The topic of my speech today is "Solving Common Problems in Hemodialysis". The purpose is to divide the problems we often encounter in our daily clinical work into several aspects for unified answers, so as to deepen patients' understanding of dialysis treatment, and the ultimate goal is to prolong the survival time, improve the quality of life, and even finally return to society.
A, hemodialysis knowledge articles
1. What about hemodialysis?
Hemodialysis is performed by using an extracorporeal circulation device such as a dialyzer. During dialysis, the patient's blood and dialysate containing certain chemical components are introduced into the dialyzer at the same time, and dialyzed through the semi-permeable membrane to eliminate metabolites, purify blood and supplement necessary substances, thus playing the role of artificial kidney.
Main principle: diffusion (figure)+convection (figure)
(dynamic diagram)
2. Why should uremia patients receive dialysis treatment?
In the case of end-stage renal damage caused by various reasons, such as chronic glomerular disease, diabetes, hypertension, cystic nephropathy, etc., the ability of kidney to excrete various metabolites (such as creatinine and urea nitrogen) and water gradually decreases, which will lead to a series of clinical symptoms, such as hypertension, edema, nausea and vomiting. Hemodialysis is equivalent to helping the kidney to complete the above work, so it is an alternative treatment.
For example, if a normal kidney is equivalent to hiring a nanny to clean the house 24 hours a day, then hemodialysis is equivalent to hiring an hourly worker to clean it 2-3 times a week.
Should I choose dialysis or kidney transplantation?
Hemodialysis is an alternative therapy for uremia, but each has its own advantages and disadvantages.
(Table: Advantages and Disadvantages of Dialysis and Kidney Transplantation)
Specific to each patient, two alternative treatments can be considered. However, the following factors should be considered comprehensively:
Age, generally speaking, younger patients may be more suitable for kidney transplantation;
The need to return to society, if the need to return to society is strong, kidney transplantation is more appropriate;
Primary disease, if the primary disease is diabetes, renal transplantation will be treated with glucocorticoid, which is not conducive to blood sugar control, so renal transplantation is not recommended;
Economic situation, if the economic situation is not good, kidney transplantation is not recommended.
4. How long can hemodialysis last?
This is a question that patients often ask. At present, there are many cases in many good dialysis units in China, and there are many patients who have been dialysis for more than 30 years, especially those who have been dialysis for about 20 years. At present, several dialysis patients in our hospital are over 10 years old. Theoretically, as long as the complications of uremia are well handled, long-term dialysis to maintain life and even a better quality of life is a completely achievable goal. In 2006, when I was studying in Nanjing General Hospital of Nanjing Military Region, Director Ji Daxi once said: If God gives you a life span of 1000 years, our blood purification medical staff have the responsibility to prevent you from dying before the age of 99. Of course, this requires patients to better treat according to the guidance of medical staff.
5. How many times should I wear it?
Generally speaking, regular and adequate hemodialysis should be at least 3 times/week. For some patients with large urine volume, good general condition and good blood pressure control, it can be twice a week or five times a week.
6. How much water should be removed?
This problem involves the concept of "dry weight". The dry weight of dialysis patients refers to the body weight without excess water and water shortage. The dry weight is not fixed, but can change with the change of illness. We often overestimate the dry weight in clinic, and the dehydration is often not enough. However, there are also cases where the dry weight increases after improving diet. In this case, dehydration according to the original weight is a bit too much. There may be some uncomfortable symptoms, such as fatigue and loss of appetite after dialysis.
Patients who gain weight three times a week generally gain 5-7% of their dry weight. For example, a 60 kg patient should not gain more than 3-4kg. If it is higher than this figure, it means that the weight gain is too fast, the drinking water control is not good, and various complications are prone to occur. A simpler calculation is that the daily rise of water should not exceed 1 kg.
7. Is there less and less urine after hemodialysis?
Not necessarily. As long as the clinical situation permits, many patients with adequate urine volume (called "dry uremia" by Director Zhou) may not be dehydrated or have a little dehydration during dialysis. In this case, the urine volume generally does not decrease. However, if the urine volume may gradually decrease with the aggravation of the disease, in this case, it is necessary to consider starting dehydration treatment.
