CRRT治療容量如何控制幻燈片

CRRT治療容量如何控制CRRT治療中的容量管理CRRT清除水和溶質(zhì)的機(jī)制及其相關(guān)概念；重癥患者容量失衡及其危害；CRRT容量管理目標(biāo)及其監(jiān)測(cè)；CVVHDFR?b=100-200ml/min;?d=20-40ml/min;?f=8-15ml/min透析液透析液+UFCRRT治療中水和溶質(zhì)清除機(jī)制水：超濾；溶質(zhì)：彌散、對(duì)流與吸附；彌散彌散是溶質(zhì)通過(guò)半透膜的一種方式，主要驅(qū)動(dòng)力是離子濃度梯度差；在一個(gè)限定的分布空間，半透膜兩側(cè)的物質(zhì)有達(dá)到相同濃度的趨勢(shì)。Chest2007;132:1379–1388對(duì)流對(duì)流是溶質(zhì)通過(guò)半透膜的另一種方式，在跨膜壓差作用下，溶質(zhì)及溶劑一起通過(guò)半透膜。Chest2007;132:1379–1388CVVHRUF單純超濾模式TotalUF代表凈清除液體量；血液濾過(guò)模式TotalUF意味治療效果，而不指液體平衡狀態(tài)；CRRT治療中水和溶質(zhì)清除機(jī)制IntJArtiforgans.2008;31(2):145-55CVVHD透析液透析液+UF血液透析模式TotalUF控制平衡，僅代表額外治療效果；CVVHDF模式TotalUF僅代表治療效果，不影響液體平衡；CRRT治療中水和溶質(zhì)清除機(jī)制IntJArtiforgans.2008;31(2):145-55Replacementrate置換率Qr是單位時(shí)間置換入回路的液體總量，為達(dá)到目標(biāo)凈超濾率，置換率應(yīng)依超濾率而設(shè)定；TotalreplacementTR是回路置換液的總量，血液濾過(guò)模式TR代表治療效果和液體平衡；血液透析濾過(guò)模式TR同樣也意味著療效和液體平衡；CRRT水的清除機(jī)制及其相關(guān)概念I(lǐng)ntJArtiforgans.2008;31(2):145-55透析液CVVHDFR透析液+UFNetultrafiltration凈超濾量是凈清除的液體總量；(Totalultrafiltration–totalreplacement)Netultrafiltrationrate凈超濾率是單位時(shí)間凈清除液體的總量；(Ultrafiltrationrate–replacementrate)Totaleffluent總流出(廢)液量是收集到引流袋中的液體總量；CRRT水的清除機(jī)制及其相關(guān)概念I(lǐng)ntJArtiforgans.2008;31(2):145-55透析液CVVHDFR透析液+UF超濾應(yīng)在RRT治療全身狀態(tài)穩(wěn)定之后進(jìn)行；RRT治療開(kāi)始前應(yīng)充分沖洗管路；應(yīng)規(guī)律評(píng)價(jià)對(duì)超濾率的臨床反應(yīng)情況并相應(yīng)調(diào)整；IntJArtiforgans.2008;31(2):145-55CRRT治療中的容量管理CRRT清除水和溶質(zhì)的機(jī)制及其相關(guān)概念；重癥患者容量失衡及其危害；CRRT容量管理目標(biāo)及其監(jiān)測(cè)；FluidimbalanceExcessivepositivebalance(Patientfluidoverload)Excessivenegativebalance(Hypovolemia)InsufficientfluidremovalFluidgain(specialcase)Cumulativeexcessivefluidremoval(TotalUF)Excessivefluidremovalrate(TotalUF)Harm:Hazardoussituation:重癥患者容量失衡及其危害IntJArtiforgans.2008;31(2):145-55KidneyInternational.2009;76:422–427Fluidoverloadwasdefinedasmorethana10%increaseinbodyweightrelativetobaseline;measuredin618patientsenrolledinaprospectivemulticenterobservationalstudy;Fluidaccumulation,survivalandrecoveryofkidneyfunctionincriticallyillpatientswithAKIKidneyInternational.2009;76:422–427Fluidaccumulation,survivalandrecoveryofkidneyfunctionincriticallyillpatientswithAKIKidneyInternational.2009;76:422–427TheimportanceoffluidmanagementinAcutelunginjurysecondarytosepticshockChest.2009;136:102-109Thestudycohortwasmadeupof212patientswithALIcomplicatingsepticshock.Adequateinitialfluidresuscitation(AIFR)wasdefinedasthe

administrationofaninitialfluidbolusof>20mL/kgpriortoandachievementofaCVP>8mmHgwithin6haftertheonsetoftherapywithvasopressors.Conservativelatefluidmanagement(CLFM)wasdefinedaseven-tonegativefluidbalancemeasuredonatleast2consecutivedaysduringthefirst7daysaftersepticshockonset.Chest.2009;136:102-109BloodPurif2010;29:331–338TheimportanceoffluidmanagementinAcutelunginjurysecondarytosepticshockConclusions:BothearlyandlatefluidmanagementofsepticshockcomplicatedbyALIcaninfluencepatientoutcomes.TheimportanceoffluidmanagementinAcutelunginjurysecondarytosepticshockChest.2009;136:102-109CRRT治療中的容量管理CRRT清除水和溶質(zhì)的機(jī)制及其相關(guān)概念；重癥患者容量失衡及其危害；CRRT容量管理目標(biāo)及其監(jiān)測(cè)；Clinical

SkinTurgorCapillaryrefillVenousdistentionOrthostasisBloodPressureOrganomegalyPulmonaryedemaUrinevolumeUrineOsmolalityMonitoringInvasiveCentralVenousPressurePulmonaryArteryPressureCardiacOutput(PAC,PICCO)Pre-LoadparametersVolumeresponsiveness(SPV,PPV)Non-InvasiveEchocardiographyBioimpedanceSpectroscopyAssessmentofVolumeStatusDesign:Prospective,nonrandomized,nonblindedinterventionalstudy；健康志愿受試者(n=12group1,n=32group2)；組1肺動(dòng)脈導(dǎo)管置入并進(jìn)行血管造影組2容量測(cè)量的超聲心動(dòng)檢測(cè)并在3小時(shí)內(nèi)輸注生理鹽水3000mlCritCareMed.2004;32:691–699CritCareMed.2004;32:691–699CritCareMed.2004;32:691–699CritCareMed.2004;32:691–699CritCareMed.2004;32:691–699AssessmentofVolumeStatus壓力僅僅是壓力，壓力不能準(zhǔn)確反映容量狀態(tài)容量狀態(tài)評(píng)估---困難！應(yīng)密切監(jiān)測(cè)下綜合評(píng)價(jià)CRRT治療中的液體平衡總體負(fù)平衡：脫水，運(yùn)用于所有液體超負(fù)荷的少尿/無(wú)尿病人；總體平衡：病人的容量狀況在正常范圍或前期脫水治療后需要維持在平衡狀態(tài)；機(jī)器零平衡：對(duì)于急性腎衰的恢復(fù)期以及部分非腎衰危重病人，血濾僅僅用于清除機(jī)體代謝產(chǎn)物或炎性介質(zhì)；Fluid