therefore, Special groups such as newborns need to choose catheters with corresponding circumferences, while for normal adult patients, a double-lumen NCC with a circumference of 10 to 12 Fr or a double-lumen TCC with a circumference of 11 to 14 Fr is recommended as the vascular access for RRT.

3. Cannulation tej yam kev mob thiab ib puag ncig: Raws li cov kev cai ntawm aseptic cov hauv paus ntsiab lus, TCC catheter tso kawm tiav nyob rau hauv lub chav ua hauj lwm, thiab NCC sim nws qhov zoo tshaj plaws ua raws li TCC txoj kev phais. AKI cov neeg mob hauv chav saib xyuas mob hnyav yog qhov pheej hmoo loj ntawm kev thauj mus los, thiab tag nrho cov txheej txheem catheterization thiab RRT yuav tsum ua kom tiav ntawm lub txaj.

Cov kev tshawb fawb tau pom tias lub sijhawm tiag tiag ntawm ultrasound-coj kev puncture los tsim kom muaj kev nkag mus rau vascular muaj kev nyab xeeb dua thiab qhov tshwm sim ntawm cov teeb meem kho tshuab tau txo qis. Muaj kev sib raug zoo ntawm txoj haujlwm catheter thiab txoj haujlwm catheter. Lub taub ntawm cov hlab ntsha sab hauv jugular thiab subclavian vein dialysis catheter nyob rau hauv cov neeg mob nrog NCC yuav tsum nyob rau hauv lub superior vena cava. Teb Chaws Asmeskas FDA pom zoo tias qhov ntxeev ntawm sab hauv jugular leeg NCC yuav tsum nyob ntau dua 3 cm saum toj ntawm txoj cai atrium. Femoral vein dialysis Lub hau ntawm lub catheter yuav tsum nyob rau hauv inferior vena cava, los yog tsawg kawg yog 3 cm proximal rau lub bifurcation ntawm sab laug thiab txoj cai iliac leeg.

4. Kev saib xyuas catheter thiab kev xaiv cov tshuaj sealing: Kev saib xyuas tsis tu ncua ntawm qhov chaw nres nkoj sab nraud ntawm lub catheter thiab qhov chaw puncture tuaj yeem tiv thaiv kab mob ntsig txog catheter. Cov txiaj ntsig ntawm kev tshawb nrhiav rov qab ntawm cov neeg mob hemodialysis cov neeg mob tau pom tias tus nqi ntawm catheter sab nraud qhov chaw nres nkoj kis tau raug txo qis tom qab siv cov hnav tsis taus.

Unfractionated heparin thiab citrate tov yog siv raws li niaj hnub sealing kua. Kev siv cov kua sealing kom tsim nyog tuaj yeem txo qhov tshwm sim ntawm catheter ntsig txog thrombosis thiab kab mob. Ib qho kev ntsuam xyuas meta pom tau tias kev siv cov kev daws teeb meem xauv tuaj yeem txo qhov kev pheej hmoo ntawm cov kab mob catheter-related bacteremia los ntawm peb zaug. Ntau qhov kev tshawb fawb soj ntsuam tau pom tias tsis muaj qhov hloov pauv tseem ceeb hauv catheter patency tus nqi tswj hwm los ntawm qis qis (10 mg / ml) heparin locking, tab sis qhov zaus ntawm kev siv cov tshuaj thrombolytic nce ntau, thiab siab heev (100 mg / . ml) heparin locking kua yuav ua rau muaj kev pheej hmoo los ntshav. 4% sodium citrate tov thiab heparin lock tov muaj cov txiaj ntsig zoo sib xws hauv kev tswj cov catheter patency, tab sis me ntsis zoo dua li heparin lock tov hauv kev tiv thaiv kab mob ntsig txog catheter, thaum 30% thiab 4% citrate lock solutions tuav catheter patency. Ib zaug ntxiv, tsis muaj qhov sib txawv tseem ceeb, tab sis muaj siab concentration (30%) citrate tov tuaj yeem ua rau cov hlab ntsha peripheral paresthesia hauv qee cov neeg mob.

Qhov tshwm sim ntawm central venous catheter cuam tshuam thrombosis yog 2% mus rau 64%. Thrombosis ncaj qha cuam tshuam rau kev ua haujlwm tsis zoo ntawm catheter. Plasmin yog cov tshuaj feem ntau siv los kho, nrog rau lub sijhawm luv luv ntawm 40% mus rau 92%. Nyob rau hauv qhov chaw hloov lub catheter ntawm ib tug guidewire yog ib tug zoo txhais tau tias ntawm kev kho catheter malfunction. Cov ntaub ntawv qhia tias qhov kev ua tau zoo ntawm kev ua haujlwm no yog 93%. Thaum catheter-related bacteremia tshwm sim nrog lub hauv paus venous catheter yog tias lub catheter tsis raug tshem tawm thiab cov tshuaj tua kab mob tsuas yog siv rau kev kho mob, 75% ntawm cov neeg mob yuav muaj tus kab mob rov ua dua tom qab cov tshuaj tua kab mob raug txiav.

Cistanche kho mob raum li cas?

