圖書章節 图书章节
血液透析中的安全監測器
Safety Monitors in Hemodialysis 下载PDF
透析治療手冊，第 9 版，101-117 頁
Handbook of Dialysis Therapy, 9, 101-117
血液透析監測包括機器、設備、協議和人員。主要目標是確保患者在血液透析過程中的安全。所有檢查、觀察、跟踪和控制血液透析治療的任務都是監測程序。這些重要任務往往被輕視。
Hemodialysis monitors include machines, devices, protocols, and personnel. The major goal is to ensure patient safety during the hemodialysis procedure. All tasks that check, observe, keep track of, and control the hemodialysis treatment is monitoring procedures. These important tasks are too often lightly dismissed.
本章專注於液體輸送系統和體外循環系統，以及它們各自的監測設備、功能、位置、性能標準和管理。患者的監測和血液透析處方在透析前、透析中和透析後的內容在本書的其他部分中涵蓋。納入了由健康與人類服務部醫療補助和醫療保險服務中心（CMS）於 2008 年 10 月 3 日生效的末期腎病（ESRD）設施的覆蓋條件（CfCs）的一部分。修訂的法規更新了為透析患者提供安全、高品質護理的標準。關於透析液的具體法規（§494.40 條件：水和透析液質量）保持不變。首次針對透析液的法規包括混合、分配、標籤和使用。
This chapter focuses on the fluid delivery system and extracorporeal circuit, their respective monitoring devices, functions, locations, performance standards, and management. Monitoring of the patient and hemodialysis prescription pre, during, and post dialysis are covered in other sections of this book. Incorporated are parts of the Conditions of Coverage (CfCs) dictated by the Department of Health and Human Services Center for Medicaid and Medicare Services (CMS), effective October 3, 2008, for end-stage renal disease (ESRD) facilities. The revised regulations update standards for delivering safe, high-quality care to dialysis patients. Specific regulations regarding dialysate (§494.40 Condition: Water and Dialysate Quality) remain unchanged. First-time regulations specific for dialysate include mixing, distribution, labeling, and use.
定義與概述 Definitions and Overview
液體輸送系統通常稱為「機器」。液體輸送系統準備透析液，這是一種體溫的電解質溶液。透析液流經透析器的透析液腔室，在此進行透析。血液泵將患者的血液循環通過體外循環到透析器的血液腔室，然後再回到患者身上。需要監測的兩個主要類別是透析液回路和血液回路。
The fluid delivery system is commonly called “the machine.” The fluid delivery system prepares dialysate, a body temperature electrolyte solution. The dialysate flows through the dialysate compartment of the dialyzer, where dialysis occurs. A blood pump circulates the patient's blood through the extracorporeal circulation to the blood compartment of the dialyzer and back to the patient. The two major categories to monitor are the dialysate circuit and blood circuit.
血液循環系統由血管管路組（動脈和靜脈）、透析器的血液側、靜脈（IV）生理食鹽水及給藥管路，以及肝素注射器和輸注管路組成。
The blood circuit consists of a blood tubing set (arterial and venous), blood side of the dialyzer, intravenous (IV) normal saline and administration line, and heparin syringe and infusion line.
血液和透析液是兩個獨立的回路，在透析器膜上相互連接。機器設計必須涉及對這兩個回路的廣泛監控。當機器的預設限制被超過和/或存在不安全情況時，必須啟動特定的警報。
The blood and dialysate are separate circuits that interface at the dialyzer membrane. The machine design must involve extensive monitoring of both circuits. Specific warning alarms must be initiated when the machine's preset limits are exceeded and/or an unsafe condition exists.
透析液 Dialysate Solution
透析液或透析液體是一種非無菌的水性電解質溶液，與細胞外液中正常的電解質水平（表 9.1）相似，唯一的例外是緩衝劑碳酸氫根和鉀。透析液幾乎是一種等滲溶液，通常的滲透壓約為 300 ± 20 毫滲透摩爾每升（mOsm/L）。為了確保病人安全並防止紅血球（RBC）因溶血或皺縮而破壞，透析液的滲透壓必須接近血漿的滲透壓。血漿的滲透壓為 280 ± 20 mOsm/L。透析液通常含有六種電解質：鈉（Na + ）、鉀（K + ）、鈣（Ca 2 + ）、鎂（Mg 2 + ）、氯（Cl – ）和碳酸氫根（HCO 3 – ）。第七種成分，非電解質葡萄糖或右旋糖，通常存在於透析液中。透析液中葡萄糖的濃度通常在 100 到 200 mg/dL 之間。新鮮製備的透析液在體外循環系統中不斷循環到透析器。透析液經過透析器單次通過後，排出的透析液會進入排水系統。
Dialysate solution or dialyzing fluid is a nonsterile aqueous electrolyte solution that is similar to the normal levels of electrolytes ( Table 9.1 ) found in extracellular fluid, with the exception of the buffer bicarbonate and potassium. Dialysate solution is almost an isotonic solution, with the usual osmolality of approximately 300 ± 20 milliosmoles per liter (mOsm/L). To ensure patient safety and prevent red blood cell (RBC) destruction by hemolysis or crenation, the osmolality of dialysate must be close to the osmolality of plasma. The osmolality of plasma is 280 ± 20 mOsm/L. Dialysate solution commonly contains six electrolytes: sodium (Na + ), potassium (K + ), calcium (Ca 2 + ), magnesium (Mg 2 + ), chloride (Cl – ), and bicarbonate (HCO 3 – ). A s). A seventh component, the nonelectrolyte glucose or dextrose, is invariably present in the dialysate. The dialysate concentration of glucose is commonly between 100 and 200 mg/dL. Freshly prepared dialysate solution circulates continuously to the dialyzer in the extracorporeal circuit. After making a single pass through the dialyzer, the effluent dialysate goes to the drain.
Comparison of Normal Blood Values and Dialysate Composition
From Pittard J, De Palma J. Dialysate Monograph . 1st ed. Glendale, CA: Hemodialysis, Inc.; 2013.
| 電解質 Electrolyte | 透析液濃度範圍 Dialysate Level Range | 正常血液值範圍 Normal Blood Value Range |
|---|---|---|
| 鈉 Sodium | 135–145 mEq/L | 135–145 mEq/L |
| 鉀 Potassium | 0–4 mEq/L | 3.5–5.5 mEq/L |
| 鈣 Calcium | 2.25–3.0 mEq/L | 4.5–5.5 mEq/L |
| 鎂 Magnesium | 0.5–1.0 mEq/L | 1.5–2.5 mEq/L |
| 氯化物 Chloride | 100–115 mEq/L | 95–105 mEq/L |
| 碳酸氫根 Bicarbonate | 30–40 mEq/L | 22–28 mEq/L |
| 非電解質 Nonelectrolyte | ||
| 葡萄糖 Dextrose | 0–200 毫克/分升 0–200 mg/dL | 80–120 毫克/分升 80–120 mg/dL |
液體輸送系統 Fluid Delivery System
美國絕大多數的透析設施使用單病人液體供應系統。這種設備是自給自足的，僅為個別機器準備透析液。一些透析設施使用中央供應系統，中央製造透析液。雖然該系統更具經濟性，但其安全性不如個別機器。本討論將重點放在單病人機器上。也將探討一些獨特於中央供應系統的安全問題。
The vast majority of dialysis facilities in the United States use single-patient fluid delivery systems. This type of equipment is self-contained, preparing the dialysate only for the individual machine. Some dialysis facilities use central delivery systems with central manufacture of dialysate. Although that system is more economical, it is less safe than the individual machines. The discussion will focus on single-patient machinery. A few safety issues unique to a central delivery system are explored as well.
控制面板和顯示器顯示
Control Panel and Monitor Display
所有現代流體輸送系統都有一個前置控制面板（圖 9.1），通過該面板可以設置壓力和其他限制，並查看系統參數。控制面板和機器正面的顯示器將作為安全透析監測的必要部分，配備可聽和可視的警報。
All modern fluid delivery systems have a frontal control panel ( Fig. 9.1 ) by which pressure and other limits may be set and system parameters may be viewed. The control panel and monitor display on the face of the machine will have audible and visual warning alarms as a mandatory part of safe dialysis monitoring.
Control Panel and Monitor Display.
(From Pittard J. Hemodialysis Nursing, Training Manual . 7th ed, version 7.0. Santa Monica, CA; 2003, with permission.)
監視器故障 Monitor Failure
機器監視器可以是機械操作或電氣操作，或兩者的結合。所有監視器都有可能失效。應該記住並接受墨菲定律（如果有任何事情可能出錯，它就會出錯）作為事實。墨菲定律歸因於 1950 年代在洛斯阿拉莫斯實驗室工作的工程師。這一陳述的真相可以重新表述為：“如果你能想到目前設備可能發生的災難，請立即採取必要的預防措施，否則它將會發生。”如果能夠訪問事故和事件報告，幾乎每一個可能的監視器故障都已經發生，並導致病人/工作人員受傷或死亡。
Machine monitors are either mechanically or electrically operated, or a combination of both. All monitors can fail. Murphy's Law (if anything can go wrong, it will) should be remembered and accepted as fact. Murphy's Law is attributed to an engineer working at the Los Alamos laboratories in the 1950s. The truth of this statement can be reworded to, “If you can think of a possible disaster with the present equipment, take the necessary precautionary steps immediately, or it will happen.” If one can access misadventure and incident reporting, virtually every possible projected failure of a monitor has occurred and has resulted in patient/staff injury or death.
失效安全，誤稱 Fail-Safe, a Misnomer
機器監控器常被認為是安全失效裝置，但事實並非如此。真正的安全失效裝置無法被電子或人為干預所覆蓋以造成傷害。根據這一狹義定義，並不存在安全失效的透析機監控器。因為所有透析機監控器都有可能失效，因此它們應該簡單易操作且準確，並在超出限制或運作不正常時發出警告。任何重要因素都需要雙重監控：機器監控裝置和透析人員。沒有任何機器、電腦或裝置可以取代血液透析人員的持續監控。
Machine monitors are frequently thought to be fail-safe devices, but they are not. A truly fail-safe device cannot be overridden to cause harm either by electronic or human intervention. By this narrow definition, there are no fail-safe dialysis machine monitors. Because all dialysis machine monitors can fail, they ought to be simple to operate and accurate—and should signal a warning when they are out of limits or not working properly. Any important factor requires dual monitoring: the machine monitor device and dialysis personnel. No machine, computer, or device can replace the continuous surveillance of the hemodialysis personnel.
透析液迴路 Dialysate Circuit
圖 9.2 顯示了透析液路徑的組件。透析液監測包括處方、成分（導電性和 pH 值）、溫度、流量、壓力、排出液、雜質的缺失（清潔和消毒劑）、潛在的致熱源以及微生物檢測。每個監測器或控制裝置按液體的通常流動順序進行討論，從水進口電磁閥到排出透析液的排水管。
Fig. 9.2 displays components of the dialysate fluid path. Dialysate monitoring includes prescription, composition (conductivity and pH), temperature, flow, pressure, effluent, absence of impurities (cleaning and disinfecting agents), potential pyrogenic agents, and microbiologic testing. Each monitor or control is discussed in order of the usual flow of fluid, from the water inlet solenoid valve to the effluent dialysate drain line.
Fluid Pathway Simplified.
(From Pittard J. Hemodialysis Nursing, Training Manual . 7th ed, version 7.0. Santa Monica, CA; 2003, with permission.)
為什麼要討論透析機器的細節？
Why Discuss the Details of Dialysis Machinery?
每次透析治療都會使末期腎病（ESRD）患者的血液接觸到數百升的透析液。透析液應為藥品級，因為透析液相當於靜脈注射液。製造透析液的機器可能因污染物或不正確的溶質濃度而無聲無息地對患者造成嚴重傷害或死亡。更令人不安的是，如果機器製造出一種顯著的低滲透液，但濃度不會引起溶血，患者可能會迅速發展為水中毒、腦水腫、癲癇發作和非心源性肺水腫——這些徵兆和症狀透析人員可能會輕易誤解為需要更多的超濾和更多的透析！
Each dialysis treatment exposes the ESRD patient's blood to hundreds of liters of dialysate. The dialysate should be of pharmaceutical grade, as dialysate is the equivalent of an IV solution. The machinery that manufactures dialysate can silently and quickly cause a patient serious injury or death because of contaminants or incorrect solute concentration. Even more distressing, if the machinery manufactures a substantially hypotonic fluid, but at a concentration that does not cause hemolysis, the patient may rapidly develop water intoxication, cerebral edema, seizures, and noncardiogenic pulmonary edema—signs and symptoms that the dialysis staff can easily misinterpret as requiring more ultrafiltration and more dialysis!
目前的治療使用血流速率為 300 至 450 mL/min，整個病人的循環血液可能在不到 15 分鐘的時間內暴露於有毒化學物質或溶血狀態。即使在死後檢查中，死亡也可能迅速發生且原因未被診斷。所討論的每個透析液回路組件，如果發生故障，可能會引起溶血。
With current therapy using blood flow rates of 300 to 450 mL/min, the entire patient's circulating blood may be exposed to toxic chemicals or a hemolytic state in less than 15 minutes. Death can be both swift and the cause undiagnosed, even with postmortem examination. Each component of the dialysate circuit discussed, if it malfunctions, may induce hemolysis.
水進口電磁閥 Water Inlet Solenoid
水進口電磁閥在主電源開關啟動時允許處理過的水流入透析機，當主電源關閉時則停止水流。處理過的水通過水進口閥進入機器，水壓通常在 20 到 105 磅每平方英寸（psi）之間。血液透析所用的處理水必須符合醫療儀器協會（AAMI）的標準。並非所有機器都有水進口電磁閥。在未啟動機器主電源開關的情況下允許水流入機器，可能會導致該部分流體通道中細菌滋生的問題。
The water inlet solenoid permits the flow of treated water into the dialysis machine when the main power switch is activated and stops the flow when the main power is turned off. Treated water enters the machine via a water inlet valve with water pressure usually between 20 and 105 pounds per square inch (psi). The treated water for hemodialysis must meet the Association for the Advancement of Medical Instrumentation (AAMI) standards. Not all machines have a water inlet solenoid. Allowing water to flow into the machine without activating the machine's main power switch can cause problems with bacterial buildup in that portion of the fluid pathway.
電磁閥監控 Solenoid Monitoring
進水壓力可以使用指針式壓力計來測量。該機制在開啟或關閉狀態下可能會故障或洩漏。此設備沒有已發布的性能標準或標準警報。許多機器都有持續的可聽警報，以提醒工作人員出現問題。如果存在警報條件，顯示水流或壓力不足，其作用可能是防止水被加熱器過熱。過熱的透析液會導致明顯的溶血。
The inlet water pressure can be measured using a dial-type manometer. This mechanism may malfunction or leak in the on or off position. There are neither published performance standards nor standard alarms for this device. Many machines have a continuous audible warning alarm to alert the staff of problems. If an alarm condition exists that indicates inadequate water flow or pressure, its role may be to prevent water from being overheated by the water heater. Overheated dialysate causes gross hemolysis.
透析液溫度 Dialysate Temperature
加熱器將進水的溫度提高到約人體溫度。加熱會部分去氣冷水，這改善了水和透析液濃縮液的混合。熱敏電阻反饋電路通常控制電加熱元件。加熱器可能在機器內部有粗調整控制，並在前面板上有細調整控制。在某些機器內可能有一個簡單的雙金屬刻度溫度計，雖然沒有警報，但提供其功能的視覺觀察。
A heater raises the temperature of the incoming water to approximately body temperature. Heating partially degasses the cold water, which improves the mixing of water and dialysate concentrate. A thermistor feedback circuit usually controls the electrical heating elements. The heater may have a coarse adjustment control inside the machine and a fine adjustment control on the front panel. There may be a simple bimetallic dial thermometer within some machines that, though not alarmed, provides visual observation of its function.
