CRRT模式選擇ppt課件

CRRT：溶質(zhì)分子與模式選擇,1,Case,男性，50歲單純高鉀血癥循環(huán)穩(wěn)定CRRT策略：高流量的CVVH,？,2,內(nèi)容提要,CRRT的基本概念CRRT的溶質(zhì)清除原理CRRT的基本模式CRRT在ICU中的應(yīng)用,3,CRRT:所有連續(xù)性清除水和溶質(zhì)的治療技術(shù)CAVH,CVVH,SCUF,CAVHD,CVVHD,CAVHDF,CVVHDF,CVVH,HVHF.CBP:連續(xù)性血液凈化1995年第一屆CRRT學(xué)術(shù)會(huì)議在美國(guó)圣地亞哥舉行，每年一次學(xué)術(shù)會(huì)議,CRRT基本概念,4,CRRTamajortreatmentoptionforARF?,AcuteRenalFailure,Treatmentoptions:Drugtherapy(fluids,diuretics)IntermittentHemodialysis(IHD)PeritonealDialysisContinuousRenalReplacementTherapies(CRRT),AdditionalindicationsforCRRT,ChronicHeartFailureandoverhydrationMulti-organFailure(MOF)AcuteRespiratoryDistressSyndrome(ARDS)BurnPatientsLiverFailureSepsis,5,內(nèi)容提要,CRRT的基本概念CRRT的溶質(zhì)清除原理CRRT的基本模式CRRT在ICU中的應(yīng)用,6,CRRT水和溶質(zhì)清除原理,清除水Ultrafiltration清除溶質(zhì)DiffusionConvectionAdsorption,7,Hollowfibrestructure,BloodInlet,8,9,壓力梯度差形成的液體移動(dòng),超濾作用,正壓,負(fù)壓,不能通過膜的溶質(zhì)做成膠體滲透壓,10,CRRT溶質(zhì)清除原理,清除溶質(zhì)DiffusionConvectionAdsorption,11,小分子物質(zhì),氯化鈉SodiumChloride58.5尿素Urea60磷酸PhosphateAcid96肌酐Creatinine113尿酸UricAcid168葡萄糖Glucose180,12,中分子物質(zhì),多肽PeptideA778維生素B12VitaminB121355菊糖Inulin5200微球蛋白B2-microglobulin11800肝素Heparin11200肌球蛋白Myoglobin17000因子DFactorD24000白介素1Interleukin-131000蛋白酶Pepsin35000腫瘤壞死因子TumorNecrosisFactor39000-225000,13,大分子物質(zhì),前白蛋白Pre-albumin55000抗凝血酶原3Antithrombin365000白蛋白Albumin66000血紅蛋白Hemoglobin68000凝血酶原Prothrombin68000轉(zhuǎn)鐵蛋白Transferrin76500免疫球蛋白GIgG160000纖維蛋白原Fibrinnogen341000纖維連接蛋白Fibronectin(dimer)450000,14,Diffusion,SolutesmovefromaHigherconcentration(Blood)toaLowerconcentration(Dialysate)VeryefficientforremovingsmallmoleculesInHemodialysis.BFRdependentInCRRT.DialysateFlowDependent,15,Diffusion,RedBloodcell,Bicarbonate,Cratinine,Chlorure,Potassium,Urea,Blood,Membrane,Filtrate,AssociatedwithDialysate,16,17,Efficientforremovingsmallmolecules,小分子物質(zhì)血液濃度高膜內(nèi)外濃度差大小分子物質(zhì)易于擴(kuò)散相同膜對(duì)小分子物質(zhì)阻力小,18,Convection,Soluteremovalwitha“waterflow”SoluteDrag(Pressuregradient)GoodforlargermolecularweightsubstancesThefastertheflow,thebettertheclearanceReplacementsolutionsmustbephysiologicalandsterile,19,對(duì)流,溶質(zhì)隨水流移動(dòng)，“溶劑拖移”,20,影響對(duì)流作用的因素,增加某種溶質(zhì)的對(duì)流清除率有兩種方法:1.選擇一塊更易于溶質(zhì)通過的簿膜2.