Cistancheyog ib hom tshuaj suav tshuaj ntsuab siv rau ntau pua xyoo los kho ntau yam mob, suav nrograumkab mob. Nws yog muab los ntawm qhuav stems ntawmCistanchedeserticola, ib tsob nroj nyob rau hauv cov suab puam ntawm Tuam Tshoj thiab Mongolia. Lub ntsiab active Cheebtsam ntawm cistanche yogphenylethanoidglycosides, echinacoside cov tshuaj, thiabacteoside, uas tau pom tias muaj txiaj ntsig zoo rau lub raum kev noj qab haus huv.

Kab mob raum, tseem hu ua kab mob raum, hais txog ib yam mob uas lub raum ua haujlwm tsis zoo. Qhov no tuaj yeem ua rau muaj cov khoom pov tseg thiab cov co toxins hauv lub cev, ua rau muaj ntau yam tsos mob thiab teeb meem. Cistanche tuaj yeem pab kho mob raum ase los ntawm ntau lub tshuab.

Ua ntej, cistanche tau pom tias muaj cov nyhuv diuretic, txhais tau tias nws tuaj yeem ua rau cov zis ntau ntxiv thiab pab tshem tawm cov khoom pov tseg ntawm lub cev. Qhov no tuaj yeem pab txo lub nra ntawm lub raum thiab tiv thaiv kev tsim cov co toxins. Los ntawm kev txhawb nqa diuresis, cistanche kuj tseem tuaj yeem pab txo qis ntshav siab, ib qho teeb meem ntawm cov kab mob raum.

Ntxiv mus, cistanche tau pom tias muaj cov teebmeem antioxidant. Kev ntxhov siab oxidative, tshwm sim los ntawm qhov tsis sib xws ntawm kev tsim cov dawb radicals thiab lub cev tiv thaiv antioxidant, ua lub luag haujlwm tseem ceeb hauv kev mob raum. ies pab neutralize dawb radicals thiab txo Oxidative kev nyuaj siab, yog li tiv thaiv lub raum los ntawm kev puas tsuaj. Cov phenylethanoid glycosides pom hauv cistanche tau tshwj xeeb hauv kev tshem tawm cov dawb radicals thiab inhibiting lipid peroxidation.

Tsis tas li ntawd, cistanche tau pom tias muaj cov nyhuv anti-inflammatory. Kev mob yog lwm yam tseem ceeb hauv kev loj hlob thiab kev loj hlob ntawm cov kab mob raum. Cistanche's anti-inflammatory zog pab txo cov zus tau tej cov pro-inflammatory cytokines thiab inhibit qhov ua kom o yuav tsum tau txoj kev, yog li alleviating o nyob rau hauv lub raum.

Tsis tas li ntawd, cistanche tau pom tias muaj cov teebmeem immunomodulatory. Hauv kab mob raum, lub cev tiv thaiv kab mob tuaj yeem ua rau tsis zoo, ua rau muaj kev mob ntau dhau thiab cov ntaub so ntswg puas. Cistanche pab tswj lub cev tiv thaiv kab mob los ntawm kev hloov kho kev tsim khoom thiab kev ua haujlwm ntawm lub cev tiv thaiv kab mob, xws li T hlwb thiab macrophages. Txoj cai tiv thaiv kab mob no pab txo qhov mob thiab tiv thaiv kev puas tsuaj ntxiv rau lub raum.

Ntxiv mus, cistanche tau pom los txhim kho lub raum kev ua haujlwm los ntawm kev txhawb nqa kev tsim kho ntawm lub raum hlab nrog cov hlwb. Lub raum tubular epithelial hlwb ua lub luag haujlwm tseem ceeb hauv kev pom thiab rov nqus cov khoom pov tseg thiab electrolytes. Hauv kab mob raum, cov hlwb no tuaj yeem raug puas tsuaj, ua rau lub raum ua haujlwm puas. Cistanche lub peev xwm los txhawb kev tsim kho ntawm cov hlwb no pab kho lub raum kom zoo thiab txhim kho lub raum tag nrho.

Ntxiv nrog rau cov kev cuam tshuam ncaj qha rau lub raum, cistanche tau pom tias muaj txiaj ntsig zoo rau lwm yam kabmob thiab lub cev hauv lub cev. Txoj hauv kev zoo rau kev noj qab haus huv no tseem ceeb tshwj xeeb hauv cov kab mob raum, vim tias tus mob feem ntau cuam tshuam rau ntau lub cev thiab lub cev. che tau pom tias muaj kev tiv thaiv rau lub siab, lub plawv, thiab cov hlab ntsha, uas feem ntau cuam tshuam los ntawm kab mob raum. Los ntawm kev txhawb nqa kev noj qab haus huv ntawm cov kabmob no, cistanche pab txhim kho lub raum tag nrho thiab tiv thaiv kev mob ntxiv.

Hauv kev xaus, cistanche yog cov tshuaj suav tshuaj ntsuab siv rau ntau pua xyoo los kho mob raum. Nws cov active Cheebtsam muaj diuretic, antioxidant, anti-inflammatory, immunomodulatory, thiab regenerative teebmeem, uas pab txhim kho lub raum ua haujlwm thiab tiv thaiv ob lub raum los ntawm kev puas tsuaj ntxiv. , cistanche muaj txiaj ntsig zoo rau lwm yam kabmob thiab lub cev, ua rau nws txoj hauv kev zoo rau kev kho mob raum.