透析液的溫度通常在整個透析治療過程中維持在 37°C 到 38°C（98.6°F 到 100.4°F）之間，儘管最近的研究表明，稍低的透析液溫度（在可耐受範圍內）可能是有益的，並且能更好地維持透析過程中的心血管穩定性。內部溫度傳感器（圖 9.3）持續監測透析液的溫度。在某些情況下，實際的溫度讀數會顯示在機器的前面板上。其他機器的前面板上有燈光指示警報狀態。大多數液體輸送機器都有高溫和低溫監測警報。一些舊型號的機器只有高溫警報。如果高或低的內部溫度超過預設的內部限制，將會產生三個動作：可聽見的警報、可視的警報和旁路模式的啟動。
The dialysate temperature is usually maintained between 37°C and 38°C (98.6°F and 100.4°F) throughout the dialysis treatment although recent research has suggested that somewhat lower dialysate temperature, as tolerated, may be beneficial and better maintain intradialytic cardiovascular stability. An internal temperature sensor ( Fig. 9.3 ) monitors the dialysate temperature continuously. In some cases, the actual temperature reading is displayed on the front panel of the machine. Other machines have lights on the front panel that indicates an alarm condition. Most fluid-delivery machines have high- and low-temperature monitor alarms. Some older-model machines have only high-temperature alarms. If the high or low internal temperatures exceed the preset internal limits, three actions result: an audible alarm, a visual alarm, and activation of the bypass mode.
(From Pittard J. Hemodialysis Nursing, Training Manual . 7th ed, version 7.0. Santa Monica, CA; 2003, with permission.)
加熱器和溫度監測
Heater and Temperature Monitoring
內部工廠設置的控制應將透析液溫度限制在 33°C（92°F）至 39°C（102°F）之間。機器前面板上的微調控制旋鈕不應能夠覆蓋此設置。
Internal, factory-set, controls should limit dialysate temperature to between 33°C (92°F) and 39°C (102°F). The fine adjustment control knob on the front panel of the machine should not be capable of overriding this setting.
溫度高於 106°F
Temperatures Greater Than 106°F
高透析液溫度的常見原因要麼是故障的水加熱器與溫度控制器，要麼是水流限制。內部高限應設置在不高於 41°C（105.8°F）。正常紅血球在 42°C 時開始溶血。過熱的透析液已知會引發心臟心律不整。
The usual causes of high dialysate temperature are either a malfunctioning water heater with a temperature controller or a water flow restriction. The high internal limit should be set no higher than 41°C (105.8°F). Normal RBCs begin to hemolyze at 42°C. Overheated dialysate has been known to precipitate cardiac arrhythmias.
儘管在透析過程中，透析液溫度的提高確實能增加擴散效率，但在沒有優良電子溫度監測的情況下，這是一種危險的提高透析效率的方法。在任何情況下，高限不應調整至 41°C 以上。文獻中的幾篇文章建議上限設置為 42°C（107.6°F），這可能過高，並可能導致溶血。應該記住，尿毒症紅血球在滲透壓上更脆弱，且其半衰期比正常紅血球短。合理的假設是，這些尿毒症紅血球對所有機械和熱源造成的創傷比正常紅血球更敏感。
Although it is true that the efficiency of diffusion during dialysis is increased with increased dialysate temperature, without excellent electronic temperature monitoring, this is a dangerous way to increase dialysis efficiency. Under no circumstances should the high limit be adjusted above 41°C. Several articles in the literature suggest that the upper limits be set at 42°C (107.6°F), which is probably too high and may cause hemolysis. It should be remembered that uremic RBCs are more osmotically fragile and have a shorter half-life than normal RBCs. It is reasonable to assume that these uremic RBCs are more sensitive to all mechanical and thermal causes of trauma than normal RBCs.
低於 98.6°F 的溫度
Temperatures Less Than 98.6°F
一些腎臟科醫生使用較低溫的透析液，認為這可以促進對高超濾的血壓反應更穩定。如果使用低溫透析液，則每降低 3°F（約 1.67°C）需將總透析時間增加約 8%，因為這是隨著溫度降低而理論上導致的擴散性損失。低透析液溫度可能會引起靜脈血管痙攣，並使得無法通過人工腎臟獲得最大血流量。
Some nephrologists use lower-temperature dialysate in the belief that this promotes a more stable blood pressure response to high ultrafiltration. If low-temperature dialysate is used, the total dialysis time needs to be increased by about 8% for every 3°C below 98.6°F, as that is the theoretical loss in diffusivity with temperature decrease. Low dialysate temperatures may induce venous vessel spasms and make it impossible to obtain maximum blood flows through the artificial kidney.
當透析液溫度低於 98.6°F 時，患者可能會抱怨感到寒冷，要求毛毯，並且有些人會實際顫抖以試圖提高他們的核心體溫。如果溫度過低，可能會觀察到冠狀血管疾病患者心臟刺激性增加。
With dialysate temperatures below 98.6°F, patients may complain of being cold, ask for a blanket, and some will actually shiver in an attempt to increase their core body temperature. An increase in cardiac irritability in patients with coronary vessel disease may be observed if temperatures are too low.
去氣系統 Deaeration System
去氣系統通過將水暴露於由真空泵產生的亞大氣壓下來去除溶解氣體。氣體聚集，形成氣泡，並通過氣泡捕集器排放到大氣中。在透析液中不當或不足的溶解氣體去除可能是幾種嚴重透析問題的隱藏原因，包括虛假的血液洩漏警報、虛假的導電性警報、干擾體積控制功能，以及因氣泡被困在透析器膜上而降低的透析效率，這會減少功能性透析器的表面積。據報導，從透析液流入血液的微氣泡會在心臟的右心房聚集，並在不觸發氣泡檢測器警報的情況下引起空氣栓塞。在滴球腔中可能還會看到誇張的起泡和血液凝塊，微小的血塊被帶到右心房。相當多的成年人可能有潛在的卵圓孔。如果肺動脈壓力增加，卵圓孔可以將血液從右心房分流到左心房。這可能導致這些小血塊轉移到左心並引起腦栓塞。 這組情況已經發生，並被稱為矛盾性栓塞，可能會被誤診為短暫性缺血發作（TIA）或其他血管損傷，而非栓塞現象。
The deaeration system removes dissolved gases by exposing water to subatmospheric pressures generated by a vacuum pump. The gases coalesce, form bubbles, and are vented to the atmosphere by a bubble trap. Improper or inadequate removal of dissolved gases in dialysate can be a hidden cause of several serious dialysis problems, including false blood-leak alarms, false conductivity alarms, interference with volumetric control function, and decreased dialysis efficiency by air bubbles trapped on the dialyzer membrane that reduces functional dialyzer surface area. Microbubbles streaming from dialysate into blood have been reported to collect in the right atrium of the heart and cause air embolism without triggering an air-foam detector alarm. Exaggerated frothing and blood clotting in the drip bulb chamber with minute blood clots being carried to the right atrium may also be seen. A substantial number of all adults have a potentially patent foramen ovale. If the pulmonary artery pressure increases, the foramen ovale can shunt blood from the right to the left atrium. This can result in a transfer of these small clots into the left heart and result in cerebral embolism. This set of conditions has occurred and is known as paradoxical embolism, which can be misdiagnosed as a transient ischemic attack (TIA) or other vascular insult and not embolic phenomenon.
去氣系統監控
Deaeration System Monitoring
頻繁的假血液洩漏警報或導電性快速波動可能表示真空泵故障。該機器應停止使用並進行維護。如果透析液進水和/或出水管路未正確連接到透析器，空氣可能會被吸入系統。透析人員在透析前設置透析機器並確保透析液管路的快速斷開連接在透析器透析液端口上的正確技術將防止此問題。
Frequent false blood-leak alarms or rapid fluctuations in conductivity can indicate a malfunction of the vacuum pump. The machine should be removed from service and undergo maintenance. If the dialysate inflow and/or outflow lines are not correctly attached to the dialyzer, air can be pulled into the system. Proper technique by the dialysis staff who set up the dialysis machinery prior to dialysis and who secure the quick disconnects of the dialysate lines on the dialyzer dialysate ports will prevent this problem.
混合裝置 Mixing Device
混合裝置，也稱為比例系統，將處理過的水和透析液濃縮液按比例混合，以創造出正確離子濃度的透析液。比例系統的比例取決於所使用的透析液濃縮液類型和液體輸送系統的類型。水與透析液濃縮液的典型混合比例為
The mixing device, also known as the proportioning system, proportions treated water and dialysate concentrate to create dialysate of the correct ionic concentration. The proportioning system ratio depends on the type of dialysate concentrate used and the type of fluid delivery system. Typical mixing ratios of water to dialysate concentrate are
- • 34:1 或 44:1 用於酸濃縮液
•34:1 or 44:1 for acid concentrate
- • 20:1 或 25:1 的碳酸氫鈉濃縮液
•20:1 or 25:1 for bicarbonate concentrate
處理水和透析液濃縮液的供應產生的透析液流速介於 500 至 1000 mL/min 之間。兩種基本的比例系統是固定比例混合和伺服控制混合。
The supply of treated water and dialysate concentrate generates dialysate flow rates between 500 and 1000 mL/min. The two basic types of proportioning systems are fixed-ratio mixing and servo-controlled mixing.
固定比例混合使用隔膜或活塞泵將一定體積的水和濃縮液輸送到混合室。伺服控制機制持續監測透析液的成分，利用導電率傳感器調整與水混合的濃縮液量，以維持可變或設定的成分。
Fixed-ratio mixing uses diaphragms or piston pumps to deliver a set volume of water and concentrate to the mixing chamber. Servo-controlled mechanisms continuously monitor the dialysate composition with conductivity sensors that adjust the amount of concentrate mixed with water to maintain a variable or set composition.
在通過伺服控制機制添加濃縮液，直到透析液達到所需導電率的機器中，第二個獨立的導電率和 pH 監測器必須在導電率不正確時發出警報。如果酸和碳酸氫鹽的輸入被顛倒，或者如果錯誤的濃縮液用於碳酸氫鹽機器，伺服迴路可能會製造出具有可接受離子強度（正確導電率）但致命離子組成的溶液。在這種情況下，pH 監測器或濃縮泵速度監測器變得至關重要。然而，並非所有機器都配備 pH 監測器，這一致命事件將無法被診斷。
In machines that add concentrate by a servo-controlled mechanism until the dialysate reaches a desired conductivity, a second independent conductivity and pH monitor must cause an alarm if the conductivity is incorrect. If acid and bicarbonate inputs are reversed, or if the wrong concentrates are used for a bicarbonate machine, the servo loops may make a solution of acceptable ionic strength (correct conductivity) but of lethal ionic composition. In this case, the pH monitor or concentrate pump speed monitor becomes critical. However, not all machines are equipped with pH monitors, and this deadly event will not be diagnosed.
混合裝置監控 Mixing Device Monitoring
導電率和 pH 監測器將通過固定比例配比系統驗證混合是否適當。使用伺服控制機制的設備需要一支勤奮且受過訓練的工作人員，以確保適當的透析液濃縮液連接到機器上的正確濃縮液管線。
The conductivity and pH monitor will verify proper mixing with a fixed-ratio proportioning system. Equipment using servo-controlled mechanisms requires a diligent and trained staff to ensure that the proper dialysate concentrate is attached to the proper concentrate lines on the machine.
透析液的成分和導電性
Composition and Conductivity of Dialysate
在混合後，對透析液進行適當成分的分析是必要的，並且在將其暴露於透析器和病人之前。所有現代液體輸送系統都配備有導電率電池和計量器。透析液的總導電率作為透析液離子含量的簡單評估和替代指標進行測量。導電率電池連接到顯示透析液總離子濃度的計量器。導電率電池應由高品質、耐腐蝕的材料製成。隨著溫度的升高，電解質溶液的導電率會增加。用於監測透析液的導電率電池必須進行溫度補償。
Analysis of the dialysate for the proper composition is necessary after it has been mixed, and prior to exposing it to the dialyzer and patient. All modern fluid delivery systems have conductivity cells and meters. Total conductivity of dialysate is measured as a simple assessment and surrogate for dialysate ionic content. A conductivity cell is connected to a meter that displays the total ionic concentration of dialysate. Conductivity cells should be made of high-quality, corrosion-resistant materials. The conductivity of an electrolyte solution increases as the temperature increases. Conductivity cells used to monitor dialysate must be temperature compensated.
測量導電性 Measuring Conductivity
在透析中，導電率通常使用雙電極系統進行測量。電極連接到恆定電流和安培計（圖 9.4）。電流通過電極之間的溶液。安培計測量通過電極之間溶液的電流流動（電阻的倒數）。導電率的測量是透析液中總離子含量的估算，並不測量或反映特定的離子或電解質。
In dialysis, conductivity is usually measured using a two-electrode system. The electrodes are connected to a constant current and an ammeter ( Fig. 9.4 ). An electric current is passed through the solution between the electrodes. The ammeter measures the flow of current (the inverse of electrical resistance) that passes through the solution between the electrodes. The conductivity measurement is an estimate of the total ionic content of the dialysate and does not measure or reflect specific ions or electrolytes.
(From Pittard J. Hemodialysis Nursing, Training Manual . 7th ed, version 7.0. Santa Monica, CA; 2003, with permission.)
導電率計以毫摩每公分（mmhos/cm）或毫西門子每公分（mS/cm）讀取導電率。標準透析液的可接受範圍為 12.5–16.0 mS/cm。一些設施更喜歡更嚴格的範圍，13.0–15.5 mS/cm。該範圍因設施而異，取決於所使用的透析液配方。
The conductivity meters read the conductivity in millimhos per centimeter (mmhos/cm) or milliSiemens per centimeter (mS/cm). A range of 12.5–16.0 mS/cm is acceptable for a standard dialysate solution. Some facilities prefer a tighter range, 13.0–15.5 mS/cm. The range varies slightly from facility to facility, depending on the dialysate formula in use.
監測導電率 Monitoring Conductivity
透析機上的導電率計設有外部和內部限制。一些機器可能設有三個內部導電率傳感器，分別在不同的控制間隔內進行設置。導電率或透析液的離子組成是如此重要，以至於這種監測冗餘成為防止單一監測器故障的常識性保障。最近的容忍內部高低限制設置為± 5%；最後一組導電率監測可能設置為正常導電率的 50%。如果前兩個監測器失效，患者在未觸發任何警報的情況下，將會接受大量的低滲透透析液輸注。由於不同的離子混合物具有不同的導電率，因此透析液配方必須確定既定的導電率設置。
Conductivity meters on dialysis machines have external and internal limits set. Some machines may have three internal conductivity sensors set at different intervals of control. The conductivity, or dialysate ionic composition, is so important that this monitoring redundancy is a commonsense safeguard against single-monitor failure. The closest tolerance internal high-low limits are set at ± 5%; the last set of conductivity monitoring may be set at 50% of normal conductivity. If the first two monitors fail, the patient, without any alarms being triggered, will receive a massive infusion of hypotonic dialysate. Because different mixtures of ions have different conductivities, it is mandatory that the dialysate formulas determine the established conductivity setting.
