Upload
gary-manning
View
282
Download
6
Tags:
Embed Size (px)
Citation preview
Water Treatment Unit
For Hemodialysis machines
Hemodialysis Solution
Dialysis solution is prepared fromDialysis solution is prepared from
Purified waterPurified water
ConcentrateConcentrate
+
Water – significance for the patient
g Needed by a human being app. 500- 800 litres per every treatment
g Dialysis patients need app. 20 m3 /yrg Demands of water for dialysis is very high
Types of pollutiong Organic pollutants
particles, colloids, bacteria, pyrogens, chloramines, pesticides
g Inorganic pollutants
monovalent/ polyvalent ions, especially calcium, sodium, magnesium, nitrate, copper, aluminium etc.
Colloids+
+
+++
+
+
+ +
+
+++
+
+
+- -
-
-
- --- - -
-
-
- ---
Water contamination is harmful for dialysis patient:Water contamination is harmful for dialysis patient:
Complications : is added for/by :
Anemia, dementia, bone
disease
Flocculating suspended
particlesAluminum:
Hemolytic anemia
Preventing bacterial
proliferationChloramine:
Pruritis, Nausea, Atrial
fibrillation
Reduce tooth decay Fluoride :
Hemolytic anemia, toxicity
Metal pipesCopper, Zinc
Lead
Pyrogenic reactions
Contaminated water
Bacteria and Endotoxins
Methods of purifying water:Methods of purifying water:
Pretreatment Primary purification Distribution
Pretreatment Primary purification Distribution
gInstallation of water pre-treatment and RO system
Mec
hanic
al Filte
r
Sand
filter
Softe
ner
Wat
er m
eter
Carbo
n filt
er Rever
se o
smos
is
with m
echa
nical
Filter
Salt ta
nk
Methods of purifying water:Methods of purifying water:
Pretreatment Primary purification Distribution
Pretreatment Primary purification Distribution
pretreatment:pretreatment:
Water softener Carbon adsorption
Water softener Carbon adsorption
Softener:Softener:
SOFTENER
Carbon adsorption:Carbon adsorption:
Adsorption by activated Carbone Is utilized to remove
Chlorine and Chloramines
Adsorption by activated Carbone Is utilized to remove
Chlorine and Chloramines
2-Activated carbon filter for adsorption principle:
*van der Waals forces *high specific surface (100g act. carbon – ca. 100.00 m2)
◊ remove chlorine from drinking water
Methods of purifying water:Methods of purifying water:
Pretreatment Primary purification Distribution
Pretreatment Primary purification Distribution
Methods of purifying water:Methods of purifying water:
Pretreatment Primary purification Distribution
Pretreatment Primary purification Distribution
Primary purification:Primary purification:
Reverse osmosis Deionization
Reverse osmosis Deionization
Reverse osmosis:Reverse osmosis:
It removes more than 95% of ionic
contamination and nonionic contaminations
It removes more than 95% of ionic
contamination and nonionic contaminations
clear water
Osmotic pressure
saline solution
semipermeable membrane
Principle of Osmosis
pressure
saline solutionclear water
semipermeable membrane
Principle of Reverse Osmosis
Reverse osmosis apparatus
Direct and indirect water feed distribution system
Deionization:Deionization:
Methods of purifying water:Methods of purifying water:
Pretreatment Primary purification Distribution
Pretreatment Primary purification Distribution
Methods of purifying water:Methods of purifying water:
Pretreatment Primary purification Distribution
Pretreatment Primary purification Distribution
The main function of the dialysate, is to remove waste material from the blood and to keep useful material from leaving the blood. Electrolytes and water are some materials included in the dialysate so that their level in the blood can be controlled
Dialysis solutions preparation:Dialysis solutions preparation:
Fixed volumes of dialysate concentrate mixed with
fix volumes of heated purified water
The final dialysate solution is checked by conductivity
Fixed volumes of dialysate concentrate mixed with
fix volumes of heated purified water
The final dialysate solution is checked by conductivity
Biff F. Palmer
Bicarbonate powder obviates the problem of bicarbonate growth in bicarbonate solutions
Hemodialysis solution
Concentrations of dialysate components used in hemodialysis :
Sodium (meq/L) 135 to 155 Potassium (meq/L) 0 to 4 Calcium (mmol/L) 1.25 to 1.75 (2.5 to 3.5 meq/L) Magnesium (mmol/L) 0 to 0.75 (0 to 1.5 meq/L) Chloride (meq/L) 87 to 120 Bicarbonate (meq/L) 25 to 40 Glucose (g/dL) 0 to 0.20
In early 1960s acetate was standard buffer
Acetate lead to cardiovascular instability and hypotension during dialysis.