8. I still have urine. Why should I be dehydrated?
Some patients still have a lot of urine, but they have other discomforts, such as uncontrollable hypertension, poor sleep, difficulty breathing and even cough. This shows that although there is urine, the amount of urine is not enough to eliminate all the excess water in the body. Therefore, proper dehydration is also needed. This situation is actually an overestimation of dry weight. (for example)
9. How about hemodialysis filtration and hemoperfusion?
As mentioned earlier, the main clearance mode of hemodialysis is dispersion, while convection is the mode of hemofiltration. What we usually call "hemofiltration" actually refers to "hemodiafiltration", which combines diffusion and convection to better remove macromolecular substances. Therefore, it is more thorough than simple hemodialysis. Qinhuangdao's medical insurance policy is that the expenses of hemodialysis and filtration treatment can be reimbursed once a month, so the majority of patients can consider doing hemofiltration once a month.
Hemoperfusion refers to connecting a perfusion device in series during dialysis. The components in this perfusion device are resin components, and their functions are adsorption. This is somewhat similar to the role of activated carbon in gas masks. When the blood passes through the perfusion device, some macromolecular toxins can be adsorbed. There is a saturation problem in the infuser, which can't last for 2 hours. It won't do much good to do it again. The application of early perfusion is mainly drug and poison poisoning, but at present, we also carry out intermittent hemoperfusion treatment in clinic, with the aim of treating secondary hyperparathyroidism, itching, encephalopathy and so on.
The disadvantage of hemoperfusion is that it is easy to be allergic and coagulated, so it needs necessary antiallergic and anticoagulant treatment.
Second, the complications of hemodialysis
1. What should I do if my blood pressure is too high to control?
Hypertension in uremic patients, especially hemodialysis patients, mainly has two factors: one is the volume factor, that is, there is too much water in the body; On the other hand, it is caused by active RAS system. Therefore, hypertension in uremic patients should mainly start from these two aspects. The first is to control weight. Many patients think they still have urine and don't want to be dehydrated. This happened to one of our patients some time ago. For a period of time, they didn't gain much weight, but their blood pressure could not be controlled. Call me. I said, try dehydration first, and sure enough, after two dialysis, the weight dropped to about 1kg, and the blood pressure was controlled immediately.
Of course, if the capacity factor is excluded, it should be considered as the factor of RAS system activation. In this regard, there are two drugs, ACEI drugs and ARB drugs, namely Lotensin or Dai Wen drugs, which can block the RAS system. Without dialysis, patients with renal insufficiency generally dare not use these two drugs, but they can use them after dialysis. These drugs not only lower blood pressure, but also improve myocardial function.
In addition, sympathetic nerve excitation is also the pathogenic factor of hypertension in uremia patients. Therefore, beta blockers such as betaloc and propranolol can be used. Pay attention to the change of heart rate when using these drugs. If your heart rate is too slow, you need to stop using them. In addition, if you have asthma, you can't use it.
2. What about hypotension during dialysis?
The first is to clarify the reasons. Generally speaking, the most common cause of hypotension in dialysis is excessive dehydration. If the heart function is worse, it is more prone to hypotension. The harm of hypotension is still serious, including the easy occurrence of insufficient blood supply to the heart and brain, occlusion of arteriovenous fistula, and aggravation of peripheral vascular diseases.
Preventive measures: strictly control the dry weight, re-evaluate the dry weight, appropriately extend the dialysis time, increase the number of dialysis times, adjust the sodium ion concentration of dialysate, and supplement carnitine (L-carnitine).
Patients with long-term hypotension can be treated with midodrine hydrochloride.
3. What is the bleeding of nose and gum skin after dialysis?
Generally speaking, this shows that the dosage of anticoagulant is too much, and the dosage of anticoagulant needs to be reassessed. Usually, the anticoagulant we use is heparin or low molecular weight heparin. The so-called low molecular weight heparin is the relatively small molecular weight fraction extracted from heparin. It's a bit like the difference between coarse sand and fine sand. Low molecular weight heparin is relatively safer than heparin, so for patients with bleeding tendency, low molecular weight heparin is generally chosen. We now have two dosage forms, low molecular weight heparin calcium and low molecular weight heparin sodium. There is not much difference between the two drugs as a whole, so you can choose as appropriate. If there is still bleeding tendency, it is suggested to check the coagulation function and rule out some blood system diseases.
4. What happened when there was a blood clot in the pipeline during dialysis?
This shows that the dosage of anticoagulant is insufficient. The dosage of anticoagulant should be appropriately increased to realize individualized anticoagulant therapy.