現在必須在為病人使用透析器之前以及在開始透析治療之前，進行並記錄獨立的導電性測試。有幾種方法可以對機器的導電性進行獨立分析。最常見的方法是使用便攜式導電率計來測量總導電性。也可以進行實驗室分析以測量每種電解質的水平。
It is now mandatory to perform and document an independent conductivity test prior to preparing the dialyzer for patient use and before the dialysis treatment is initiated. There are several methods available to perform an independent analysis of the machine's conductivity. The most common method is to use a portable conductivity meter that measures the total conductivity. Laboratory analysis that measures each electrolyte level can also be done.
使用獨立分析時，請確保參考導電率計在使用前已準確校準。所有標準溶液應為新鮮並能提供可接受的讀數。
When using independent analysis, be sure the reference conductivity meter is calibrated accurately prior to use. All standard solutions should be fresh and render acceptable readings.
如果獨立驗證透析液導電率未能驗證導電率計，則不要使用該設備對患者進行透析。在透析之前必須完全解決問題。在透析之前未能解決問題只會帶來潛在的災難。最好是引入另一台透析機器並重新開始。
If independent verification of the dialysate conductivity does not validate the conductivity meter, do not dialyze the patient with that machinery. A complete resolution of the problem is necessary before dialysis. Failure to resolve a problem prior to dialysis will only invite a potential disaster. It is best to bring in another dialysis machine and start over.
所有設施必須有一個已建立的可接受導電率範圍，並且該範圍必須公開張貼。任何導電率限制的偏差應引發導電率警報。導電率警報會在透析機上引發三個動作：可聽見的警報、可視的警報，以及旁路系統的啟動。
All facilities must have an established acceptable conductivity range, and this range must be publicly posted. Any deviation in the conductivity limits set should cause a conductivity alarm. A conductivity alarm causes three actions on the dialysis machine: an audible alarm, a visual alarm, and activation of the bypass system.
旁路系統在透析液進入通往透析器的透析液進流管之前，將其引導至排水口。因此，避免了病人的血液在透析器中接觸到不正確或不安全的透析液成分。
The bypass system diverts the dialysate to the drain before it can enter the dialysate inflow line leading to the dialyzer. Thus, exposure of the patient's blood in the dialyzer to an incorrect or unsafe dialysate composition is avoided.
無透析過程中導電率調整
No Intradialytic Conductivity Adjustments
只有合格且受過訓練的機械技術人員應該調整外部或內部導電性限制。在任何情況下，都不應在透析治療期間進行調整。必須在透析治療之前正確調整和預設導電性限制。由於導電性限制的不當調整，已發生過嚴重和致命的事故。
Only a qualified and trained machine technician should adjust the external or internal conductivity limits. Under no circumstances should they be adjusted during the dialysis treatment. They must be properly adjusted and preset before the dialysis treatment. Serious and fatal accidents have occurred as a result of improper adjustments of the conductivity limits.
低導電性 Low Conductivity
低導電率警報是最常見的導電率警報類型（圖 9.5）。通常的原因是酸和碳酸氫鹽濃縮容器中缺乏濃縮液。低導電率警報很少是由於透析液濃縮不正確所引起的。
A low-conductivity alarm is the most common type of conductivity alarm ( Fig. 9.5 ). The usual cause is a lack of concentrate in one or both acid and bicarbonate concentrate containers. Rarely, a low-conductivity alarm is due to incorrect dialysate concentrate.
(From Pittard J. Hemodialysis Nursing, Training Manual . 7th ed, version 7.0. Santa Monica, CA; 2003, with permission.)
如果內部或外部低導電性限制未正確調整和/或機器未進入旁路模式，患者的血液將暴露於低滲透壓透析液中。暴露於低滲透壓透析液可能在幾分鐘內致命。低滲透壓透析液會導致低滲透狀態，即使沒有急性溶血，也可能發生水中毒，這也可能是致命的。
If the internal or external low-conductivity limits are not adjusted properly and/or the machine does not go into the bypass mode, the patient's blood is exposed to hypotonic dialysate. Exposure to hypotonic dialysate can be fatal within a few minutes. Hypotonic dialysate causes a hypoosmolar state, and even without acute hemolysis, water intoxication can occur, which can also be lethal.
低導電性監測
Low-Conductivity Monitoring
在開始透析之前，容器中必須有足夠的透析液濃縮液。透析人員不應依賴導電率計來監測透析液濃縮液的供應。
There must be an adequate amount of dialysate concentrate in the container(s) before starting dialysis. Dialysis staff should not rely on the conductivity meter to monitor dialysate concentrate supplies.
確實，如果透析機進入旁路模式，對病人沒有傷害。但是，當透析機處於旁路模式時，並沒有進行透析，而在下一次透析會話中，失去的透析時間幾乎不會被補回來。如果接受美國的平均透析並不包括最大透析時間，而可能是最小透析時間，則常規將透析設備置於旁路模式將縮短病人的壽命。
True, if the dialysis machine goes into bypass mode, there is no harm to the patient. But, when the dialysis machine is in the bypass mode, no dialysis is taking place and the time lost on dialysis is rarely, if ever, made up with a longer dialysis time the next dialysis session. If one accepts that the average dialysis in the United States comprises not the maximal amount of dialysis time, but probably the minimal amount of dialysis time, placing the dialysis machinery in bypass routinely will shorten the patient's life span.
大多數新型液體輸送機器都配備有在透析液回路警報時停止的計時器。這確保患者能夠獲得分配的透析時間。
Most new model fluid-delivery machines have timers that stop with a dialysate circuit alarm. This ensures that the patient receives their allocated time on dialysis.
高導電性 High Conductivity
高導電性警報（圖 9.6）可能是由於供應系統的水流不足、未經處理的進水中鈣含量過高，或透析液濃縮液與透析機的連接不正確（如果使用伺服控制機制）以及鈉建模所致。新型流體輸送系統在連接不正確的情況下不會進入導電狀態。
High-conductivity alarms ( Fig. 9.6 ) can result from inadequate water flow to the proportioning system, untreated incoming water with an excess of calcium, or incorrect hook-up of dialysate concentrate to the dialysis machine (if using servo-controlled mechanisms) and sodium modeling. Newer-model fluid delivery systems will not go into conductivity with incorrect hook-ups.
(From Pittard J. Hemodialysis Nursing, Training Manual . 7th ed, version 7.0. Santa Monica, CA; 2003, with permission.)
在舊型機器中，一個常見且嚴重的高導電性原因是當兩個酸濃縮容器連接到透析機時，而不是一個酸容器連接到酸端口，另一個碳酸氫鹽容器連接到碳酸氫鹽端口。如果透析機進入旁路模式，對病人沒有傷害。然而，如果內部或外部的高導電性限制未正確設置，病人的血液將暴露於高滲透透析液中，可能導致高滲透性昏迷。
With older machines, a common, serious cause of high conductivity occurs when two acid concentrate containers are connected to the dialysis machine instead of one acid container to the acid port and one bicarbonate container to the bicarbonate port. If the dialysis machine goes into bypass mode, there is no harm to the patient. However, if the internal or external high-conductivity limits have not been set correctly, the patient's blood is exposed to hypertonic dialysate and possibly hyperosmolar coma.
新型流體輸送系統具有自動內建的導電性限制調整功能，以應對鈉的變化，這會導致導電性增加。如果鈉的變化處理不當，患者將在透析後感到口渴，處於高滲透狀態，並試圖用自由水來緩解口渴。這將導致他們的細胞外液量（ECV）顯著擴張，並可能引發惡性高血壓。
New model fluid-delivery systems have anautomatic built-in adjustment of conductivity limits for sodium variation, which causes an increase in conductivity. If sodium variation is done incorrectly, the patient will leave the dialysis thirsty, in a hyperosmolar state, and attempt to relieve that thirst with free water. This will result in a marked expansion of their extracellular volume (ECV), and possibly malignant hypertension.
高導電性監測
High-Conductivity Monitoring
如果在透析治療期間發生導電性警報，則會啟動旁路模式。在糾正警報狀況時，透析人員不得調整外部或內部導電性限制。在警報狀況下調整導電性限制會覆蓋旁路模式，並危及患者的生命。如果無法糾正警報情況，則必須停止治療，並將患者轉移到另一台透析機。
If a conductivity alarm occurs during the dialysis treatment, the bypass mode is activated. While correcting the alarm condition, the dialysis staff must not adjust the external or internal conductivity limits. Adjusting the conductivity limits during an alarm condition overrides the bypass mode and endangers the patient's life. If the alarm situation cannot be corrected, the treatment must be stopped, and the patient moved to another dialysis machine.
酸鹼（pH）控制 Acid–Base (pH) Control
較新型的液體輸送系統在 pH 值過高或過低時不會進入導電狀態。然而，大多數透析診所會在每次透析前進行獨立的 pH 測試。使用碳酸氫鈉透析液的液體輸送機可能會有或沒有 pH 監測器。前面板的透析顯示器上可能有一個 pH 計，當發生警報狀況時，燈會亮起。
Newer-model fluid-delivery systems will not go into conductivity if the pH is too high or too low. However, the majority of dialysis clinics perform independent pH tests before each dialysis. Fluid delivery machines using bicarbonate dialysate may or may not have pH monitors. There may be a pH meter on the front panel dialysis display with lights that activate when an alarm condition occurs.
監測酸鹼（pH）
Monitoring Acid–Base (pH)
透析液的 pH 值通常通過使用 pH 試紙條或碳酸氫鹽 pH 試紙條來檢查。使用 pH 試紙條時，將浸泡在透析液中的試紙條的顏色變化與各種 pH 值的顏色列表進行比較。碳酸氫鹽 pH 試紙條通過將指示墊與瓶標籤上的顏色圖表進行比較來解釋結果。測試結果的可接受範圍為 pH 7.5 ± 0.5（7.0–8.0）。如果 pH 值低於或高於可接受的範圍，而導電率計在可接受範圍內，則不應進行透析。在開始透析之前，pH 值和導電率必須在可接受範圍內。
The pH of dialysate is commonly checked by use of a pH paper test strip or bicarbonate pH test strips. With the pH paper test strips, the color change of the dialysate-soaked test strip is compared with a list of colors for various pH values. The bicarbonate pH test strips interpret the results by comparing the indicator pad to the color chart on the bottle label. Acceptable range for test results is a pH of 7.5 ± 0.5 (7.0–8.0). If the pH is below or above the acceptable limits and the conductivity meter is within acceptable limits, the dialysis should not be carried out. Both the pH and conductivity must be within acceptable limits before initiating dialysis.
繞道系統 Bypass System
旁路系統將透析液（圖 9.7）直接引導至排水管，避免病人的血液接觸到不安全的透析液。透析液旁路閥位於進入透析器的透析液回路中，會因高/低導電率、高/低 pH 值或高/低溫度而啟動。透析人員必須確認並檢查旁路閥是否將透析液引導至排水管。
The bypass system diverts dialysate ( Fig. 9.7 ) directly to the drain away from the dialyzer to avoid exposure of the patient's blood to unsafe dialysate. The dialysate bypass valve, located in the incoming dialysate circuit predialyzer, is activated by high/low conductivity, high/low pH, or high/low temperature. It is imperative to have the dialysis staff verify and check that the bypass valve diverts the dialysate to drain.
(From Pittard J. Hemodialysis Nursing, Training Manual . 7th ed, version 7.0. Santa Monica, CA; 2003, with permission.)
旁路系統監控 Bypass System Monitoring
大多數機器沒有旁路系統故障或功能的監控。機器前面板上的燈指示機器處於旁路模式。此外，通常會發出可聽見的警報。如果在透析液進水管線中有一個浮子，指示流量，浮子將會下沉到指示器的底部。通常有一個手動操作的控制來啟動旁路模式。在透析過程中，旁路閥的故障是一個關鍵且危險的情況。
There is no monitor for bypass system failure or function on most machines. A light on the front panel of the machine indicates when the machine is in the bypass mode. Also, an audible alarm usually occurs. If there is a float located in the dialysate inflow line, indicating flow, the float will drop to the bottom of the indicator. There usually is a manually operated control to initiate the bypass mode. Failure of the bypass valve during dialysis is a critical and dangerous situation.
沖洗模式 Rinse Mode
透析機的沖洗模式會覆蓋旁路系統。它允許對整個液體通道進行沖洗和消毒。在病人進行透析時，絕對不應啟動此模式。在新型機器中，當機器處於沖洗模式時，血液泵無法啟動。
The rinse mode on dialysis machines overrides the bypass system. It allows rinsing and disinfection of the entire fluid pathway. It should never be activated while a patient is on dialysis. In new-model machines, the blood pump cannot be activated when the machine is in rinse mode.
透析液壓力監測器
Dialysate Pressure Monitor
透析液壓力監測器監測超濾壓力。這是透析治療的一個關鍵功能，確保從患者身體中準確且安全地去除液體。調節患者超濾的一種方法是應用跨膜壓力（TMP）。較新的機器型號具有超濾/體積控制電路。透析人員設定所需液體去除的目標，設定透析的持續時間，並啟動超濾控制模式。機器將自動計算並應用所需的 TMP，以實現所需的超濾。
The dialysate pressure monitor monitors ultrafiltration pressures. It is a critical function of dialysis therapy that ensures accurate and safe fluid removal from the patient. One method to regulate the patient's ultrafiltration is by application of transmembrane pressure (TMP). Newer machine models have ultrafiltration/volumetric control circuits. The dialysis personnel set the goal for the desired fluid removal, set the duration of dialysis, and activate the ultrafiltration control mode. The machine will automatically calculate and apply the required TMP to achieve the desired ultrafiltration.
體積控制系統具有不同的設計特徵。一種常見的設計使用平衡腔來精確測量進入和離開透析器的液體體積。這些機器自動調整 TMP。體積控制系統使用匹配的泵，通常是隔膜泵。泵由閥門控制，並在透析液的比例後進行整合。位於平衡腔上下的閥門開啟和關閉，以引導新鮮和使用過的透析液流動。新鮮透析液被推送出去進行透析，而使用過的透析液則被推送出去排放。這兩個腔體交替功能，創造出穩定的新鮮透析液流。該系統是一個封閉循環，兩個腔體完全平衡。空氣在分離腔中從使用過的透析液中去除，以確保準確測量。
Volumetric control systems have different design features. A common design uses balancing chambers to precisely measure fluid volume entering and leaving the dialyzer. These machines automatically adjust the TMP. Volumetric control systems use matched pumps, usually diaphragm pumps. The pumps are controlled by valves and are integrated after proportioning of dialysate. Valves located above and below the balancing chambers open and close to direct the flow of fresh and used dialysate. Fresh dialysate is pushed out to dialyze, whereas used dialysate is pushed out to drain. The two chambers alternate functions, creating a constant flow of fresh dialysate. The system is a closed loop with both chambers exactly balanced. Air is removed from the used dialysate in a separation chamber to ensure accurate measurement.
建議在透析前進行壓力保持測試，以確保匹配的泵正常運作及閥門的適當密封。這測試隔膜的完整性，以確保其無缺陷或瑕疵。劣質的閥門密封可能導致不準確的超濾，這在高通量透析器中可能是災難性的。這些測試可以根據機器型號手動或自動進行。
It is recommended that a pressure-holding test be performed predialysis to ensure proper functioning of matched pumps and appropriate sealing of the valve. This tests the integrity of the diaphragms to ensure that they are free from defects or flaws. Bad valve seals can cause inaccurate ultrafiltration that is potentially catastrophic with high-flux dialyzers. These tests can be performed manually or automatically, depending on the machine model.
