KQOQI导管感染或血栓

NKFKDOQIClinicalPracticeGuidelinesandClinicalPracticeRecommendations2006UpdatesHemodialysisAdequacyPeritonealDialysisAdequacyVascularAccessI.CLINICALPRACTICEGUIDELINESFORVASCULARACCESSGUIDELINE7.PREVENTIONANDTREATMENTOFCATHETERANDPORTCOMPLICATIONSCathetersandportsareessentialtoolsforprovidingurgentand,insomecases,long-termvascularaccess.Preventionandearlytreatmentofcomplicationsshouldgreatlyreduceassociatedmorbidityandmortality.7.1Cathetersandportsshouldbeevaluatedwhentheybecomedysfunctional.Dysfunctionisdefinedasfailuretoattainandmaintainanextracorporealbloodflowof300mL/minorgreaterataprepumparterialpressuremorenegativethan–250mmHg.(B)7.2Theexceptionispediatricorsmalleradultcathetersthatarenotdesignedtohaveflowsinexcessof300mL/min.(B)7.3Methodsthatshouldbeusedtotreatadysfunctionalornonfunctionalcatheterorportinclude:7.3.1Repositioningofamalpositionedcatheter.(B)7.3.2Thrombolytics,usingeitheranintraluminallytic,intradialyticlockprotocol,oranintracatheterthrombolyticinfusionorinterdialyticlock.(B)7.3.3Catheterexchangewithsheathdisruption,whenappropriate.(B)7.4TreatmentofaninfectedHDcatheterorportshouldbebasedonthetypeandextentofinfection.7.4.1Allcatheter-relatedinfections,exceptforcatheterexit-siteinfections,shouldbeaddressedbyinitiatingparenteraltreatmentwithanantibiotic(s)appropriatefortheorganism(s)suspected.(A)7.4.2Definitiveantibiotictherapyshouldbebasedontheorganism(s)isolated.(A)7.4.3Cathetersshouldbeexchangedassoonaspossibleandwithin72hoursofinitiatingantibiotictherapyinmostinstances,andsuchexchangedoesnotrequireanegativebloodcultureresultbeforetheexchange.(B)Follow-upculturesareneeded1weekaftercessationofantibiotictherapy(standardpractice).7.4.4Portpocketinfectionsshouldbetreatedwithsystemicantibioticsandirrigation,inconjunctionwiththemanufacturers'recommendations.(B)RATIONALEEvaluationofDysfunction(CPG7.1)Catheterdysfunctioncanbeattributedtomanycauses,andprogressionofdysfunctiontononfunctionvariesaccordingly.182Themostcommoncomplicationsarethrombosisandinfection.486,487Evenwithcare,fewerthanhalfthecathetersplacedas“long-termaccess”areinuseayearaftertheirplacement,488andaboutathirdareremovedbecausetheyfailtodeliveradequatebloodflow.Thedefinitionofadequatebloodflowvariesinverselywiththe“efficiency”ofHD.High-efficiencydialysisaspracticedintheUnitedStatesrequiresdialyzer-deliveredBFRsgreaterthan300mL/mintoachievethetargetsingle-poolKt/Vof1.2(seetheKDOQIHDAdequacyGuidelines).Conversely,inEurope,BFRslessthan300mL/minfrequentlyareusedbecausedialysistreatmentdurationsarelonger.203Adequacyofdialysisisinfluencedadditionallybythesiteofplacementanddegreeofrecirculation.489,490Recirculationinfemoralcathetersissignificantlygreaterthanthatininternaljugularcatheters(13.1%versus0.4%;P0.001).193Inaddition,femoralcathetersshorterthan20cmhavesignificantlygreaterrecirculation(26.3%)thanthoselongerthan20cm(8.3%;P=0.007).ThislengthdependencymayresultfromtheultimatetippositionoflongercathetersintheIVCasopposedtothecommoniliacveinwithshortercatheters.ThegreaterbloodflowavailabletothecatheterattheIVCsitereducesrecirculation.Whendialysisdosedeliveryisapriority,placingtheshort-termcatheterintheinternaljugularveinisanadvantage.Recirculationmayincreasewhenthe“linesarereversed”(inversionofinletandoutletlumens),evenin“wellfunctioning”nonsplitcatheters(from2%to3%to10%).491Althoughreversaloftubingsmayincreaseureaclearancebyincreasingbloodflowtemporarily,184itusuallyisataBFRlessthan300mL/minandshouldneverbeusedexcepttemporarilyuntiltheproblemisdefinitivelycorrected.Adysfunctionalcatheterusuallyiseasiertosalvagethananonfunctionalcatheter,therebypreventingcomplicationsofanewplacement.249Earlytreatmentalsoreducesthelikelihoodandminimizestheextentofinadequacyofdialysiscausedbycatheterdysfunction.Deliveryofadequatedialysisdoseisdependentuponbloodflowandtreatmentduration.Foranygivendialyzer,lowBFRsduringHDextendtreatmenttimesandalltoooftenstillresultinunderdialysis(causedbyunrecognizedrecirculation).ABFRlessthan300mL/minwasnotedin15%oftreatmentswithcatheters.249Catheterdysfunctionleadsto17%to33%ofuntimelycatheterremovals,487,488andthrombosisofthecatheteroccursinaccesslossin30%to40%ofpatients.Itistobenotedthatthecriterionfordeterminingaccessdysfunction,ie,bloodflowgreaterthan300mL/min,isqualifiedbytheprepumparterialpressure182factoredforthelengthandlumendiameterofthecatheter.183,490Prepumparterialpressuremonitoringisessentialtoensurevalidbloodflows,andadequacyisdeterminedlargelybytheamountofbloodpumpedtoandthroughthedialyzer.189,191,200Consequencesofcatheterdysfunctionaremany,includingincreasesinmorbidityandmortality,20,248,258increaseineconomicexpenditures,250anda“real”concerntopatients,60%ofwhomreportfearofthrombosissecondonlytopainindecreasingtheirQOL.252InCVCs,themostlikelycauseforlowBFRsisthromboticocclusion.InthelikelyeventthatlowBFRorocclusionwilloccuratsometimeduringtheusefullifeofacatheter,prospectivemonitoringisessentialtodetectdysfunction.Regularassessmentofdialysisperformanceisstronglyrecommendedtoensuredialysisadequac