5. What should I do if I often cramp during dialysis?
The exact cause of muscle spasm during hemodialysis is not clear, but it is closely related to the following aspects. 1. Improper dehydration, too fast dehydration, too large dehydration, and dehydration below the basis weight; 2. Electrolyte abnormalities, such as low sodium dialysate, in addition, metabolic acidosis is corrected in time during hemodialysis, free calcium is reduced, and muscle excitability is enhanced; 3. Low blood pressure; 4. Poor nutrition, unable to bear dehydration. Preventive measures and emergency treatment: 1. Change body position in time to avoid cold stimulation and reduce muscle excitability. 2. Slow down water discharge and reduce blood flow. 3. Local hot compress and local massage. 4. If the blood pressure is normal, lower limb spasm can make the patient sit up and put his feet flat on the ground. 5. rehydration, such as normal saline. 6. Hypertonic solution 10% sodium chloride injection or 50% glucose injection. 7. Pay attention to the concentration of Na+ and Ca2+ when making dialysate.
Three, hemodialysis nursing articles
1. Why do you need a neck intubation?
The blood vessels of human body can not meet the needs of dialysis, so the central venous catheter should be placed without arteriovenous fistula or other vascular access. The preferred location is internal jugular vein, and other options include subclavian vein and femoral vein.
2. Why does my intubation sometimes have insufficient flow?
In vivo central venous catheterization time is generally less than 1 month for internal jugular vein and less than 1 week for femoral vein. But in fact, because other blood channels have not been established, the intubation time is often prolonged. This increases the possibility of catheter merging problems. Catheter with cuff, which we call "long-acting catheter", may also have thrombus and fibrin shell in the lumen near its proximal end. In this case, the flow is often insufficient, and urokinase can be used to dissolve the thrombus, which is generally effective, but if it still cannot be corrected, the catheter should be replaced.
3. What should I do if the intubated patient has fever or chills during dialysis?
Central venous catheter-related infection is a common complication. If there are symptoms such as fever, chills and high fever during dialysis, it is highly suggested that central venous catheter infection (CRBSI) has occurred. Treatment principle: 1, blood culture+drug sensitivity test to distinguish infected bacteria from sensitive drugs; 2. Experimental antibiotic therapy. According to statistics, at least 60-70% of CRBSI is infected by Staphylococcus aureus. Therefore, some antibiotics sensitive to Staphylococcus aureus can be used in the experiment. 3. Antibiotic sealing; 4, if necessary, replace the catheter or extubation.
It's been a month since my fistula was finished. Why can't I use it?
There is a mature period after arteriovenous fistula surgery, and each patient is different. K-DOQI guidelines suggest that internal fistula should be used at least 3 months after operation; However, because our patients do fistula too late, it is generally recommended to use it at least after 1 month, but the time of 1 month is an average, and not all patients can use it again after 1 month. Common influencing factors include female, diabetes, hyperlipidemia and so on. If the vein is too thin, it may be impossible to puncture for a long time after operation. After operation, you can make a fist movement after tying a tourniquet to promote the maturity of internal fistula.
5. What should I pay attention to at home after fistula?
1), local exercise can be carried out 3 days after operation to promote fistula maturity. Methods: Hold the rubber grip ring 3-4 times a day, each time 10 minute; You can also use your hand, tourniquet or blood pressure cuff to gently pressurize the vein above the anastomosis (such as the upper arm) to moderately dilate, and relax once every 15-20 minutes, which can be repeated three times a day.
2) Within 5-7 days after operation, keep the limbs on the operation side clean, avoid getting wet and prevent wound infection; If you find oozing blood and the pain is unbearable, contact the doctor immediately and deal with it in time.
3), teach patients how to judge whether the internal fistula is unobstructed, that is, touch the vein on the surgical side with non-surgical hands, and if there is tremor or hear vascular murmur, it will indicate patency. Otherwise, contact the doctor immediately and try again in time.
4) Early after the operation of internal fistula, we should try to wear loose underwear with cuffs to raise the limbs on the surgical side, promote blood return and reduce limb swelling. Avoid oppressing the affected limb, don't wear tight-sleeved clothes, don't wear watches, can't measure blood pressure, can't bear weight, and can't use internal fistula intravenous injection or infusion.
6. Why is there a big bag at my fistula? (figure)
Long-term dialysis patients often bulge a big bag at the blood vessel where arteriovenous fistula is located. This condition is called pseudoaneurysm formation, which is caused by repeated puncture in the same place for a long time to stimulate blood vessels. The formation of pseudoaneurysm has advantages and disadvantages, but the disadvantages outweigh the advantages. The only advantage is that the puncture success rate is high and the pain is small. But it may cause complications, such as bleeding or infection. The prevention of pseudoaneurysm is very important. For example, nurses should avoid repeated needle insertion in the same needle eye, and should adopt button or rope ladder puncture method to puncture in several needle eyes in turn. If a pseudoaneurysm has been formed, no special treatment is needed without special discomfort; If there is local pain, you can use a wristband for local compression treatment; If infection or other serious complications occur, surgery is needed.