血液洩漏探測器 Blood-Leak Detector
這個監測器的功能是通過過濾或未過濾的光線穿過已經從透析器排出的廢液透析液的柱子（圖 9.8）。透析器膜的撕裂或漏水會導致紅血球漏入透析液中，從而中斷光線傳輸。機器對血液洩漏警報的反應包括發出可聽見的警報、可視警報、血液泵停止運作，以及靜脈管夾緊閉。
This monitor functions by transmitting filtered or unfiltered light through a column of effluent dialysate that has exited the dialyzer ( Fig. 9.8 ). Tears or leaks in the dialyzer membrane cause RBCs to leak into the dialysate, interrupting the light transmission. The machine response to a blood leak alarm is an audible alarm, a visual alarm, the blood pump stops, and the venous line clamp engages.
(From Pittard J. Hemodialysis Nursing, Training Manual . 7th ed, version 7.0. Santa Monica, CA; 2003, with permission.)
建議將血液洩漏檢測閾值設置為每升透析液 0.25–0.35 毫升全血。假血液洩漏警報可能是由於路徑中存在氣泡或光學鏡頭模糊或髒污所引起的。
It is recommended to have a blood-leak detection threshold set at 0.25–0.35 mL of whole blood per liter of dialysate. False blood-leak alarms can be caused by the presence of air bubbles in the path or by cloudy or dirty optical lenses.
血液洩漏檢測器監測
Blood-Leak Detector Monitoring
如果機器顯示此警報，必須在透析液排水管線上進行即時 Hemastix（苯二胺測試條）檢測。Hemastix 測試呈陽性表示有血液洩漏。如果 Hemastix 測試呈弱陽性且患者使用的是中空纖維透析器，則可以密切監測患者，觀察透析液的流出是否有增加的混濁度（表示有氣泡或紅血球），並等待幾分鐘。洩漏的纖維可能會自行密封或凝塊。在此期間，移除超濾，降低血流速率，並以一對一的比例照顧患者。如果患者無法持續監測，則應更換透析器。
If the machinery indicates this alarm, a stat Hemastix (benzidine test strip) must be taken at the dialysate drain line. A positive Hemastix test indicates a blood leak. If the Hemastix is weakly positive and the patient is on a hollow-fiber dialyzer, it is possible to closely monitor the patient, observe the dialysate outflow for increased turbidity (indicates air bubbles or RBCs), and wait a few minutes. The leaking fibers may seal or clot off. During this time, remove the ultrafiltration, decrease the blood flow rate, and attend the patient on a one-to-one ratio. If the patient cannot be continuously monitored, the dialyzer should be replaced.
如果重複的 Hemastix 測試結果為陰性，可以繼續透析。如果血液洩漏警報持續響起或在透析液管路中可見血液，則應停止透析，並根據單位協議更換透析器。透析器應予以丟棄。
If the repeat Hemastix is negative, dialysis can be continued. If the blood-leak alarm continues or if blood is visible in the dialysate lines, the dialysis should be stopped, and the dialyzer changed per unit protocol. The dialyzer should be discarded.
在血液洩漏後，清潔血液洩漏探測器的光學路徑非常重要。始終保持狹窄的敏感度範圍。不要對有故障的血液洩漏探測器進行透析。重大血液洩漏可能是致命的。
After a blood leak, it is important to clean the optical path of the blood leak detector. Always maintain a narrow range of sensitivity. Do not dialyze a patient with a faulty blood-leak detector. A major blood leak can be fatal.
透析液流量 Dialysate Flow
透析液流速可以預設或調整。傳統透析器的通常透析液流速最低為 500 mL/min。對於高效能和高通量透析器，通常為 700–800 mL/min。使用高血流速與高效能或高通量透析器時，若透析液流速低於血流速的 1.5 倍，則會適得其反，並提供低效的透析。足夠的透析液流速對於有效的透析至關重要。
The dialysate flow rates may be preset or adjustable. The usual dialysate flow rate for conventional dialyzers is a minimum of 500 mL/min. For high-efficiency and high-flux dialyzers, it is usually 700–800 mL/min. It is counterproductive and provides an inefficient dialysis to use high blood flow rates with high efficiency or high-flux dialyzer with a dialysate flow of less than one and one-half the blood flow rate. Adequate dialysate flow is essential for efficient dialysis.
透析液流量監測
Dialysate Flow Monitoring
這些警報條件包括進水壓力過低、透析液泵故障、流動路徑阻塞和電源故障。
These alarm conditions include low incoming water pressure to the machine, dialysate pump failure, obstruction in the flow path, and power failure.
大多數機器在這些條件下都有持續的可聽警報。通常沒有警報能夠提醒工作人員當透析液流速設置過低時，例如，設置為 500 mL/min 而不是 800 mL/min。透析人員必須在監測這一護理方面上保持警惕。
Most machines have a continuous audible alarm with these conditions. There are usually no alarms that alert the staff when the dialysate flow rate is set too low, for example, at 500 mL/min instead of 800 mL/min. Dialysis personnel must be diligent in monitoring this aspect of care.
廢水透析液管線 Effluent Dialysate Line
透析人員必須監測透析液排放管道，以確保其未被阻塞並正確放置於排水口。阻塞可能導致透析液腔內的回壓，並可能降低透析液流速。
Dialysis personnel must monitor the dialysate effluent line to the drain to ensure that it is not obstructed and is properly placed in the drain. An obstruction can cause backpressure into the dialysate compartment and may decrease the dialysate flow rate.
電氣安全 Electrical Safety
透析機對患者或工作人員構成電擊風險。所有電子設備必須定期檢查和測試。工作人員，尤其是在患者護理區域，必須承擔識別和報告任何潛在危險情況的責任。所有電氣元件應充分隔離液體洩漏，設備外部應防止液體溢出。電氣元件必須插入正確的插座，並使用接地插頭。所有透析人員必須接受電氣安全課程和設備安全使用的培訓。
Dialysis machines pose a risk of electrical shock to a patient or staff member. All electronic equipment must be inspected and tested on a periodic basis. The staff members, most frequently in the patient care areas, must accept responsibility for identifying and reporting any potential hazardous conditions. All electric components should be adequately isolated from liquid leaks and the outside of equipment shielded from liquid spills. Electric components must be plugged into the correct socket, and grounded plugs used. Electrical safety classes and safe use of equipment are mandatory for all dialysis personnel.
透析液循環中需監測的其他區域
Other Areas to Monitor in the Dialysate Circuit
其他需要監測的領域包括正確的處方、無雜質（清潔和消毒劑）、微生物計數，以及無潛在的致熱源。
Additional areas requiring monitoring include correct prescription, absence of impurities (cleaning and disinfecting agents), microbiologic count, and absence of potential pyrogenic agents.
透析液處方 Dialysate Prescription
透析人員必須確認醫生所開的透析液成分與所交付的透析液處方相符。透析液處方並非靜態。一些醫生會根據個別患者的需要調整鈉、鉀、鈣、鎂和葡萄糖的含量。在一個設施中使用多種個性化透析液配方的主要問題是人員出錯的風險增加。透析單位中變數越多，員工出錯的固有風險就越大，隨著透析單位中變數的增加而增加。
Dialysis personnel must confirm that the physician's orders prescribing the dialysate content match the delivered prescription of dialysate. The dialysate prescription is not static. Some physicians model and individually tailor sodium, potassium, calcium, magnesium, and dextrose. A major problem with using many individualized dialysate formulas in one facility is the increase in risk for error by personnel. The more variables that exist in a dialysis unit, the greater the inherent risk of staff errors increases as the variables increase in a dialysis unit.
透析液處方監測
Dialysate Prescription Monitoring
員工必須檢查和驗證所有透析液濃縮劑容器的適當內容。每個容器必須清楚標示。不得使用未標示的透析液濃縮劑容器。標籤必須包括每種電解質；混合的數量、時間和日期；以及執行任務的人的姓名。所有添加劑必須在標籤上正確記錄。這對於碳酸氫鹽濃縮劑尤其重要，必須在混合後的 24 小時內使用。24 小時的預防措施可降低細菌生長以及鈣和鎂沉澱的風險。正確的透析液濃縮劑必須連接到透析機上的正確濃縮劑端口。
Staff must check and verify all dialysate concentrate containers for the appropriate content. Each container must be clearly labeled. No unlabeled dialysate concentrate container should be used. Labels must include each electrolyte; the amount, time, and date mixed; and the name of the person performing the task. All additives must be properly recorded on the labels. This is especially important for the bicarbonate concentrate, which must be used within a 24-hour period after mixing. The 24-hour precaution reduces the risk of bacterial growth and calcium and magnesium precipitation. The correct dialysate concentrate must be attached to the correct concentrate port on the dialysis machine.
無菌性與雜質 Sterility and Impurities
透析液非常乾淨，但並非無菌。美國大多數透析設施使用反滲透（RO）系統過濾進水。理論上，產品水應該是無菌的。然而，當水通過透析單元的塑料管道到達透析機並經過流體通道時，會接觸到細菌、內毒素、致熱源和其他雜質。
The dialysate solution is very clean but not sterile. Most dialysis facilities in the United States use reverse osmosis (RO) systems to filter the feed water. Theoretically, the product water should be sterile. But, as the water courses through the plastic piping of the dialysis unit to the dialysis machine and traverses through the fluid pathway, it comes in contact with bacteria, endotoxins, pyrogens, and other impurities.
所有透析機器中的液體通道必須定期沖洗、清潔和消毒。沖洗和清潔過程保持透析機器的內部環境清潔，無細胞碎片或沉積物，以確保正常運作。消毒消除細菌生長，並防止發熱反應的風險。每個透析機構使用不同的技術來達成這一目的。
All fluid pathways in the dialysis machines must be routinely rinsed, cleaned, and disinfected. The rinsing and cleaning process keeps the internal environment of the dialysis machine clean and free of cellular debris or deposits for proper operation. The disinfection eliminates bacterial growth and prevents the risk of pyrogen reactions. Each dialysis facility uses different techniques to achieve this end.
水處理系統、透析液輸送系統和透析液濃縮容器的清潔和消毒不足會導致細菌數量過高。消毒不足可能是由於消毒頻率不足、冷化學消毒劑濃度過低以及消毒劑接觸時間不足所致。
Inadequate cleaning and disinfection of the water treatment system, dialysate delivery system, and dialysate concentrate containers lead to high bacterial counts. Inadequate disinfection can be due to lack of frequent disinfection, too low concentrations of cold chemical disinfectants, and inadequate contact time of the disinfectant.
AAMI 要求每月至少進行一次測試。該測試旨在驗證設備的正確消毒。測試液體輸送系統的樣本應在“透析結束時，在透析液從透析器排出的點取樣。”行業標準建議進行額外取樣。應在這些容器消毒之間的最長時間和濃縮液的最長儲存時間之後，從透析液濃縮容器和混合槽中取樣。
AAMI requires a minimum of once-a-month testing. The testing is to validate the proper disinfection of equipment. The sample for testing the fluid delivery system is taken “at the termination of dialysis at the point where dialysate exits the dialyzer.” Industry standards recommend additional sampling. Samples from dialysate concentrate containers and mixing tanks should be taken after the longest period between disinfection of these containers and after the longest storage time for the concentrate.
所有測試結果必須被記錄。
All test results must be documented.
微生物測試 Microbiologic Testing
微生物監測是檢查活細菌的存在。每單位體積中活細菌的數量以菌落計數或每毫升形成菌落單位（CFU/mL）報告。細菌測試要求總可活微生物計數不得超過每毫升 200 個形成菌落單位（表 9.2）。微生物測試結果必須記錄。微生物計數超過行業標準需要進行分析，並且需要更頻繁和徹底的消毒程序。如果水平超過 50 CFU/mL，建議採取行動。“行動”是消毒系統並在幾個位置重複培養。如果在一組培養中只有一個超過行動限值，則行動可能是重複培養。
Microbiologic monitoring is to check for the presence of live bacteria. The number of living bacteria in a set volume is reported as the colony count or colony-forming units per milliliter (CFU/mL). Bacterial testing requires that the total viable microbial count is not to exceed 200 colony-forming units per milliliter ( Table 9.2 ). Microbial test results must be documented. Microbial counts exceeding the industry standards require analysis and a more frequent and vigorous disinfecting routine. It is recommended to take action if levels exceed 50 CFU/mL. “Action” is to disinfect the system and repeat cultures at several sites. The action may be to repeat the culture, particularly if only one in a set of cultures was above the action limit.
AAMI Microbiologic Standards
From Pittard J, De Palma J. Dialysate Monograph . 1st ed. Glendale, CA: Hemodialysis, Inc.; 2013.
| 液體 Fluid | 細菌最大行動水平 Bacteria Maximum Action Level | 內毒素最大作用水平 Endotoxin Maximum Action Level |
|---|---|---|
| 用水準備透析液、重新處理透析器和準備消毒劑 Water to prepare dialysate, to reprocess dialyzers, and prepare germicides | < 200 CFU/mL | < 2.0 EU/mL |
| ≥ 50 CFU/mL | ≥ 1 EU/mL | |
| 透析液 Dialysate | < 200 CFU/mL | < 2.0 EU/mL |
| ≥ 50 CFU/mL | ≥ 1 EU/mL | |
| 重碳酸鹽濃縮液 Bicarbonate concentrate | < 200 CFU/mL | < 2.0 EU/mL |
| ≥ 50 CFU/mL | ≥ 1 EU/mL | |
| 最小頻率 Minimum frequency | 每月 Monthly | 每月 Monthly |
AAMI , Association for the Advancement of Medical Instrumentation.
碳酸氫鈉濃縮液中的細菌
Bacteria in Bicarbonate Concentrate
酸性透析液濃縮液具有抑菌作用，能抑制細菌的生長或繁殖。然而，用於製作碳酸氫鈉濃縮液的碳酸氫鈉粉末可能會受到細菌、霉菌和/或致熱源的污染。未能妥善清潔和消毒水和透析液流經的所有區域會導致細菌生長，通常在液體通道中出現假單胞菌。
The acid dialysate concentrate is bacteriostatic, inhibiting growth or multiplication of bacteria. However, bicarbonate powder used to make bicarbonate concentrate can be contaminated with bacteria, molds, and/or pyrogens. Failure to properly clean and disinfect all areas where water and dialysate travel leads to bacterial growth, often with Pseudomonas , in the fluid pathways.
內毒素測試 Test for Endotoxins
內毒素是細菌脂多醣。它們是當微生物被分解或死亡時從細胞壁釋放出的物質。它們的來源通常是革蘭氏陰性菌。內毒素的存在是通過使用美洲螃蟹血細胞溶解液（LAL）檢測來測量的。LAL 濃度應低於每毫升兩個內毒素單位（< 2 EU/mL）。如果水平超過 1.0 EU/mL，建議採取行動。
Endotoxins are bacterial lipopolysaccharides. They are substances released from cell walls when a microorganism is broken down or dies. Their origin is usually from gram-negative bacteria. The presence of endotoxins is measured using the limulus amebocyte lysate (LAL) assay. The LAL concentration should be less than two endotoxin units (EU) per milliliter (< 2 EU/mL). It is recommended to take action if levels exceed 1.0 EU/mL.
