外科加護病房緩慢低效率每日血液透析過濾術

Sustained Low-Efficiency Daily Diafiltration (SLEDD-f) in the Surgery Intensive Care Units

蔡壁如(Pi-Ru Tsai) ； 柯文哲(Wen-Je Ko)

《重症醫學雜誌》 9卷4期 (2008/12) Pp. 242-249

https://doi.org/10.30035/TCCM.200812.0003

摘要

在加護病房中常有休克及多種器官衰竭合併急性腎衰竭的病患，需要腎臟替代治療(RRT, renal replacement therapy)，以達到降低尿毒、移除水分及供給靜脈營養、注射的目的。加護病房急性腎衰竭的血液透析傳統上最常被使用的型式爲間歇性血液透析(IHD)或連續性腎臟替換療法(CRRT)。間歇性血液透析最常見的併發症爲短期間內脫水的總量非常大，重症病患短期間內大量的脫水容易造成低血容積、低血壓而休克。對於血行動力學不穩定的病患，因低血容積性休克，臨床照顧更加困難。連續性腎臟替代治療(CRRT)雖可以緩慢的脫水及維持穩定的血行動力學，但病患需24小時使用抗凝血劑及被約束，加上全自動化的CRRT機器及管線的複雜，不僅費用高，第一線的護理人員學習門檻甚高及需高度護理人力去照顧機器，增加護理人員負荷。
近幾年的文獻開始建議採用每日延長血液透析治療，進行緩慢低效率每日血液透析治療(sustained low efficiency daily dialysis, SLEDD)，將每次血液透析時間延長爲6~12小時，且將透析液的流速調降爲每分鐘300毫升或更低，可維持穩定的血行動力學及足夠的小分子毒素清除。在嚴重敗血症需血液透析患者，更提出緩慢低效率每日血液透析過濾術(Sustained low efficiency daily diafiltration, SLEDD-f)，緩慢低效率每日血液透析過濾治療，結合連續性血液過濾及間歇性血液透析，對於重症病患之體內毒素及水份緩慢的移除，提供線上補充液，有穩定的血行動力學，兼具血液透析及連續性血液過濾的效果及優點。不僅可以將分子量小的尿毒分子給洗掉，更可以將較大分子量的一些發炎物質(inflammatory cytokine)如，IL-1，IL-6，TNF-α移除，讓嚴重敗血症的病人可以免於一些發炎物質所引起的器官傷害。以專業團隊來執行緩慢低效率每日血液透析過濾術，以提高重症病人腎臟替代療法的品質。SLEDD-f每日作業8~10小時，上班時間由外科加護病房技術員負責裝機設定，臨床專科護理師依臨床情況調整脫水量及治療時間，以及故障排除。不需由第一線護理人員來執行，治療品質較可靠，且病人每日有12小時以上不必進行透析治療，也較方便於護理照顧。因此血液透析過濾術對於嚴重敗血症並需血液透析患者，應是目前較好的透析治療方法。

關鍵字

急性腎衰竭 ； 連續性腎臟替代治療 ； 間歇性血液透析 ； 緩慢低效率每日血液透析 ； 緩慢低效率每日血液透析過濾術

並列摘要

Dialysis for patients in intensive care units who have developed acute renal failure (ARF) has traditionally been provided intermittent hemodialysis (IHD) or continuous renal replacement therapy (CRRT). IHD is often complicated by hypotension and inadequate fluid removal. Delivery of adequate solute removal is also problematic for a variety of reasons. Although CRRT addresses some of the drawbacks of IHD, it is associated with significantly greater complexity, the need for continuous anticoagulation, and substantially higher costs. Recently, prolonged HD using conventional equipment has been described as an alternative therapy. The most frequently used terms are extended daily dialysis, sustained low-efficiency hemodialysis (SLED), and sustained low-efficiency daily hemodiafiltration (SLEDD-f). All have in common the use of conventional HD machines, with the same blood flow as IHD but dialysate flow rates lower that of IHD. Treatment duration and frequency are more than in IHD. Hemodynamic tolerance and solute clearance have been good, whereas the complexity and the workload for ICU staff were significantly reduced.
Conclusion: SLEDD-f provides stable renal replacement therapy and good clinical outcomes. SLEDD-f treatment can be prescribed by ICU physicians, and conducted by technician and nursing practitioner. SLEDD-f is a viable alternative to CRRT in critical care setting.

並列關鍵字

Acute renal failure ； Continuous renal replacement therapy ； Intermittent hemodialysis ； Sustained low-efficiency dialysis SLED ； Sustained low-efficiency daily diafiltration SLEDD-f