Four, hemodialysis diet articles
1. What should the diet of hemodialysis patients pay attention to?
First of all, we should pay attention to the control of the amount of liquid, not only water, but also soup, porridge, drinks, etc. Don't gain too much weight in the dialyzer; Potassium intake should be controlled. Severe hyperkalemia may lead to cardiac arrest, which is a very serious complication. Long-term dialysis patients should also pay attention to limiting phosphorus intake; Control the salt intake of patients with hypertension.
2. How much water should I drink?
In principle, the total daily drinking water should be urine volume +500ml. For example, if the 24-hour urine output is about 1000ml, then the daily water consumption can be controlled at about 1500ml, but it should be noted that this figure includes all kinds of drinks, soups, milk, etc.
3. What are the foods with high potassium content?
Drinks: coffee, tea, sports drinks, fruit juice, chicken essence;
Traditional Chinese Medicine: Ginseng, Lycium barbarum, Cordyceps sinensis, etc.
Fruits: bananas, oranges, strawberries, cantaloupes, pears, persimmons, pineapples, pitaya, apples, longan, lychee, chestnuts, etc.
Vegetables: mushrooms, water spinach, spinach, pickled mustard tuber, dried bamboo shoots, laver, fungus, etc.
Blanching vegetables with water before cooking can reduce the potassium content.
4. What are the high-phosphorus foods?
Seafood: shrimp, river crab, sea crab, abalone, etc.
Nuts: walnuts, almonds, peanuts, pistachios, sesame seeds, sunflower seeds, cashews, pine nuts, lotus seeds, etc.
Viscera: liver, kidney, heart tube, fat intestine, etc.
Staple food: brown rice, cereal, whole wheat bread, coix seed, etc.
Beans: soybeans, red beans, mung beans, broad beans, tofu, etc.
Dairy products: milk powder (except low-phosphorus milk powder), cheese, fresh milk and condensed milk;
Others: coke, chocolate, tea, egg yolk, carbonated drinks, lecithin, pollen, etc.
5. What can I eat?
Protein: Weight per kilogram per day1-1.2g. Try to choose high-quality protein such as milk, eggs, lean meat and fish. For example, for a weight of 60 kilograms, the daily intake is about 60-70 grams, which is the amount of 300 grams of lean meat. If there are two eggs, don't eat the yolk of the second egg. Thanks to the objection raised by enthusiastic netizens, I was wrong about protein's quantity. )
Fat and calories: Fat has a high calorie content. Dialysis patients should properly limit the intake of fat, and the calories are mainly met by sugar. It is recommended to use vegetable oil, which has a high content of unsaturated fatty acids.
Sugar: the main source of calories. Without diabetes, 50% of calories should be met by sugar. The main sources include: cereal, pasta (steamed bread), bread, rice, candy and so on.
Sodium: daily intake 1-2g, especially for patients with hypertension. Sources include edible salt, pickled food, canned food and foreign fast food.
It is generally heavier in the north, so it is suggested to put salt at the end when cooking at home, or put a separate portion of salt.
6. Why should Kaitong, calcium carbonate and calcium acetate be eaten with meals?
The main purpose of taking calcium (also containing calcium) is to control hyperphosphatemia by combining phosphorus in food. As mentioned above, almost all foods contain phosphorus. In fact, as long as there is protein, there is phosphorus. Therefore, taking the above drugs during meals can combine some phosphorus in food to the maximum extent and reduce the degree of hyperphosphatemia.
Five, hemodialysis drugs
1. Antihypertensive drugs
As mentioned above, the first step of antihypertensive treatment for dialysis patients is to achieve the real dry weight and control the volume factor. On this basis, if blood pressure is still not well controlled, you need to take some antihypertensive drugs. Our patients don't know much about several common antihypertensive drugs. Let's introduce them separately:
1) Bai Xintong (Xi 'an Dafu)
Medicare Class B drugs, uremia and chronic diseases could have been reimbursed. It is a calcium antagonist antihypertensive drug with the same composition as nifedipine, and its antihypertensive mechanism is to regulate the expansion of cardiovascular system. The side effect is edema.
2) Amlodipine
Another calcium antagonist, a long-acting drug, has a stronger antihypertensive effect than nifedipine. Some patients said, I ate a bunch of antihypertensive drugs, why can't I get down? I asked, what did you eat? Said: Amlodipine, Baixintong, Fudafu, Xintongding. I said, it's like going to a restaurant to order food, and asking for a fried peanut, boiled peanut and vinegar soaked peanut. It looks like several dishes, but they are all the same. These medicines are all from the same family, so going out to fight is just a trick, and you can't add more. What shall we do? Stop ordering peanuts and shoot a cucumber or something!