致熱源 Pyrogens
高細菌數量使人易於發生致熱反應。最常見的致熱源來自死細菌的碎片。然而，任何類型的細胞碎片，即使是無菌的，也能引起致熱反應。致熱反應的增加與使用高通量透析器和碳酸氫鹽透析液有關。
High bacterial counts predispose to pyrogen reactions. The most common type of pyrogen is from fragments of dead bacteria. However, any type of cellular debris, even if it is sterile, can cause pyrogen reactions. An increase in pyrogen reactions is associated with the use of high-flux dialyzers and bicarbonate dialysate.
透析液和/或透析機的流體通道中缺乏充分去除細菌及其代謝產物，無疑是這些致熱反應的主要原因。即使在重複使用透析器的情況下，實施嚴格水消毒和控制的透析設施幾乎不會發生致熱反應。
The lack of adequate removal of bacteria and bacterial end products from the dialysate solutions and/or fluid pathway of the dialysis machines is invariably the principal cause of these pyrogenic reactions. Dialysis facilities that practice scrupulous water disinfection and control, even with reuse of dialyzers, have virtually no pyrogenic reactions.
一些文獻提到高通量膜對整個細菌的孔隙度增加是引起熱原反應的主要原因。然而，即使在使用再處理高通量透析器的透析單位中，糾正進水和輸出透析液中的高微生物數量總是能消除所有熱原反應。
Some literature invokes the increased porosity of the high-flux membrane to whole bacteria as a substantial cause of pyrogen reactions. However, even in dialysis units using reprocessed high-flux dialyzers, correcting the high microbial counts of the feed water and delivered dialysate invariably eliminates all pyrogen reactions.
超純透析液 Ultrapure Dialysis Fluid
“超純”一詞自 1990 年代初期開始使用。透析液的微生物質量決定了超純透析液的定義。這種液體由超純透析液和水組成，應該含有的細菌數量少於 0.1 CFU/mL，內毒素水平少於 0.03 EU/mL。這些水平在歐洲社區中確立，與美國使用的標準相比，對微生物檢測有著更嚴格的標準。
The term “ultrapure” has been in use since the early 1990s. The microbiologic quality of dialysis fluid dictates the definition of ultrapure dialysis fluid. This fluid, composed of ultrapure dialysate and water, should contain a bacteria count less than 0.1 CFU/mL and endotoxin levels less than 0.03 EU/mL. These levels, established in the European community, have much stricter standards for microbiologic testing as compared to the standards in use in the United States.
歐洲血液透析最佳實踐指導建議所有患者和所有模式使用超純透析液作為目標，並提供測試以驗證液體純度的建議。證據表明，使用“超純”透析液可減少透析患者群體中出現的炎症過程。改善整體發病率和死亡率。
The European Best Practice Guidelines for Hemodialysis recommend the use of ultrapure dialysis fluid as a goal for all patients and all modalities, along with recommendations on testing to validate the purity of the fluid. Evidence suggests that the use of “ultrapure” dialysate diminishes inflammatory processes seen in the dialysis patient population. Improving the overall morbidity and mortality rates.
目前在美國使用創新的方法。用於製造超純透析液的細菌和致熱源過濾器正被整合進液體輸送系統中。
Innovative approaches are currently in use in the United States. Bacterial and pyrogen filters for manufacturing ultrapure dialysis fluid are being integrated into the fluid delivery systems.
清潔與消毒
Cleaning and Disinfection
看起來很明顯，透析設備的清潔和消毒應該在所有病人完全斷開連接後進行。儘管這很明顯，但有幾個報告的案例顯示，在所有病人斷開連接之前開始相應的清潔程序時，病人曾經被“漂白”或“煮熟”。
It would seem obvious that cleaning and disinfection of the dialysis machinery should only be done after all patients have been completely disconnected. Although obvious, there are several reported instances of patients being “bleached” or “cooked” when the respective cleaning procedure began before all patients were disconnected.
中央系統危害 Central System Hazard
一個服務多於一個房間的中央液體輸送系統承擔著這種致命意外的巨大風險。必須由兩個人仔細徹底地檢查病床和椅子，以確認在該環境中沒有病人正在接受透析。
A central fluid-delivery system that services more than one room carries the enormous risk of this lethal misadventure. A careful and thorough bed and chair check by two individuals must be performed to verify that no patient is on dialysis in that setting.
常規清潔 Routine Cleaning
流體輸送系統的常規清潔是通過用純水（AAMI 標準）沖洗和每日對流體通道進行酸性清潔來完成的。酸性清潔可最小化與碳酸氫鈉透析液相關的鈣沉澱物的積聚。酸性清潔並不消毒機器。酸性清潔是使用醋酸（5%）或醋、檸檬酸、過醋酸基消毒劑和酸濃縮液來完成的。在進行酸性清潔之前，建議至少進行 5 分鐘的水沖洗。
Routine cleaning of fluid delivery systems is accomplished by rinsing with purified water (AAMI standard) and acid cleaning of the fluid pathway on a daily basis. Acid cleaning minimizes the buildup of calcium precipitate that is associated with bicarbonate dialysate. Acid cleaning does not disinfect the machine. Acid cleaning is accomplished with the use of acetic acid (5%) or vinegar, citric acid, peracetic-based disinfectants, and acid concentrate. A minimum of a 5-minute water rinse is recommended before acid cleaning.
在病人使用或化學消毒之前，必須徹底沖洗透析機。可以使用 pH 試紙輕鬆檢測醋酸的殘留。
A thorough rinse of the dialysis machine must be done before patient use or chemical disinfection. Acetic acid can easily be tested for residuals by using pH test paper.
流體輸送系統消毒
Fluid Delivery System Disinfection
流體傳遞系統的消毒是通過熱消毒和/或化學消毒來完成的。化學消毒通常每週進行一次，或在必要時更頻繁地進行。消毒的頻率取決於常規細菌計數和醫療主任的指示。在消毒之前應採集細菌計數樣本。
Disinfection of the fluid delivery system is done by heat and/or chemical disinfection. Chemical disinfection is done usually once each week or more often if necessary. Frequency of disinfection depends on routine bacterial counts and the orders of the medical director. Samples for bacterial counts should be taken before disinfection.
熱消毒 Heat Disinfection
某些流體輸送機型配備了熱消毒功能。在大多數情況下，這是每日進行的。熱消毒是在透析機的內部流體通道中使用加熱至約 85°C 的水進行的。熱暴露的平均時間約為 30 分鐘。遵循製造商的建議非常重要。如果在熱消毒後要使用該機器，則在病人使用之前必須允許適當的冷卻循環。大多數使用熱消毒的機器都有內建的安全功能，該功能會在溫度降至 42°C 以下之前不允許機器進入“透析”模式。
Certain models of fluid delivery machines are equipped to use heat disinfection. In most cases, this is done on a daily basis. Heat disinfection occurs with water heated to about 85°C in the internal fluid pathway of the dialysis machine. The average length of heat exposure is about 30 minutes. It is important to follow the manufacturer's recommendations. If the machine is to be used following heat disinfection, it is critical to allow the proper cooling down cycle before patient use. Most machines using heat disinfection have a built-in safety feature that will not allow the machine to go into the “dialyze” mode until the temperature has dropped below 42°C.
化學消毒 Chemical Disinfection
化學消毒可以使用多種化學品。最常用的化學消毒劑包括次氯酸鈉、過醋酸和甲醛。在使用腐蝕性化學品進行消毒時，徹底的水沖洗是必不可少的。在使用化學消毒劑時，重要的是要記住所有消毒劑都需要一定的接觸時間。水中高微生物數量需要更長的接觸時間。
Chemical disinfection may be done with a variety of chemicals. The most common chemical disinfectants in use are sodium hypochlorite, peracetic acid, and formaldehyde. A thorough water rinse is essential when using corrosive chemicals for disinfection. When using chemical disinfectants, it is important to remember that all disinfectants require a certain amount of contact time. High microbial counts in water require longer contact times.
流體通道中存在死腔、盲迴路或不當分流至排水的非活動透析站特別危險。所有死腔都難以消毒。
Fluid pathways that have dead spaces, blind loops, or inactive dialysis stations that are improperly shunted to drain are especially hazardous. All dead spaces are difficult to disinfect.
所有機器都需要標示一個標誌，指示化學消毒劑的存在以及在消毒被認為完成之前需要進行殘留測試。
All machines require labeling with a sign indicating the presence of the chemical disinfectant and the need for residual testing before the disinfection is deemed complete.
次氯酸鈉 Sodium Hypochlorite
次氯酸鈉（漂白水）是一種冷消毒劑。它有不同的濃度，範圍從 5%到 10%。次氯酸鈉的優點是成本低、有效性高和安全性。游離氯是一種強氧化劑。它有效地清潔並消除流體通道中可能干擾機器運作的任何細胞殘留物。
Sodium hypochlorite (bleach) is a cold disinfectant. It is available in different concentrations ranging from 5% to 10%. The advantages of sodium hypochlorite are its low cost, its effectiveness, and safety. Free chlorine is a strong oxidant. It effectively cleans and eliminates any cellular debris in the fluid pathway that may interfere with the machine operation.
殘留測試氯酸鈉非常簡單，使用氯試劑試紙進行測試，能檢測到 0.5 部分每百萬（ppm）。殘留測試非常敏感。氯酸鈉在超過 1:25,000 的微量下會產生溶血。一些透析單位用漂白水清洗其碳酸氫鈉濃縮液的塑料容器，但在重新填充碳酸氫鈉濃縮液之前並未仔細沖洗或測試殘留氯。這使得漂白水被透析進入患者體內，導致低水平的持續性溶血，這種情況常常被忽視或歸因於功能性缺鐵。未能進行殘留測試將導致急性溶血或可能未被檢測到的緩慢溶血。
Residual testing for sodium hypochlorite is simple and done with chlorine reagent test strips that test down to 0.5 parts per million (ppm). The residual test is very sensitive. Sodium hypochlorite in minute amounts greater than 1:25,000 produces hemolysis. Some dialysis units clean their bicarbonate concentrate plastic containers with bleach but do not carefully rinse or test for residual chlorine before refilling with bicarbonate concentrate. This allows bleach to be dialyzed into the patient, causing a low-level persistent hemolysis that is ignored or attributed to functional iron deficiency. Failure to perform residual testing will result in acute hemolysis or slow hemolysis that may go undetected.
甲醛 Formaldehyde
甲醛是一種冷消毒劑，當以適當濃度使用並給予足夠的接觸時間時，能有效殺死所有微生物，包括孢子和耐藥病毒。有多篇報告指出，使用不充分的甲醛濃度來消毒透析機器的液體通道，導致嚴重甚至致命的敗血症。它是流體輸送系統中最常用的定期消毒劑。這是一種便宜且穩定的溶液，具有長期的保質期。
Formaldehyde is a cold sterilant that effectively kills all microorganisms, including spores and resistant viruses, when used in proper concentrations and given adequate contact time. There are several reports of serious to deadly septicemia, with inadequate formaldehyde concentrations being used to disinfect the fluid path of dialysis machinery. It is the most common periodic disinfectant used for fluid-delivery systems. It is an inexpensive and stable solution with a long shelf life.
甲醛是一種氣體，溶解在水中形成化合物福爾馬林。福爾馬林是甲醛在水中的飽和溶液。100% 的福爾馬林溶液相當於 37%–40% 的甲醛。在透析中，使用 4% 的甲醛（11% 福爾馬林）濃度。
Formaldehyde is a gas that is dissolved in water to form the compound formalin. Formalin is the saturated solution of formaldehyde in water. A 100% formalin solution is equivalent to 37%–40% formaldehyde. In dialysis, a 4% formaldehyde (11% formalin) concentration is used.
濃度低於 4%的甲醛在水中無法有效殺死鱗狀分枝桿菌。甲醛氣體對眼睛有刺激性，並且有刺鼻的氣味。處理甲醛時必須始終佩戴手套，以防止皮膚炎和過敏反應。房間必須通風良好。任何濺出必須最小化。面罩可提供全面的面部保護。處理甲醛時至少必須佩戴眼部保護裝置（護目鏡）。
Concentrations lower than 4% formaldehyde do not kill Mycobacterium chelonae in water adequately. The formaldehyde gas is irritating to the eyes and has an offensive odor. Gloves must always be worn when handling formaldehyde to prevent dermatitis and allergic sensitivities. The room must be well ventilated. Any splashing must be minimized. A face shield gives total protection to the face. Minimally, eye protection (goggles) must be worn when handling formaldehyde.
甲醛沒有清潔特性。甲醛使蛋白質變性並固定大多數細胞殘骸。因此，在使用之前，流體通道需要用水沖洗並使用其他化學物質去除任何現有的細胞殘骸和沉積物。流體輸送機的流體通道在清潔後充滿甲醛，以摧毀所有微生物。通常，甲醛會在機器內放置過夜，以確保有效的接觸時間。
Formaldehyde has no cleaning properties. Formaldehyde denatures protein and fixes most cellular debris. Therefore, before its use, the fluid pathway requires water rinsing and use of another chemical substance to remove any existing cellular debris and deposits. The fluid pathway of the fluid- delivery machines is filled with formaldehyde after cleaning to destroy any and all microorganisms. Generally, the formaldehyde is left in the machine overnight for effective contact time.
敏感的殘留測試現在已經可用。指示劑測試條現在已上市，用於測試殘留的甲醛，靈敏度為 1.0 ppm。這種冷消毒劑的原理與過醋酸的描述相同。過去，甲醛的安全測試要求使用希夫試劑。希夫試劑的測試靈敏度為 5 ppm。較新的指示劑測試條更為敏感。
Sensitive residual testing is now available. Indicator test strips are now on the market to test for residual formaldehyde to a sensitivity of 1.0 ppm. The same principles apply to this cold sterilant as described for peracetic acid. In the past, safety tests for formaldehyde called for the use of Schiff reagent. Schiff reagent will test to 5 ppm. The newer indicator test strips are more sensitive.
已經發生幾起餵水受到殘留甲醛污染的疫情，導致多名使用單人機器的透析病人出現嚴重的休克、昏迷及半致命的後果。
There have been several outbreaks of feed water being contaminated with residual formaldehyde, which led to a number of dialysis patients on single patient machines becoming seriously ill with shock, coma, and semilethal consequences.
過氧乙酸 Peracetic Acid
使用穩定的過醋酸、過氧化氫和醋酸混合物可能是流體輸送系統的首選冷消毒劑。與甲醛不同，這種混合物不會留下有毒殘留物。它在與有機物質反應後分解為氧氣和醋酸。氣味刺鼻，類似於醋的氣味。
The use of a stabilized mixture of peracetic acid, hydrogen peroxide, and acetic acid is probably the cold sterilant of choice for fluid delivery systems. Unlike formaldehyde, this mixture leaves no toxic residues. It decomposes into oxygen and acetic acid after reacting with organic material. The odor is pungent, similar to the smell of vinegar.
過醋酸、過氧化氫和醋酸的混合物除了作為冷消毒劑外，還充當清潔劑。這種混合物是一種強氧化劑，能夠輕易清除所有細胞殘留物以及機器中的沉澱物或水垢，當定期使用時效果顯著。作為冷消毒劑，它在 11 小時的接觸時間內有效。由於它是一種強氧化劑，必須仔細遵循製造商的建議，以免對機器中的材料造成不利影響。
The mixture of peracetic acid, hydrogen peroxide, and acetic acid acts as a cleaning agent in addition to a cold sterilant. The mixture is a strong oxidant that readily cleans all cellular debris and precipitates or scales in the machines when used routinely. As a cold sterilant, it is effective with an 11-hour contact time. Because it is a strong oxidant, the manufacturer's recommendations must be followed carefully so that materials in the machines will not be adversely affected.