Acetate buffer
Acetate buffer
Hemodynamic instability Pts with reduced mass muscle more
intolerant to acetate buffer included malnourished Pts,elderly Pts and women.
Bicarbonate (meq/L) 25 to 40
Standard solutions have 35 or 38 meq/L In alkalemic pts (metabolic or respiratory)
standard solutions must be changed to a solution with 20-28 meq/L of bicarbonate
Concentration of base adjusted to a predialysis plasma con of 20-23 meq/L
Con beyond 20-23 meq/L increased risk of Ca-P precipatation and cardiac arrhythmia
Bicarbonate Concentrate
NaHCO3
Bicarbonate Concentrate
NaHCO3
Acid Concentrate
(acetic acid, citric acid ,Na, K, Mg, Cl, dextrose
Acid Concentrate
(acetic acid, citric acid ,Na, K, Mg, Cl, dextrose
HCO3 + H+ = H2CO3
PH: 7-7.4
HCO3 + H+ = H2CO3
PH: 7-7.4
NaHco3 = 32mmol ± 8 mmol
Bicarbonate Concentration for Acidotic Patient =35-38 mEq/L
Sodium level:135-145meq/L
Dialysate with low Na level predispose to hypotension and cramps because of hypoosmolality and more fluid shifting from extracellular space to intracellular space.
Dialysate with high Na level may cause thirst and weight gain and prevent hypotension during dialysis.
Standard Dilution 1 + 34Variable 1 + 25 1 + 37 Acetate 135mmol Base Na Bicarbonate 138mmol
NaHco3 + Acid Solution 32mmol + 106 mmol
Potassium level :0-4meq/L
Usual dialysis K level is 2 meq/L unless predialysis plasma K is less than 4.5 or unless patient is receiving digitalis.
In the two instances ,dialysis K level is 3 meq/L
Calcium level:2.5-3.5 meq/L
In pts taking calcium-containing phosphorus Ca level is 2.5 meq/L
In pts taking newer phosphate binder which don’t contain Ca , Ca level may increased towards 3.5meq/L
Air Detector
Blood Leak Detector
PT
PT = Pressure Transducer
PT
Venous clamp
Anticoagulant
Blood from Patient
Blood return to Patient
Dialysate In
Dialysate / UF Out (green / yellow)
Informational Display
A “Standard” HD Delivery System
PT
Mixing System
Conductivity Meter
Water, Acid Concentrate, Bicarbonate
Concentrate In
Pre-mixed or sorbent
regenerated dialysate
Saline
Drip Chamber
مایع نهایی غلظتبیکربنات دیالیز
Na :135meq/lK:1 & 2 meq/lMg:1 meq/lCa:2.5 meq/lCl:104 meq/lAcetate :35 meq/lGlucose : 200mg/dl
Na :106 + 32 meq/lK:1 & 2 meq/lMg:1 meq/lCa:2.5 meq/lCl:111.5 meq/lAcetate :3.5 meq/lGlucose : 200mg/dlBicarbonate :32 meq
مایع نهایی غلظتاستات دیالیز
What is sodium modeling in hemodialysis patients?