增加超濾出來的容量,C=S*UFRUFR=Lp*A*TMP,S:篩過系數(shù),21,22,Adsorption,RedBloodcell,Creatinine,Chlorure,Potassium,Urea,Sang,Membrane,Filtrate,InflammatoryMediators,23,吸附作用,有些膜材料帶有吸附特性:(例如AN69膜)發(fā)生在膜表面的吸附如果份子能通過膜表皮，更大規(guī)模的吸附發(fā)生在膜的深層,份子粘附在膜的表面或深層,24,25,內(nèi)容提要,CRRT的基本概念CRRT的溶質(zhì)清除原理CRRT的基本模式CRRT在ICU中的應(yīng)用,26,CRRT治療方式,27,ContinuousRenalReplacement,Therapies,SCUF,C,A,V,H,SPONTANEOUS,BloodCirculation,PUMPED,BloodCirculation,HEMOFILTRATION,CONVECTION,HEMODIALYSIS,DIFFUSION,HVHF,28,RemovalofwaterisdonebyUFNoSubstitutionliquidisusedUsedmainlyforCHF+FluidOverload,SCUF,(SlowContinuousUltrafiltration),29,CVVHD,(ContinuousVeno-VenousHemodialysis),Theprinciple(clearances)isDiffusionEliminatemainlySmallMoleculesNetFluidRemovalisdesiredUsedofSterileDialysateSolution,30,CVVHPostdilution,(ContinuousVeno-VenousHemofiltration),Theprinciple(clearances)isConvectionEliminateSmall,Mid+LargemoleculesNetFluidremovalifdesiredInpost-DilutionFluidsarereturningaftertheFilterinsidethevenousline,31,CVVHPre-dilution,Theprinciple(clearances)isConvectionEliminateSmall,Mid+LargemoleculesNetFluidremovalifdesiredInpre-DilutionFluidsarereturningbeforetheFilterthroughthepreDilutionline,32,CVVH-HVHFPre/Postdilution,AssociatedwithHighVolumeHemofiltration,Theprinciple(clearances)isConvectionEliminateSmall,Mid+LargemoleculesNetFluidremovalifdesiredInpre+post-DilutionFluidsarereturningtothepatientbeforeandaftertheFilter,33,Theprinciple(clearances)isConvection+DiffusionEliminateSmall+MidmoleculesNetFluidremovalifdesiredUseofSterileDialysate+ReplacementSolutions,CVVHDF,(ContinuousVeno-VenousHemodiafiltration),34,CRRT特點(diǎn),穩(wěn)定的血流動(dòng)力學(xué)持續(xù)穩(wěn)定的控制氮質(zhì)血癥和水電/酸堿平衡能夠不斷清除循環(huán)中的毒素或中分子物質(zhì)按需提供營(yíng)養(yǎng)補(bǔ)充和藥物治療,35,CRRTvsIRRT,36,內(nèi)容提要,CRRT的基本概念CRRT的溶質(zhì)清除原理CRRT的基本模式CRRT在ICU中的應(yīng)用,37,CRRT病理生理指征,1.液體過負(fù)荷保持水平衡2.代謝產(chǎn)物堆積(氮質(zhì)血癥)清除代謝產(chǎn)物3.嚴(yán)重的酸堿失衡恢復(fù)酸堿失衡4.嚴(yán)重的電介質(zhì)紊亂恢復(fù)電介質(zhì)平衡5.容量治療受限營(yíng)養(yǎng)支持，補(bǔ)充膠體6.嚴(yán)重的組織器官水腫7.炎癥反應(yīng)清除或吸附炎癥介質(zhì)8.中毒清除毒物或藥物9.惡性高熱降溫,BellomoRandRoncoC.CritCare,2000,4:339-345,38,血流動(dòng)力學(xué)不穩(wěn)定的ARF嚴(yán)重的SIRS重癥胰腺炎，燒傷重癥感染和感染性休克MODS與ARDS水中毒與急性肺水腫頑固性心衰中毒惡性高熱容量治療受限的ARF/CRF,CRRT臨床指征,BellomoRandRoncoC.CritCare,2000,4:339-345,39,CRRTIndications,Acutepulmonaryoedema:SCUFToavoidkalium-hydricoverloadduringcardiacsurgerywithEBC(extracorporealbloodcirculation):SCUFSevereoedemain:congestivec