測試條可用於檢查過醋酸混合物的存在或缺失。指示劑測試條確保這種冷消毒劑在機器中的存在。在過醋酸混合物從機器中沖洗後，殘留測試條檢測過醋酸混合物的缺失。殘留測試非常敏感，檢測下限可達 < 1 ppm。
Test strips are available to check for the presence or absence of the peracetic acid mixture. Indicator test strips ensure the presence of this cold sterilant in the machines. After the peracetic acid mixture is rinsed from the machine, residual test strips test for the absence of the peracetic acid mixture. The residual testing is very sensitive, testing down to < 1 ppm.
由於過醋酸混合物是一種強氧化劑，其處理需要特別注意以避免化學燒傷。必須佩戴手套和面部防護。意外接觸此化學品需要用水沖洗並尋求醫療幫助，類似於對甲醛的處理。
Because the peracetic acid mixture is a strong oxidant, its handling requires careful attention to avoid chemical burns. Gloves and face protection are mandatory. Accidental contact exposure to this chemical requires water flushes and medical attention similar to those described for formaldehyde.
無論在設施中使用何種清潔或消毒劑，必須在添加化學品之前以及清潔和消毒後進行徹底的水沖洗。必須在最終沖洗後進行安全測試，以驗證所使用化學品的缺失。依賴定時沖洗而不使用有效的安全測試是危險的。殘留測試可防止因化學品暴露而造成的病人傷害。
Regardless of the type of cleaning or disinfecting agent used in the facility, a thorough water rinse must be done before adding chemicals and after cleaning and disinfection. Safety tests must be done after the final rinse to validate the absence of the chemical used. It is dangerous to rely on a timed rinse without the use of a valid safety test. Residual testing prevents patient injury due to chemical exposure.
化學消毒的一般原則
General Principles for Chemical Disinfection
時間是化學消毒中的一個重要因素。完全消毒需要化學物質與需殺死的生物充分接觸的時間。化學物質的濃度、溫度以及需殺死的生物數量決定了接觸時間的長短。需殺死的生物數量越多，所需的接觸時間就越長。像孢子這樣的生物需要比細菌更長的接觸時間。
Time is an important factor in chemical disinfection. Total disinfection requires adequate time exposure of the chemical to the organisms to be killed. The concentration of the chemical, temperature, and the number of organisms to be killed determine the amount of exposure time. The greater the number of organisms to be killed, the longer is the exposure time needed. Organisms such as spores require longer exposure time than bacteria.
化學消毒劑需要保持濕潤才能有效。乾燥的化學消毒劑將不再有效。化學物質的濃度必須符合製造商的建議。較低的濃度可能無法有效殺死所有微生物，而較高的濃度則可能不會更有效。血液和有機物會降低化學消毒劑的有效性。化學消毒劑不應混合，因為混合可能會改變其活性。
Chemical disinfectants need to remain moist for effectiveness. A chemical disinfectant that dries up is no longer effective. The concentration of the chemical must be in accordance with the manufacturer's recommendations. Lower concentrations may not be effective in killing all microorganisms, whereas concentrations that are higher may not be more effective. Blood and organic matter decrease the effectiveness of the chemical disinfectant. Chemical disinfectants should not be mixed, as mixing can alter their activity.
透析液系統必須沒有任何死角。設計不良的透析液系統如果有死角，將無法充分消毒。為了評估化學消毒是否充分，應使用培養物監測設備。
Dialysate systems must not have any dead spaces. A poorly designed dialysate system with dead spaces is impossible to disinfect adequately. To assess adequate chemical disinfection, monitor the equipment with cultures.
額外的原則包括以下幾點：(1) 不要使用過期的化學消毒劑，(2) 始終標示含有化學消毒劑的設備，(3) 在所有化學消毒之前和之後進行充分的水沖洗，並在所有化學消毒後進行適當的安全測試，以確保化學物質的缺失（不要依賴定時沖洗）。
Additional principles include the following: (1) do not use chemical disinfectants beyond their expiration date, (2) always label equipment that contains a chemical disinfectant, and (3) perform an adequate water rinse prior to and after all chemical disinfection and perform the appropriate safety test after all chemical disinfection to ensure the absence of the chemical (do not rely on a timed rinse).
透析液監測文檔
Documentation of Dialysate Monitoring
在患者的每日透析記錄和/或機器或日誌表上記錄所有安全測試的表現和結果。對透析液監測中所有活動的文檔或圖表記錄對於患者安全至關重要。在所有適當的檢查完成並根據設施內的既定政策記錄後，請勿啟動透析。
Document the performance and results of all safety tests on the patient Daily Dialysis Record and/or the machine or log sheet. Documentation or charting of all activities in dialysate monitoring is critical for patient safety. Do not initiate dialysis until all of the appropriate checks are complete and recorded according to the established policies in the facility.
所有員工的教育對於安全且運行良好的透析單位至關重要。必須對任何新的透析液濃縮液、透析液濃縮液的準備、安全測試和液體輸送系統進行在職教育。在透析治療之前或期間，對透析液區域監測不足會對患者的健康造成許多風險（表 9.3）。
Education of all staff members is critical to a safe and well-run dialysis unit. In-service education must be given for any new dialysate concentrates, preparation of dialysate concentrates, safety tests, and fluid delivery systems. There are many risks ( Table 9.3 ) to the patient's well-being with inadequate monitoring of the dialysate compartment prior to or during the dialysis treatment.
Risks to Patients With Inadequate Monitoring
From Pittard J, De Palma J. Dialysate Monograph . 1st ed. Glendale, CA: Hemodialysis, Inc.; 2013.
| 問題 Problem | 潛在的病人風險 Potential Risk to Patient |
|---|---|
| 錯誤處方 Wrong prescription | 電解質失衡，特別是鉀，導致心律不整和心臟驟停 Electrolyte imbalances, especially with potassium, leading to cardiac arrhythmias and cardiac arrest |
| 導電性低 Conductivity low | 溶血—死亡 Hemolysis—death |
| 導電性高 Conductivity high | 高滲透壓昏迷—死亡 Hyperosmolar coma—death |
| 高溫 High temperature | 血液透析—死亡 Hemodialysis—death |
| 透析液流量缺失 Dialysate flow rate absent | 無透析，存在嚴重電解質失衡的風險，特別是高鉀血症、心律不整和心臟驟停 No dialysis with risk of serious electrolyte imbalances, especially hyperkalemia, cardiac arrhythmias, and cardiac arrest |
| 透析液流量低 Dialysate flow rate low | 不足和無效的透析 Inadequate and inefficient dialysis |
| 殘留化學物質（漂白劑、甲醛、過醋酸） Residual chemicals (bleach, formaldehyde, peracetic acid) | 血液透析—死亡 Hemodialysis—death |
| 高細菌數量 High bacterial count | 輕度至重度致熱反應 Mild to severe pyrogen reaction |
血液循環 The Blood Circuit
血液（體外）循環（圖 9.9）監測動脈和靜脈血管中的壓力，以及循環系統的完整性，以檢測空氣和血液洩漏。四個主要的血液循環監測器（圖 9.10）分別是動脈壓力監測器、靜脈壓力監測器、空氣泡沫探測器和血液洩漏探測器。
The blood (extracorporeal) circuit ( Fig. 9.9 ) monitors pressures in the arterial and venous blood lines, and the integrity of the circuit for the presence of air and blood leaks. The four main blood circuit monitors ( Fig. 9.10 ) are the arterial pressure monitor, venous pressure monitor, air-foam detector, and blood-leak detector.
Blood (Extracorporeal) Circuit.
(From Pittard J. Hemodialysis Nursing, Training Manual . 7th ed, version 7.0. Santa Monica, CA; 2003, with permission.)
(From Pittard J. Hemodialysis Nursing, Training Manual . 7th ed, version 7.0. Santa Monica, CA; 2003, with permission.)
血液洩漏檢測器作為血液循環警報，但完全整合在透析液循環中，已經被描述過。該設備對血液循環警報的反應包括啟動可聽警報、視覺警報、停止血液泵，以及啟動靜脈管夾以停止血液在血液循環中的流動。
The blood-leak detector acts as a blood-circuit alarm but is entirely incorporated within the dialysate circuit and has already been described. The machinery responds to blood-circuit alarms by activating an audible alarm, a visual alarm, stopping the blood pump, and engaging the venous line clamp to stop the blood flow through the blood circuit.
在血液循環中，需額外監測的區域包括血流速率、肝素治療和生理食鹽水供應。
Additional areas to monitor in the blood circuit are blood flow rate, heparin therapy, and normal saline supply.
動脈壓監測器—血泵前
Arterial Pressure Monitor—Pre–Blood Pump
動脈壓力監測器測量患者動脈通路與血液之間動脈血管內的壓力。當血泵設定的血流速率高於 200 mL/min，甚至可達 450 mL/min 時，這段血管管路中的壓力通常為亞大氣壓或負壓。這部分的血液循環系統可能成為空氣進入血液循環的來源，並被視為高風險區域。
The arterial pressure monitor measures the pressure in the arterial blood line between the patient's arterial access and the blood. With the blood pump set to blood flow rates greater than 200 mL/min to as high as 450 mL/min, the pressure in this blood tubing segment is commonly subatmospheric to negative. This portion of the blood circuit can be a source of air entry into the blood circuit and is considered a high-risk area.
動脈壓監測器無漏氣，具有可調的高/低限制（圖 9.11），可讀取以毫米汞柱（mm Hg；10% 準確度）表示的負壓和正壓。此監測器需要一個過濾器，以防止病毒、細菌或血液回流到動脈壓監測器中。這個過濾器是必需的，因為病毒性肝炎已通過空氣裝置的污染而傳播。
The arterial pressure monitor is leak-free with adjustable high/low limits ( Fig. 9.11 ), which reads negative and positive pressures in millimeters of mercury (mm Hg; 10% accuracy). This monitor requires a filter to prevent viruses, bacteria, or blood from being refluxed back into the arterial pressure monitor. This filter is essential, as viral hepatitis has been transmitted by contamination of air devices.
(From Pittard J. Hemodialysis Nursing, Training Manual . 7th ed, version 7.0. Santa Monica, CA; 2003, with permission.)
這些過濾器或液體障礙物稱為隔離器和/或傳感器過濾器/保護器。它們保護監視器免受血液污染和患者之間感染的擴散。在透析過程中，壓力監測管線必須保持未夾緊且通暢。一些血液管線具有可折疊的枕形段，這可能會引發錯誤警報。
These filters or fluid barriers are called isolators and/or transducer filters/protectors. They protect the monitor from blood contamination and the spread of infection between patients. The pressure monitor lines must be unclamped and patent during dialysis. Some blood lines have collapsible pillow-shaped segments, which can initiate a false alarm.
在設置、灌注和沖洗透析器的過程中，高/低限制是開放的。一旦開始透析治療，透析人員必須將低壓或負壓限制設置在所需血流量讀數的稍下方。上限和下限監測應設置在實際讀數的 50–100 mm Hg 範圍內，以便檢測問題。較新的機器型號將自動將高/低限制調整至實際壓力的約 50 mm Hg 以上和以下。
During set-up, priming, and rinsing of the dialyzer, the high/low limits are opened. As soon as the dialysis treatment is initiated, the dialysis personnel must set the low, or negative, pressure limit just below the reading at the desired blood flow. Upper and lower monitor limits should be set within 50–100 mm Hg of actual reading to detect problems. Newer machine models will automatically adjust the high/low limits approximately 50 mm Hg above and below the actual pressure.
將低動脈限制設置在接近實際壓力的水平，大約低於該壓力 50 毫米汞柱，將能夠檢測到動靜脈（AV）瘺管的早期血壓下降。一些單位將最低動脈限制限制為-100 毫米汞柱。
Setting the low arterial limit close to the actual pressure, about 50 mm Hg below that pressure, will detect early drops in blood pressure with arteriovenous (AV) fistulas. Some units limit the minimum arterial limit to –100 mm Hg.
真空越大，從任何裂縫、不當粘合或安裝的接頭、樣本端口、生理鹽水輸注管線或病人的通道進入這段管道的空氣風險就越大。建議將高限制設置在接近零的值，這樣可以檢測到來自瘻管針的動脈血管線的中斷。
The greater the vacuum, the greater the risk of air entering this tubing segment from any crack, improperly glued or fitted joint, sample port, saline infusion line, or the patient's access. It is advisable to set the high limit just below zero, which will pick up a disruption of the arterial blood line from the fistula needle.
動脈壓監測
Arterial Pressure Monitoring
低限動脈壓警報的常見原因包括血壓下降（僅在動靜脈瘻管的情況下）、進針口與血泵之間的動脈血管線扭曲、動脈針位置不當、動脈通路問題以及動脈管路堵塞。應始終檢查迴路是否有氣泡。
The usual causes of a low-limit arterial pressure alarm are a drop in blood pressure (only with AV fistulas), a kink in the arterial blood line between the access and blood pump, malpositioned arterial needle, or problem with arterial access, and a clotted arterial line. The circuit should always be checked for air bubbles.
高限動脈壓警報的常見原因包括血管線分離（僅當上限設置低於 0 mm Hg 時）、鹽水輸注管未夾緊、患者血壓上升、患者與監測器之間的回路漏血，以及泵段的血管管破裂。檢查是否有漏血是非常重要的。
The usual causes of a high-limit arterial pressure alarm are bloodline separation (only if the upper limit is set below 0 mm Hg), the saline infusion line is unclamped, an increase in patient's blood pressure, a leak in the circuit between the patient and the monitor, and torn blood tubing in the pump segment. It is important to check for leaking blood.
對壓力警報的適當反應是，首先靜音可聽警報；其次，調查問題；第三，修正問題；第四，通過按下重置/重新啟動按鈕來重新啟動血泵。在問題未修正之前，請勿重新啟動血泵以確保病人安全。未能修正問題將導致警報再次出現。
The appropriate response to pressure alarms is to, first, mute the audible alarm; second, investigate the problem; third, correct the problem; and fourth, restart the blood pump by pressing the reset/restart button. Do not restart the blood pump until the problem is corrected for patient safety. Failure to correct the problem will cause the alarm to reoccur.
靜脈壓力監測器 Venous Pressure Monitor
靜脈壓力監測器位於透析器後方，監測靜脈滴液室的壓力、滴液室與病人靜脈通路之間的段落，以及額外的通路內壓力。進入靜脈通路的血流阻力使壓力為正（圖 9.12），高於 0 mm Hg。
The venous pressure monitor, located postdialyzer, monitors pressure at the venous drip chamber, the segment between the drip chamber and the patient's venous access, and the added intra-access pressure. The resistance to the blood flow entering the venous access causes the pressure to be positive ( Fig. 9.12 ), above 0 mm Hg.
(From Pittard J. Hemodialysis Nursing, Training Manual . 7th ed, version 7.0. Santa Monica, CA; 2003, with permission.)
靜脈壓力監測器的結構和標準類似於動脈前血泵監測器所描述的。此壓力監測器需要通過過濾器或傳感器液體屏障進行保護。
The venous pressure monitor's structure and standards are similar to those described for the arterial pre–blood pump monitor. This pressure monitor requires protection by a filter or transducer fluid barrier.
靜脈壓監測
Venous Pressure Monitoring
高靜脈壓警報的原因包括滴液室與病人靜脈通道之間靜脈血管線的扭曲、靜脈滴液室內及/或病人下游的血塊，以及靜脈針的位置不當或靜脈通道裝置的問題。
Causes of a high venous pressure alarm are a kink in the venous blood line between the drip chamber and patient's venous access, a clot in the venous drip chamber and/or downstream to the patient, and a malpositioned venous needle or problem with the venous access device.