3) Dai Wen (valsartan)
Angiotensin receptor antagonist, its function is to inhibit the activity of angiotensin receptor. Similar drugs: Cozuya, Irbesartan, etc.
4) Lotensin (Benazepril)
Angiotensin II invertase inhibitors are used to inhibit the action of angiotensin II invertase. Both drugs are blockers of RAS system, which is another important mechanism of hypertension in dialysis patients. The side effects of Lotensin are cough and hyperkalemia.
5) Betaloc
Beta blockers. Function is to lower blood pressure and heart rate. Side effects: bradycardia, asthma, etc.
6) Terazosin
Alpha receptor blocker. The antihypertensive effect is obvious. It can also inhibit the degree of prostatic hyperplasia. Side effects: postural hypotension. So eat at night.
2. Drugs to correct anemia
Target value for correcting anemia:110g/l.
1) Erythropoietin (Huaerbo, Ipoh)
The anemia correction of many patients in our outpatient department is not ideal. The first thing to consider is that the amount of EPO is not enough. Recently, many patients have doubled the dosage of cyclosporine every time, and hemoglobin has risen rapidly. Of course, if the dose cannot be properly corrected, other factors should be considered, such as bleeding, infection and the formation of rare anti-erythropoietin antibodies.
2) Iron agents (ferrous lactate, iron sucrose)
Intravenous iron supplementation is the first choice for dialysis patients. The problem now is that the amount of intravenous iron supplementation is too high. When we check serum iron, it is very high, which will increase the risk of infection. So generally speaking, the dosage of iron sucrose for dialysis patients is once every 1-2 weeks. In the case of infection, iron cannot be used.
3) Folic acid
This is also a component of synthetic hemoglobin, which can be eaten often, but because the folic acid content in food is very rich, it is not a big problem not to eat it.
4) Shengxuening
This is the product of a recent company. It is an extract of chlorophyll, which is said to have similar effect to erythropoietin. It's just a self-funded medicine, which is more expensive. If the economic situation is not good, it is not recommended.
3. Drugs for preventing and treating calcium and phosphorus metabolic disorder and secondary hyperparathyroidism.
Director Bian Weijing has just talked about this part in great detail, so I won't say much.
1) calcium acetate and calcium carbonate
Mainly used to combine phosphorus in food. But to prevent hypercalcemia.
2) Aluminum hydroxide
It is also a phosphorus binder. It can be applied in a short time.
3) Calcitriol
Different doses are given according to different parathyroid hormone levels.
4. Anticoagulants
1) heparin
The most commonly used anticoagulant. Its application should be individualized, that is, the first dose plus maintenance dose. Stop using before dialysis ends 1 hour. Adverse reactions include: allergy, thrombocytopenia, excessive bleeding, hyperlipidemia and so on.
2) Low molecular weight heparin
Degraded from heparin, it has better anticoagulant effect, less side effects and higher price, and is not included in medical insurance.
3) Aga Quban
When thrombocytopenia occurs, heparin-induced thrombocytopenia (HIT) should be considered first. In this case, heparin or low molecular weight heparin cannot be used for anticoagulation. Agatraban is a thrombin III inhibitor and an ideal anticoagulant. But expensive out-of-pocket drugs. Pay attention to monitoring liver function.
Correct acidosis
1) sodium bicarbonate
Our current dialysis mode is carbonate dialysis, which has been able to correct acidosis very well. However, because dialysis is an intermittent process, severe acidosis often occurs in days without dialysis. Therefore, the current mainstream view is that taking sodium bicarbonate to correct acidosis.
6. Others
1) L-carnitine
L-carnitine is a carrier substance necessary for fat metabolism to produce energy. If energy is equivalent to Datong coal, then carnitine is like a train from mitochondria. Carnitine was originally used in patients with congenital carnitine deficiency. Due to the lack of carnitine, these patients will have symptoms such as muscle weakness, cardiomyopathy and abnormal liver function, and the risk of infection will also increase. During dialysis, 70% of free carnitine is removed, which may lead to some symptoms such as fatigue and muscle weakness. Carnitine supplementation may be helpful to some patients, such as reducing the incidence of myocardial lesions, improving appetite and preventing hypotension. However, at present, there is also the opposite view that the benefits of importing L-carnitine are not great. In addition, this medicine is self-funded and patients can use it according to their own economic situation.