What is sodium modeling in hemodialysis patients?
Fluid removal
Plasma refilling
Low Na 130-135 meq/l
Na
Fluid removal Fluid removal
Na
Increased risk of hypotension
Historically the dialysate Na was maintained at hyponatremic level, 130-135:
Historically the dialysate Na wasmaintained at hyponatremic level, 130-135:
To prevent: Intradialytic hypertension Thirsty Interdialytic weight gain
To prevent: Intradialytic hypertension Thirsty Interdialytic weight gain
Disadvantages of dialysates with low sodium concentration:
Disadvantages of dialysates with lowsodium concentration:
Increased risk of hypotension Increased risk of intradialytic cramps Increased risk of dialysis disequilibrium
syndrome
Increased risk of hypotension Increased risk of intradialytic cramps Increased risk of dialysis disequilibrium
syndrome
Water movement during standard hemodialysis
Water movement
Intracellular fluid Extracellular fluid Dialyzer
Osmolality320 mosm/kg
Osmolality320 mosm/kg
Loss of urea and water
step1
step2
step3
280
Osmolality320 mosm/kg
Falling to 290mosm/kg
as diffusion occurs
Compensatory refilling
urea removed by dialyzer
Effluent Dialysate
Inffluent Dialysate
urea sequestration in tissue
Increased intracellular osmolarity
fluid
Na
fluid
Causes of Intradialytic hypotension(IDH(
Intradialytic Hypotension
Reduced ECVImpaired Vaso-
constriction
Heart problems
Myocardial Infarction
Structural heart dis.
Arrythmias
Pericardial tamponadeDialyzer Rxn Air embolism
Hemolysis
Hemorrhage
Reduced plasma refill-
ing rate
Excessive fluid removal
Ultrafiltration rate > 0.35 ml/min/kg
Decrease in plasma vol. > 20%
Patient-related factors
Autonomic neuropathy (e.g. DM, Uremia)Antihypertensive medications
Sympathetic failure ( 적절한 plasma NE↑ 가 無 )RAS and arginine-vasopressin syst. sensitivity↓
Food ingestion(splanchnic vasodilation)Tissue ischemia(adenosine mediated)
Bacterial sepsisIntradialytic venous pooling
Core body temp↑.Anemia.
Dialysis-related factors
Acetate dalysate (adenosine-mediated)Low dialysate Na &/or ionized Ca conc.
Complemant activation (C3a and C5a-mediated)Cytokine generation(IL-1 and NO-mediated)
High dialysate sodium:High dialysate sodium:
Advantages:
Decreased risk of hypotension
Decreased risk of intradialytic cramps
Decreased risk of dialysis disequilibrium syndrome
Advantages:
Decreased risk of hypotension
Decreased risk of intradialytic cramps
Decreased risk of dialysis disequilibrium syndrome
Disadvantages:
Increased rate of hypertension
Interdialytic weight gain
Polydipsia
Disadvantages:
Increased rate of hypertension
Interdialytic weight gain
Polydipsia
Low Na >145 meq/l
Na
Fluid removal Plasma refilling
Na
Different patterns of sodium modeling Different patterns of sodium modeling
Na concentration
Hours after dialysis initiation
145-155 meq/lit
135-140 meq/lit
Dialysate Na should be regulated based on serum Na:
Dialysate Na should be regulated based onserum Na:
hyponatremia:
If Na > 130: Dialysate Na: 140-(140-predialysis Na(
If Na<130: Dialysate Na: Predialysis Na + 15-20
Hypernatremia:
Dialysate Na: Predialysis Na-2 mmol
hyponatremia:
If Na > 130: Dialysate Na: 140-(140-predialysis Na(
If Na<130: Dialysate Na: Predialysis Na + 15-20
Hypernatremia:
Dialysate Na: Predialysis Na-2 mmol