低靜脈壓警報的原因包括血液管路分離或血液泵與靜脈通路之間的連接中斷；血液管路在透析器後和靜脈滴注室前的扭曲；透析器內血塊；以及血液泵速度降低。請注意，將低限設置得接近靜脈滴注室的操作壓力，可以警示血液泵與靜脈通路之間的血液循環中斷。當循環中斷時，靜脈壓將降至 0 mm Hg。
Causes of a low venous pressure alarm are blood line separation or disruption of connections between the blood pump to and including the venous access; a kink in the blood line postdialyzer and pre–venous drip chamber; a clotted dialyzer; and a lowering of the blood-pump speed. Note that setting the low limit close to the operating pressure of the venous drip chamber can alert to a disruption of the blood circuit between the blood pump and venous access site. With a disruption of the circuit, the venous pressure will drop to 0 mm Hg.
應該記住，靜脈壓監測器反映了方程 TMP = P BO – P DO 中的 P BO 。高靜脈壓可能導致超濾速率過高，除非使用的是超濾控制機器。
It should be remembered that the venous pressure monitor reflects P BO in the equation TMP = P BO – P DO . High venous pressures can result in too high ultrafiltration rates unless an ultrafiltration-controlled machine is being used.
空氣泡沫探測器 Air-Foam Detector
氣泡檢測器監測靜脈管路中的血液（圖 9.13），以檢測空氣、泡沫和微氣泡的存在。必須再次強調，幾乎所有的內部動靜脈瘻管/移植物和靜靜脈透析之間，動脈通道和滾輪泵之間存在顯著的亞大氣壓。在這部分電路中有許多接頭和熱封接頭。如果肝素輸注管路位於負壓區段而不是血泵後，則可能增加空氣進入的風險。在血泵之後，血液電路處於相當的正壓下，空氣只能通過泵送或注入進入其餘電路。空氣栓塞是一種可預防且非常嚴重的透析意外。
The air-foam detector monitors blood in the venous tubing ( Fig. 9.13 ) for the presence of air, foam, and microbubbles. It must be reemphasized that with almost all internal AV fistulas/grafts and venovenous dialysis, a significant subatmospheric pressure exists between the arterial access and the roller pump. There are many junctions and heat-sealed joints in this portion of the circuit. If the heparin infusion line is in the negative-pressure segment rather than post–blood pump, it may increase the risk for air entry. After the blood pump, the blood circuit is at considerable positive pressure, and air can enter only by pumping or injecting it into the remainder of the circuit. Air embolism is a preventable and very serious dialysis misadventure.
(From Pittard J. Hemodialysis Nursing, Training Manual . 7th ed, version 7.0. Santa Monica, CA; 2003, with permission.)
目前使用兩種空氣泡沫探測器：超聲波探測器和反射光探測器。據信，目前只有超聲波設備在銷售。然而，許多反射光型設備仍在使用中。令人驚訝的是，對於空氣的可允許檢測並沒有標準，因為任何類型的探測器在正確裝備和運行時都能輕易識別靜脈滴注室中血液的明顯空氣位移。直徑從 5 到 500 微米的微氣泡則代表著另一個問題，因為它們隨著血流一起流動。這些微氣泡被攪拌在血液中。
Two types of air-foam detectors are in use: the ultrasonic and reflected light detectors. It is believed that only the ultrasonic device is currently being sold. Nevertheless, many of the reflected light-type devices are still in use. Surprisingly, there are no standards for permissible detection of air because either type of detector readily identifies gross air displacement of blood in the venous drip chamber when properly armed and functioning. Microbubbles from 5 to 500 μm in diameter represent a different problem as they stream along with the blood flow. These microbubbles are entrained in the bloodstream.
雖然這兩種類型的監測器都能檢測微氣泡，但其保證檢測需要的靈敏度設置可能會因流體流動中的湍流而導致許多誤報。折衷方案是對超聲設備進行靈敏度調整，以致發生一些需要透析人員注意的誤報。在某些情況下，微氣泡可能無法被檢測到，並導致臨床空氣栓塞。這些設備的當前標準要求對血液、血液和生理鹽水混合物或生理鹽水中的空氣作出反應。只有超聲設備能滿足這一要求。反射光設備的一個危險方面是，它僅在感測患者的全血時有效。在進行預充、啟動或沖洗時，無法準確啟動。
Although both types of monitors can detect microbubbles, their guaranteed detection requires a sensitivity setting that may result in many false alarms because of turbulence in fluid flow. The compromise is a sensitivity adjustment of the ultrasonic devices such that some false alarms occur that require the attention of dialysis personnel. In certain situations, microbubbles can go undetected and cause clinical air embolism. The current standards for these devices require response to air in blood, a blood and saline mixture, or saline. Only the ultrasonic device can meet this requirement. A dangerous aspect of the reflected light device is that it is effective only when sensing the whole blood of the patient. It cannot be accurately armed during priming, initiation, or rinsing.
靜脈導管夾 Venous Line Clamp
空氣檢測器警報必須啟動靜脈管夾（圖 9.13）。靜脈管夾必須完全阻塞靜脈血管，並能承受 800 mm Hg 的腔內壓力。靜脈管夾的設計應不損壞血管，並且在開放位置時不應限制血管管路。靜脈管夾的電路必須與血泵接口並停止血泵。大多數集成的空氣泡沫檢測器都符合這些標準。
An air detector alarm must activate the venous line clamp ( Fig. 9.13 ). The venous line clamp must completely occlude the venous blood line and withstand an intraluminal pressure of 800 mm Hg. The venous line clamp should be constructed to not damage the blood lines and should not restrict the blood tubing when in an open position. The venous line clamp circuitry must interface with and stop the blood pump. Most integrated air-foam detectors meet all of these standards.
有些透析機器是不安全的，因為它們可以在氣漏檢測器和靜脈管夾都被解除的情況下進行透析，且只有一些微弱的指示顯示這種解除狀態。
There are dialysis machines that are unsafe as they include the ability to dialyze with both the air-leak detector and venous line clamp disarmed and only some marginal indication of this disarmed state.
空氣泡沫探測器和靜脈導管夾監測
Air-Foam Detector and Venous Line Clamp Monitoring
在氣泡檢測器警報狀態下，確認靜脈管夾已啟動且血液泵已停止。從靜脈通道向後檢查整個血液循環系統，查看是否有空氣、泡沫或微氣泡。檢查靜脈滴注室的液位——應該是四分之三滿。檢查靜脈滴注室是否正確放置在其支架中，液位檢測器門是否關閉並鎖定，且滴注室中的網格位於氣體檢測器下方。同時檢查氣體傳感器是否乾淨。在重新啟動血液泵和解除靜脈管夾之前，始終確認沒有空氣存在。如果有空氣，請將病人與體外循環系統斷開連接。
With an air-foam detector alarm state, identify that the venous line clamp is engaged and the blood pump is stopped. Visually inspect the entire blood circuit from the venous access backward to the arterial end for the presence of air, foam, or microbubbles. Check the level in the venous drip chamber—it should be three-quarters full. Check that the venous drip chamber is properly placed in its holder, the level detector door is closed and latched, and the mesh in the drip chamber is below the air detector. Also, check if the air sensors are clean. Always validate the absence of air before restarting the blood pump and disengaging the venous line clamp. If air is present, disconnect the patient from the extracorporeal circuit.
在開始透析之前，確保氣泡檢測器已開啟並正常運作，並且靜脈血管路徑正確放置在夾管架上。超聲波裝置通常在回路的灌注過程中啟動。反射光裝置在靜脈管路中全血達到滿血比時才能啟動。
Before beginning dialysis, make sure that the air-foam detector is turned on and operational and that the venous blood line is properly placed in the line-clamp holder. Ultrasonic devices are usually activated during priming of the circuit. Reflected light devices cannot be activated until whole blood at full hematocrit is in the venous tubing.
因為每個品牌的檢測器操作方式不同，確保透析人員了解設施中使用的設備類型，並接受其獨特功能和操作的在職培訓。不幸的是，當工作人員在響應此警報狀況時按下重置/重新啟動按鈕，血液泵會重新啟動。這可能是一個潛在致命的反應。肉眼可能看不見的微氣泡可能會流入病人體內。我建議工作人員在響應血液中空氣警報時手動關閉血液泵。在所有檢查完成後，按下重置按鈕不會自動啟動血液泵。然而，如果問題未得到解決，警報將會再次出現，但對病人不會造成傷害。
Because each brand of detector varies in its operation, ensure that dialysis personnel are aware of the type of device used in the facility and are in-serviced on its unique features and operation. Unfortunately, when staff pushes the RESET/RESTART button in responding to this alarm condition, the blood pump restarts. This can be a potentially deadly response. Microbubbles that may not be visible to the naked eye can flow into the patient. I advise staff to manually turn off the blood pump when responding to an air-in-blood alarm. After all inspections are complete, pushing the reset button will not automatically start the blood pump. However, if the problem is not corrected, the alarm will reoccur with no harm to the patient.
這裡概述了四種警報條件以供一般參考。
Four alarm conditions are outlined here for general information.
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警報狀態 1. 仔細檢查顯示靜脈滴注室的血液-空氣水平正常，且管路或透析器的任何部分均無微氣泡（泡沫）。這是虛假警報—鬆開管夾並重置檢測器。
Alarm condition 1. Careful inspection reveals that the blood-air level in the venous drip chamber is normal and that there are no microbubbles (foam) in any portion of the line or dialyzer. This is a false alarm—release the line clamp and reset the detector. -
警報狀態 2。靜脈滴注室的血液水平已下降。為此，檢查上游是否有氣泡。如果沒有，則使用常規技術將滴注室的血液-空氣水平恢復到正常，放開管道夾，並重置警報。
Alarm condition 2. The blood level in the venous drip chamber has fallen. In response, check for upstream bubbles. If none is present, return the blood-air level to normal in the drip chamber with the usual technique, release the line clamp, and reset the alarm. -
警報狀態 3。靜脈管路中有微氣泡（泡沫）。為此，夾住靜脈管路和靜脈通路，將注意力轉向病人，以防需要緊急處理氣栓。另一人應從氣體檢測夾中移除管路，將病人與血液循環斷開，並無菌地將血液循環的動脈端和靜脈端連接以進行再循環。移除超濾，打開生理鹽水以去除血液循環中的空氣，並將其收集在靜脈滴注室中。如果此措施成功，將靜脈管路放入氣體檢測夾中並重新啟動氣泡檢測器。如果沒有進一步的警報被激活，則將血液循環管路重新連接到病人並重新開始透析。
Alarm condition 3. There are microbubbles (foam) in the venous line. In response, clamp the venous line and the venous access line, directing attention to the patient in the event that emergency management of air embolism is necessary. Another person should remove the line from the air detector clamp, disconnect the patient from the blood circuit, and aseptically join the arterial and venous ends of the blood circuit for recirculation. Remove ultrafiltration, open the saline to remove air from the blood circuit, and collect it in the venous drip chamber. If this measure is successful, place the venous line into the air-detector line clamp and rearm the air-foam detector. If no further alarm is activated, reconnect the blood circuit lines to the patient and reinitiate dialysis. -
警報狀態 4。大量空氣和氣泡充滿整個血液循環系統，包括透析器。為此，夾住“靜脈”管線，並將注意力轉向患者以進行氣栓的緊急處理。處理整個血液循環系統，包括透析器，並設置一個新的系統以重新開始透析。
Alarm condition 4. Gross air and bubbles fill the entire blood circuit, including the dialyzer. In response, clamp the “venous” line and direct attention to the patient for emergency management of air embolism. Dispose of the entire blood circuit, including the dialyzer, and set up a new one to reinitiate dialysis.
肝素輸注泵 Heparin Infusion Pump
肝素輸注泵通常位於血泵後段。肝素輸注管連接到裝有肝素的注射器。這使得在透析過程中可以進行肝素的輸注。電動馬達驅動活塞向前移動肝素活塞以輸注肝素。透析人員必須打開肝素泵並設置正確的每小時輸注速率。如果泵未開啟或設置了不正確的每小時輸注速率，則不會發出警報。大多數機器在注射器中的肝素水平非常低時會發出可聽見的警報。
The heparin infusion pump is usually located in the post–blood pump segment. A heparin infusion line attaches to a syringe filled with heparin. This allows for the infusion of heparin during dialysis. An electric motor drives a piston to move the heparin plunger forward to infuse the heparin. Dialysis personnel must turn the heparin pump on and set the correct hourly infusion rate. No alarms occur if the pump is not turned on or an incorrect hourly infusion rate is set. Most machines have an audible alarm when the heparin level in the syringe is very low.
肝素輸注泵監測
Heparin Infusion Pump Monitoring
人員必須確保根據肝素泵的校準使用正確尺寸的注射器。確保注射器和活塞正確放置在支架中。檢查泵是否開啟，並確認可變的每小時速率設置正確。實施每小時檢查以確保肝素治療的正確輸注。較新的機器型號允許人員編程肝素推注、輸注速率和輸注時間長度。
Personnel must make sure they are using the correct-size syringe based on the way the heparin pump is calibrated. Make sure the syringe and plunger are placed properly in the holder. Check that the pump is on and the variable hourly rate is set correctly. Implement hourly checks to ensure the correct infusion of heparin therapy. Newer machine models allow the personnel to program the heparin bolus, infusion rate, and length of time for the infusion.
血流速率 Blood Flow Rate
血流速率是影響透析器清除效率的重要參數。所有血液泵都有開/關開關和可調變速泵。如果未正確設置所需的血流速率，則機器不會發出警報。
The blood flow rate is an important parameter that influences the efficiency of dialyzer clearance. All blood pumps have an on/off switch and an adjustable variable speed pump. There are no machine alarms if the desired blood flow rate is not set correctly.
血流速率監測
Blood Flow Rate Monitoring
再次確認血流速率是否正確設置。合格人員必須對血液泵進行校準，以確保實際血流與血流設置相當。設施必須使用適當的血管管尺寸，以確保滾輪泵的正確閉合。不充分的閉合會導致回流、起泡，並可能引起溶血。過度閉合會導致管道損壞、血液洩漏，並有可能引起溶血。
Double-check that the blood flow rate is properly set. A qualified person must calibrate blood pumps to ensure that the actual blood flow is comparable to the blood-flow setting. The facility must use appropriate blood-tubing size for proper occlusion of the roller pump. Inadequate occlusion causes backflow, foaming, and possibly hemolysis. Over occulsion causes tubing damage, blood leaks, and the potential for hemolysis.
血泵和血管線
Blood Pump and Blood Lines
狹窄的血泵管道段
Narrowed Blood-Pump Tubing Segment
在 1998 年，美國三個不同州的 30 名患者在接受血液透析時出現溶血，伴隨或不伴隨胸痛、呼吸急促、噁心或腹痛。兩名患者死亡。所有這些災難都是由於血管管路中血泵段的一小部分存在製造缺陷。工作人員在插入血泵段時未注意到該缺陷。該段的明顯狹窄導致這些患者出現大規模溶血，最初無法解釋，並需要美國疾病控制與預防中心（CDC）進行正式調查。
In 1998, 30 patients in three different states in the United States developed hemolysis with or without chest pains, shortness of breath, nausea, or abdominal pain while undergoing hemodialysis. Two patients died. All of these catastrophes were due to a manufacturing defect in a small portion of the blood-pump segment of the blood tubing. The staff did not notice the defect when inserting the blood-pump segment. A marked narrowing of this segment induced massive hemolysis in these patients, which initially was unexplained and required a formal investigation by the Centers for Disease Control and Prevention (CDC).
扭曲的動脈血管線
Kinked Arterial Blood Lines
在 1989 年 12 月至 1990 年 12 月的 1 年期間，門診血液透析單位共發生 10 起溶血反應。八名患者住院，其中一名患者死亡。所有患者在使用漂白劑-甲醛再處理的中空纖維 Cuprophan 透析器進行 4 小時的血液透析會話中，平均在 2.5 小時後出現嚴重的腹痛或背痛。所有患者在離心血比容中均可見溶血，七名患者的血比容顯著下降，六名患者發展為胰腺炎。儘管更換為 15 號針頭、從重用程序中去除漂白劑以及停止重用透析器，溶血反應仍然持續發生。
In a 1-year period, from December 1989 to December 1990, a total of 10 hemolytic reactions occurred in an outpatient hemodialysis unit. Eight patients were hospitalized, and one died. All patients developed severe abdominal or back pain an average of 2.5 hours into a 4-hour hemodialysis session using bleach-formaldehyde reprocessed hollow-fiber Cuprophan dialyzers. All had visible hemolysis in a spun hematocrit, seven had a significant decrease in hematocrit, and six developed pancreatitis. Hemolytic reactions continued despite changing to 15-gauge needles, removing bleach from the reuse procedure, and stopping reuse of the dialyzers.
每次事件的調查未能發現透析液的溫度或滲透壓異常；銅、鋅、硝酸鹽、氯胺或甲醛的透析液或水位；或血液泵或靜脈警報。在第八次溶血事件中，一名透析工作人員注意到動脈血管線有扭結。隨後發生了兩次溶血反應；在每次反應中，動脈血管線中發現了扭結，無論是在血液泵和滴定室之間的多餘管道中，還是在透析前段中。在更換為沒有多餘管道的新動脈血管線並固定所有管道後，未再發生進一步的溶血反應。
Investigation of each episode failed to find an abnormality in dialysate temperature or tonicity; dialysate or water levels of copper, zinc, nitrates, chloramine, or formaldehyde; or blood pump or venous alarm. On the eighth hemolytic episode, a dialysis staff member noted a kink in the arterial blood line. Two subsequent hemolytic reactions occurred; in each, kinks were found in the arterial blood line, either in the excess tubing between the blood pump and drip chamber or in the predialyzer segment. No further hemolytic reactions occurred after changing to a new arterial blood line without redundant tubing and securing all lines.
靜脈鹽水輸注 IV Saline Infusion
進入體外循環的生理食鹽水（0.9% NaCl）通過位於動脈血路徑起始處的食鹽水給藥管線進行接入。生理食鹽水用於為透析器和血管管路進行預充，替代透析過程中患者的體液，並在透析結束時沖洗紅血球。
Access to normal saline (0.9% NaCl) into the extracorporeal circuit occurs via the saline administration line located at the beginning of the arterial blood circuit. Normal saline is used to prime the dialyzer and blood tubing for patient use, to replace volume in the patient during dialysis, and rinse the RBCs at the conclusion of dialysis.
靜脈鹽水輸注監測
IV Saline Infusion Monitoring
人員必須確保在透析治療期間有足夠的生理食鹽水可供立即使用。應避免使用生理食鹽水滴注。雖然生理食鹽水裝在可折疊的塑料袋中，但如果在透析過程中這些袋子意外空掉，幾百毫升的空氣將進入血液循環，可能導致氣栓。
Personnel must make sure an adequate amount of normal saline is available for immediate use during the dialysis treatment. Normal saline drips should be discouraged. Although normal saline comes in collapsible plastic bags, if these accidentally empty during dialysis, a few hundred milliliters of air will enter the blood circuit, possibly causing an air embolism.
結論 Conclusion
透析的世界經歷了許多變化。液體輸送系統變得更加複雜，透析器的效率也更高。無論是電子設備、故障安全裝置、閃爍的燈光、警報器、儀表盤還是操作程序，都無法取代一名警覺且受過良好訓練的透析工作人員。在美國，非註冊護理人員或病人護理技術員（PCT）負責 75%的末期腎病（ESRD）患者的直接護理，因此他們必須了解潛在的警報情況，並接受徹底的訓練以確保透析治療的安全。
The world of dialysis has undergone many changes. The fluid delivery systems are much more sophisticated and dialyzers more efficient. No amount of electronic machinery, fail-safe devices, flashing lights, sirens, dials, or protocols can take the place of an alert and well-trained dialysis staff member. Non–registered nurses or patient care technicians (PCTs) perform 75% of direct patient care of ESRD patients in the United States, and it is essential they understand potential alarm situations and are thoroughly trained to ensure safe dialysis treatment.
推薦閱讀 Recommended Reading
- 匿名：1998 年內布拉斯加州和馬里蘭州血液透析患者的多州溶血疫情。MMWR Morb Mortal Wkly Rep. 1998; 47: 頁 483-484。
Anonymous : Multi state outbreak of hemolysis in hemodialysis patients, Nebraska and Maryland, 1998. MMWR Morb Mortal Wkly Rep. 1998; 47: pp. 483-484. - 作者指出了一系列之前從未描述過的不幸事件。在三個州，共有 30 名患者在接受血液透析時出現溶血。經過廣泛調查以排除溶血的原因後，確定使用同一製造商的血管管道進行透析的患者出現了問題。發現製造的血管管道的開口異常狹窄，導致紅血球的機械性溶解。所有血管管道均被召回。這些事件導致了溶血、重病和死亡。
The author points out a series of misadventures heretofore never described. In three states, a total of 30 patients developed hemolysis while undergoing hemodialysis. Following an extensive investigation to rule out the cause of hemolysis, it was determined that the patients dialyzed using the same manufacturer's blood tubing. An abnormal narrowing of the aperture of the manufactured blood line, causing a mechanical lysis of the RBCs, was discovered. All blood lines were recalled. These resulted in hemolysis, serious illness, and death. - 醫療儀器進步協會 (AAMI) : 血液透析用透析液 (RD52:2004) .2004.AAMI 阿靈頓, VA
Association for the Advancement of Medical Instrumentation (AAMI) : Dialysate for Hemodialysis (RD52:2004) .2004.AAMIArlington, VA - 醫療儀器進步協會 (AAMI)：血液透析應用及相關療法的水處理設備 (RD62:2006) .2011.AAMI 阿靈頓, VA
Association for the Advancement of Medical Instrumentation (AAMI) : Water Treatment Equipment for Hemodialysis Applications and Related Therapies (RD62:2006) .2011.AAMIArlington, VA - AAMI 制定了血液透析用水的水質標準。美國國家標準協會（ANSI）採納了 AAMI 制定的標準。目前使用的標準是 ANSI/AAMI RD52:2004 和最近的 RD62:2006。這些標準已納入 CfCs。這些標準針對設施（使用者）和製造商。這些標準中包含了食品和藥物管理局（FDA）的建議。FDA 的建議基於對血液透析設備風險和危害的研究。AAMI 對設施的標準涉及兩個基本類別，微生物和化學污染物監測。
The AAMI developed water quality standards for the water used in hemodialysis. The American National Standards Institute (ANSI) adopted the standards established by AAMI. Standards currently in use are ANSI/AAMI RD52:2004 and, most recently, RD62:2006. These standards are included in the CfCs. The standards address both the facilities (users) and the manufacturers. Incorporated into these standards are recommendations of the Food and Drug Administration (FDA). The FDA bases its recommendations on a study on risks and hazards of hemodialysis devices. The AAMI standards for facilities address two basic categories, microbiologic and chemical contaminant monitoring. - De Palma J.R.: Bicarbonate Dialysis & Water Treatment. Contemporary Dialysis & Nephrology 1988; 9: pp. 20-21. 41
- The author, Dr. De Palma, cites that in the beginning of hemodialysis, acetate was the buffer used. It took years before bicarbonate replaced acetate as a buffer. This article reviews both buffer bases and their strengths and weaknesses. Acetate as a buffer was initially used because it was bactericostatic, easy to mix, and stable in solution. However, cases of patients developing pulmonary problems, headaches, nausea, vomiting, and hypotension were cured when bicarbonate as a buffer was used in Dr. De Palma's dialysis clinics. The company Cobe, Inc., was contacted and then produced their own bicarbonate concentrate, based on Dr. De Palma's work. Several other companies produced bicarbonate, including liquid bicarbonate, which proved to grow bacteria.
- De Palma J.R.: Bleach & Murphy's Law. Contemporary Dialysis & Nephrology 1988; 9: pp. 30-31. 39
- The author, Dr. De Palma, a nephrologist and early pioneer in hemodialysis, warns all hemodialysis staff to expect the unexpected, that if anything can go wrong, it will and compromise patient safety. Since the 1960s, Dr. De Palma has been building and running many dialysis clinics. Along the way, he encountered many misadventures that were unknown to the dialysis community. I concur with his explanation of “Murphy's Law” and that no machinery can substitute for competent human care.
- European Best Practice Guidelines for Haemodialysis (Part 1) : SECTION IV. Dialysis fluid purity. Nephrol Dial Transplant 2002; 17: pp. 46-62.
- This article discusses various aspects of using ultrapure water. “Ultrapure” is defined as water virtually free from bacteria and endotoxins with microbiologic counts containing < 0.1mL of colony-forming units/mL (CFU/mL) and endotoxin units of < 0.03 endotoxin units/mL (EU/mL). This is the standard in Europe but not in the United States or around most of the world. The benefits to the dialysis population in improving the overall morbidity and mortality rates are discussed. It should be mentioned that absolutely pure water is corrosive and will leach metals such as iron and copper from piping, caveat lector.
- Gutch C.F., Stoner M.H., Corea A.L.: Hemodialysis for Nurses and Dialysis Personnel.6th ed1999.MosbySt. Louispp. 54-56. 59-65. ISBN: 0-8151-2099-0
- The authors presented the material in a different format from most books. Questions are presented, followed by descriptive answers that are intended to give the reader a basic understanding of the information. It is one of the best educational books for nurses and patient care technicians in the field of dialysis.
- Yukihiro Nosé: Manual on Artificial Organs. Vol. I.The Artificial Kidney.1969.CV Mosby CompanySaint Louis, MO:pp. 120-151.
- Dr. Nosé's chapter on “Dialysate Supply Systems” published in 1969 presents the information on the chemistry of dialysate, dialysate composition, water for dialysate, final checks for dialysate composition, and all aspects of the equipment used in that era. It is clearly written and the concepts presented are easy to understand. The diagrams are clearly presented. The fundamental information remains a classic and applicable today.
- Pittard J.D.: Hemodialysis Nursing—Version 7.0.2003.Hemodialysis, IncGlendale, CA
- The author of this syllabus distills into an outline and into one resource the knowledge and experience acquired in two and one-half decades of teaching. This syllabus is primarily a teaching tool for both nurses and hemodialysis technicians, to assist them during the classroom lectures. It contains core lecture information taught in Ms. Pittard's hemodialysis training program. The classroom lectures are augmented with slides of bulleted text and colored graphics. This syllabus is derived from these slides and contains the course outline, lecture objectives, elemental lecture content, and recommended readings. I referred to the lectures that directly pertain to dialysate, the fluid delivery system, and monitors in dialysis.
- Pittard J.D., De Palma J.R.: Monitors.2004.Hemodialysis, IncGlendale, CApp. 20-76.
- The authors wrote this monograph as a home study course for dialysis nurses and technicians, who are awarded 30 contact hours of continuing education on completion of the monograph posttest. This monograph describes the machinery and personnel monitoring of the hemodialysis process. It is an in-depth review of hemodialysis safety monitors, covering both blood and dialysate circuits. Most, if not all, information is obtained from clinical research and actual hemodialysis experience. Expert and seasoned MDs and RNs in the ESRD field have reviewed all.
- Pittard J.D., De Palma J.R.: Principles of Dialysis.3rd ed2006.Hemodialysis, IncGlendale, CApp. 65-85.
- The authors of this monograph, recently updated to the third edition, covers acute and chronic renal failure, principles of hemodialysis, application of diffusion and ultrafiltration, dialysate solution, dialyzers, the hemodialysis system, the hemodialysis prescription, dialysis dose, access to the circulation, anticoagulation therapy, and alternative therapies. This monograph is a home study course for dialysis nurses and technicians, who are awarded 30 contact hours of continuing education on completion of the monograph posttest.
- Pittard J., De Palma J.: Dialysate Monograph.1st ed2013.Hemodialysis, IncGlendale, CA
- The authors of this monograph thoroughly discuss the composition and clinical use of hemodialysate. Knowledge of the fundamental principles regarding the preparation and clinical applications will help the reader provide better care to the ESRD patient. It covers all of the new and current regulations regarding dialysate, including mixing, distribution, labeling, and use. This monograph is a home study course for dialysis nurses and technicians, who are awarded 30 contact hours of continuing education on completion of the monograph posttest.
- Sweet S.J., McCarthy S., Steingart R., Callahan T.: Hemolytic reactions mechanically induced by kinked hemodialysis lines. Am J Kidney Dis. 1996; 27: pp. 262-266.
- The authors discuss 10 hemolytic events occurring in the course of 1 year. This article describes blood lines being kinked. Kinks originated in the arterial blood line due to excess tubing between the blood pump and drip chamber or in the predialyzer segment. The elimination of kinks in the tubing resolved the problem. This emphasizes the importance of absolute mandatory training required of staff that provides direct patient care and the attention to detail that must be adhered to, even though blood tubing placement is a routine procedure.
- The Department of Health and Human Services Center for Medicaid and Medicare Services (CMS) : Conditions for Coverage (CfCs): Subpart B—patient safety, 494.40. Water and dialysate quality. Fed Regist 2008; 73:
- The ESRD CfCs Final Rule modernizes Medicare's ESRD health and safety conditions for coverage and updates CMS standards for delivering safe, high-quality care to dialysis patients. The ESRD CfCs are the minimum health and safety rules that all Medicare and Medicaid participating dialysis facilities must meet in order to operate and be Medicare certified. This condition incorporates by reference the AAMI and American National Standard for Dialysate for Hemodialysis, 2004 (RD52:2004). This condition has “Tags” or “V” codes; V175-278 (> 100) addressing expected guidelines and specific conditions for facilities to meet. This Interpretive Guidance is to replace all previously released versions. Specific regulations regarding dialysate are included. First-time regulations specific for dialysate include mixing, distribution, labeling, and use. It is essential to incorporate these rules into training of staff.
- Utoh J., Harasaki H.: Damage to erythrocytes from long-term heat stress. Clin Sci 1992; 82: pp. 9-11.
- The authors researched the effects of heat on erythrocytes, RBCs. In particular, they hypothesized that erythrocytes might be damaged at lower temperatures if incubated for prolonged periods. The study was conducted using healthy human donor blood. Various time frames and temperatures were used. The study showed that prolonged exposure induced hemolysis at 42°C. It is critical that dialysate temperatures be preset with the internal high limit set at no higher than 41°C (105.8°F). Dialysate temperatures in excess of 106°F induce RBC hemolysis. Careful monitoring is mandatory. Staff education is critical in this area. Under no circumstances should the high limit be adjusted above 41°C. It should be remembered that uremic RBCs are more osmotically fragile and have a shorter half-life than normal RBCs. It is reasonable to assume that these uremic RBCs are more sensitive to all mechanical and thermal causes of trauma than normal RBCs.